Community Pediatric Research Articles

An Improvement Project in Reducing After-Visit Phone Calls in a Community Pediatric Neurology Clinic: Too Much Communication?

Physicians strive to provide high-quality clinical care, yet after-visit patient telephone calls create extra demands on a clinician's time. Pediatric neurologists are particularly affected by this challenge given the number of patients with chronic illnesses they serve and the volume of worried parents they support. Added workload coupled with a busy office practice increases the likelihood of early physician burnout, which can have downstream effects on the quality of patient care and patient satisfaction. Using the IHI model for quality improvement (abbreviated QI moving forward), QI methodology was used to determine volume and key drivers of patient/family communications after a visit to a pediatric neurology clinic. Interventions aimed at reducing telephone messages by 15% over a 6-month period were put into place. A baseline audit of clinic phone calls was completed in 2019 to develop an overview of after-visit communications. After-visit telephone calls and web-based portal messages were then tracked for 3-week periods in 2019, 2020, and 2021 to understand key trends. A key driver diagram of patient/family communications after a clinic visit was created, and interventions aimed at reducing telephone messages were discussed. These interventions included optimizing MD-RN workflows, synchronous and asynchronous educational initiatives, and changes to our clinic's voicemail phone tree. Our primary outcome measure was the average monthly telephone call volume, and this measure was tracked monthly from November 2020 through December 2022. Similarly, electronic portal message volume was tracked and served as our balancing measure. Physicians, nurses, and patients were primary drivers of phone call volume. After interventions were in place, the average monthly call volume decreased by 30% from a baseline of 293 calls to 203 calls. This change was sustained for at least 1 year. The average monthly portal message volume remained consistent throughout the study period at 359 messages. Both physicians and nurses agree that after-visit patient communication affects their workload. This study illustrates that QI methodology can be used to plan and implement interventions aimed at decreasing after-visit telephone calls.

Perspectives on Professional Development Among University and Community Pediatric Hospitalists.

Multiple professional societies have emphasized the importance of professional development for physicians. This qualitative study aimed to explore pediatric hospitalists' perceptions of professional development needs and to refine a framework for professional development in pediatric hospital medicine (PHM). We conducted four focus groups in April to May 2019 with 19 pediatric hospitalists at six clinical sites within a single institution. Participants identified key components of professional development including skill development, personal growth, career satisfaction, and individualization. Hospitalists agreed upon 8 domains of professional development: clinical excellence, advocacy, global health, health care administration, informatics, medical education, quality improvement, and research. They also identified missing the mentorship necessary to change their passions into career advancement, highlighted barriers and facilitators, and noted that an alignment in personally meaningful projects to what is meaningful to the institution was in everyone's best interests. Faculty programs should build infrastructure to aid pediatric hospitalists in achieving their career goals.

Seize the Opportunity: Increasing the HIV Screening Rate in Adolescents Presenting to a Community Pediatric Emergency Department.

Our objective was to increase human immunodeficiency virus (HIV) screening in adolescents presenting to our community pediatric emergency department with symptoms suggestive of a sexually transmitted infection (STI) and who were being tested for gonorrhea and chlamydia. Specifically, we aimed to increase the monthly average proportion of adolescents concurrently screened for HIV in this target group from 11% to 50% in 6 months. We identified barriers to HIV screening, focusing on physician-related challenges and adolescents' concerns about confidentiality. We designed interventions targeting these barriers and implemented them in plan-do-study-act cycles beginning in February 2020. We educated physicians and nurses about screening recommendations, emphasized a physician-conducted private interview during which confidential contact information could be obtained, and assured confidentiality on after visit summaries by removing STI results. We also provided regular feedback to physicians on the screening rate. In addition, we implemented an electronic health record quick order set and a documentation tool. Using a statistical process control chart, we measured the average monthly proportion of adolescents in the target group who were offered HIV screening or tested for HIV before and after interventions. A total of 140 adolescents in the target group presented to our pediatric emergency department from February 2020 through December 2021. After plan-do-study-act cycles, the average monthly screening rate increased to 80%. Raising physician awareness of HIV screening recommendations and the importance of conducting a private interview improved screening rates. Assuring adolescent minors of confidentiality in a private interview, removing STI results from the after visit summary, and obtaining confidential contact information were important measures to overcome confidentiality barriers.

Impact of COVID-19 on the Sense of Job Security Among Community Pediatric Hospitalists.

The coronavirus disease 2019 (COVID-19) pandemic offers a prime opportunity to examine the ability of community pediatric hospital medicine programs to respond to external stressors. This study aims to characterize the impact of the COVID-19 pandemic on compensation and furlough among community pediatric hospitalists, as well as self-reported sense of job security. This study was part of a larger quantitative project investigating community pediatric hospitalists' career motivators. The survey was drafted through an iterative process by the authors. It was disseminated via e-mail to a convenience sample of community pediatric hospitalists obtained through direct contact with community pediatric hospital medicine programs. Data were collected on changes in compensation and furlough because of COVID-19, as well as worry about job security measured as self-reported worry about one's job being permanently terminated on a 5-point Likert scale. Data were collected from 31 hospitals across the United States with 126 completed surveys. Because of COVID-19, many community pediatric hospitalists experienced reduced base pay and benefits and a minority experienced furlough. Nearly two-thirds (64%) reported some worry about job security. Initial base pay reduction, working in suburban areas compared with rural areas, and affiliation with a university-based center or free-standing children's hospital were significantly associated with greater worry about job security. The initial response to the COVID-19 pandemic resulted in changes in compensation and furlough for some community pediatric hospitalists and many expressed concerns about job security. Future studies should identify protective factors for community pediatric hospitalists' job security.

Virtual Collaborative Behavioral Health Model in a Community Pediatric Network: Two-Year Outcomes.

Due to the pervasive shortage of behavioral health (BH) specialists, collaborative partnerships between pediatric primary care practitioners (PPCPs) and BH specialists can enhance provision of BH services by PPCPs. We aimed to create a new model of collaborative care that was mostly virtual, affordable, and scalable. The pilot program was implemented in 18 practices (48 PPCPs serving approximately 150 000 patients) in 2 consecutive cohorts. Outcomes were assessed by administering pre-program and post-program surveys. Across the 18 practices, PPCPs reported significantly increased confidence in their BH knowledge and skills, and significantly increased their provision of target BH services. Barriers to BH service provision (resources, time, and staff) were unchanged. This compact, mostly virtual model of BH collaboration appears to be beneficial to PPCPs while also offering convenience to patients and affordability and scalability to the practice network.

Sustaining Long-term Asthma Outcomes at a Community and Tertiary Care Pediatric Hospital.

Implementing asthma Clinical Practice Guidelines (CPG) have been shown to improve length of stay (LOS) and readmission rates on a short-term basis at both tertiary care and community hospital settings. Whether these outcomes are sustained long term is not known. The goal of this study was to measure the long-term impact of CPG implementation at both tertiary and community sites in 1 hospital system. A retrospective study was conducted using the Pediatric Health Information System database. LOS and 7- and 14-day emergency department (ED) revisit and readmission rates from 2009 to 2020 were compared pre and post implementation of asthma CPG in 2012 at both sites. Implementation involved electronic order sets, early metered dose inhaler introduction, and empowering respiratory therapists to wean per the bronchodilator weaning protocol. Interrupted time series and statistical process control charts were used to assess CPG impact. Implementation of asthma CPG was associated with significant reductions in the variability of LOS without impacting ED revisit or readmission rates at both the tertiary and community sites. Secular trends in the interrupted time series did not demonstrate significant impact of CPG on LOS. However, the overall trend toward decreased LOS that started before CPG implementation was sustained for 7 years after CPG implementation. Early metered dose inhaler introduction, respiratory therapist-driven bronchodilator weaning, and electronic order sets at both the community and tertiary care site led to a significant reduction in the variation of LOS, without impacting ED revisit or readmission rate.

Sustainable Development Goals in Ireland: How Public Health Nurses Are Contributing Through Engagement in an Interagency Community Pediatric Clinic.

United Nations Sustainable Development Goals (SDGs) were adopted as a plan of action for people, planet, and prosperity by 2030. SDG 3 aims to ensure healthy lives and promote well-being for all ages, and other goals focus on reduction of inequality, abolition of poverty, decent work for all, and building effective, accountable, and inclusive institutions. A community pediatric clinic, Kidscope, was established in a vulnerable Irish community offering free developmental assessment and onward referral of children 0 to 6 years. The Kidscope model involves multiagency input with local public health nurses (PHNs) acting as fundamental partners in the provision of specialist early years support to vulnerable children and families. This study evaluates PHN involvement in Kidscope in the context of SDGs. To record and understand PHN roles within Kidscope and to capture their contribution to achieving SDGs in a disadvantaged Irish community. Qualitative stakeholder analysis and mapping design. Snowball sampling identified participants. Data collection involved scoping interviews, questionnaires, one-to-one interviews, and a focus group. A Stakeholder Matrix Table was developed in line with the guiding framework. Transcripts were thematically analyzed. PHNs are key stakeholders in Kidscope contributing to clinic development, delivery, and sustainability. Six themes were identified: lead referrers, in-clinic support, learning and education, child and family follow-up, specialist early years role, and partnership working. PHNs contribute to six SDGs through the Kidscope model. PHNs are fundamental partners in achieving SDGs in a disadvantaged Irish community through ameliorating childhood developmental delay by intercepting the gap within Ireland's early intervention system and disrupting the impact exclusion to healthcare has on vulnerable children and their families. Findings underscore a shift from the current "cradle to grave" model of working toward a specialist early years PHN role.

#31 Bloodstream Infections and Microbiology during Induction Chemotherapy over a Decade at a Community Pediatric Cancer Center

Abstract Background Bloodstream infections (BSIs) remain a significant cause of morbidity and mortality in children with leukemia. They are at an increased risk of infectious complications secondary to intense chemotherapeutic regimens during induction resulting in prolonged and profound neutropenia. To our knowledge, there is limited literature regarding pathogens and antibiotic resistance from smaller institutions similar to ours. The primary objective of this review was to describe the microbiology of BSIs, and second to evaluate our rates of BSIs during induction chemotherapy as compared to larger institutions. Method Retrospective chart review of 82 eligible patients between the age of 1 and 21 years with newly diagnosed leukemia between May 1, 2010 and May 31, 2020. Patients who did not complete the entirety of induction chemotherapy at our hospital were excluded. A microbiologically documented infection was defined as a causative pathogen isolated from the blood in the setting of fever and/or neutropenia. Neutropenia was defined as an absolute neutrophil count (ANC) of less than 0.5x109 cells/L. Results Of the 82 patients, 12 (14.6%) patients had a BSI during induction chemotherapy. The most common organisms identified were Gram-positive cocci (75%), Gram-negative bacilli (16.6%), and Gram-negative cocci (8.3%). Methicillin-susceptible Staphylococcus aureus (MSSA) was the most frequently isolated organism (42%) overall. No methicillin-resistant Staphylococcus aureus (MRSA) was identified. Of the Gram-negative bacteria isolated, Escherichia coli (8%) and Pseudomonas aeruginosa (8%) were identified. No extended spectrum beta-lactamase (ESBL) or multi-drug resistant organisms were identified. No fungi were isolated. Conclusion The incidence of BSIs in children during induction chemotherapy at our institution is similar to what is reported from larger, academic centers. Gram-positive cocci comprise 75% of BSIs with no MRSA isolates in 10 years. Our antibiogram shows no resistant Gram-negative bacteria. This is in contrast to what is reported to larger pediatric cancer centers. Therefore, current empiric monotherapy with a fourth generation cephalosporin at the onset of febrile neutropenia remains adequate for our pediatric oncology patients.

COVID-19 Era Effect on Pandemic and Post-pandemic Pediatric Telemedicine Use: A Survey of the European Academy of Pediatrics Research in Ambulatory Settings Network.

Background: During the COVID-19 pandemic, telemedicine use has increased within community pediatrics. This trend runs counter to reluctance to adaptation of the new mode of healthcare that existed prior to the pandemic. Little is known about what we can expect after the pandemic: if physicians will opt for telemedicine modalities and if tele-pediatrics will continue to be a significant mode of community pediatric care.Objective: The goal of this study was to survey primary pediatric care providers as to their experiences and clinical decision making with telemedicine modalities prior to and during the COVID-19 pandemic, as well as their projected use after the pandemic ends.Material and methods: Using the EAPRASnet database we surveyed pediatricians throughout Europe, using a web-based questionnaire. The survey was performed during the COVID-19 pandemic (June–July 2020), assessed telemedicine use for several modalities, prior to and during the pandemic as well as predicted use after the pandemic will have resolved. Participants were also surveyed regarding clinical decision making in two hypothetical clinical scenarios managed by telemedicine.Results: A total of 710 physicians participated, 76% were pediatricians. The percentage of respondents who reported daily use for at least 50% of all encounters via telemedicine modalities increased during the pandemic: phone calls (4% prior to the pandemic to 52% during the pandemic), emails (2–9%), text messages (1–6%), social media (3–11%), cell-phone pictures/video (1–9%), and video conferencing (1–7%) (p < 0.005). The predicted post-pandemic use of these modalities partially declined to 19, 4, 3, 6, 9, and 4%, respectively (p < 0.005), yet demonstrating a prospectively sustained use of pictures/videos after the pandemic. Reported high likelihood of remotely treating suspected pneumonia and acute otitis media with antibiotics decreased from 8 to 16% during the pandemic to an assumed 2 and 4% after the pandemic, respectively (p < 0.005).Conclusions: This study demonstrates an increased utilization of telemedicine by pediatric providers during the COVID-19 pandemic, as well as a partially sustained effect that will promote telemedicine use as part of a hybrid care provision after the pandemic will have resolved.

Low Rates of Clinician Monitoring for Second Generation Antipsychotic Medications in Community Pediatric Practice.

Second generation antipsychotic (SGA) medications are frequently prescribed to pediatric patients in the United States. This retrospective observational study sought to ascertain the extent of adherence to established pediatric SGA monitoring guidelines in community practice. The team used the electronic health record to determine clinician adherence to SGA monitoring guidelines at baseline, 12-week, and annual times relative to prescribing an SGA. At the time of their SGA prescription, 5.5% of pediatric patients had received all of the orders according to the monitoring guidelines. Annually, 2.5% of patients had received the necessary orders to completely adhere to monitoring guidelines; 42% of patients received no monitoring orders. Monitoring was more likely for children who had multiple types of providers and interacted with the healthcare system beyond a traditional office visit. This research informs healthcare providers about the gap between prescribing and monitoring for SGA medications in community practice for pediatric populations.

Uptake of an Integrated Electronic Questionnaire System in Community Pediatric Clinics.

The study aimed to evaluate an integrated electronic questionnaire system implementation in outpatient community pediatric practices on workflow, completion rates, and recorded scores. We evaluated the implementation and outcomes of an integrated electronic questionnaire system at 45 community pediatric practices that used standardized questionnaires to screen for autism, depression, and substance use and to measure asthma control. Electronic health record (EHR) data for all well child visits were extracted for the 3 months before and after implementation. We used statistical process control charts to evaluate questionnaire completion rates and Chi-square tests to evaluate screening completion and positive screening rates. The collection and entry of questionnaire information was observed and timed. EHR data included 107,120 encounters across 45 practices that showed significant and sustained improvement in completion rates for all questionnaires. The rate of recorded concerning questionnaires decreased for asthma control (19.3 vs. 12.8%, p < 0.001), stayed the same for autism (96.6 vs. 96.2%, p = 0.38), decreased for depression (9.5 vs. 6.7%, p ≤ 0.001), and increased for any substance use (9.8 vs. 12.8%, p < 0.001). Twelve practices were observed, and patient time and staff time managing questionnaires were decreased after implementation. Electronic questionnaire administration saved staff time and patient time. We report overall improvement in questionnaire completion rates, with notable variation in improvement in completion across practices and in change in concerning recorded result rates across measures. Conversion of four standard paper questionnaires to an integrated electronic system reduces patient and staff time while increasing completion rates when well integrated into routine care.

Assessment of Community Pediatric Providers’ Approach to Children With Helicobacter pylori

In 2016, the European and North American Societies for Pediatric Gastroenterology, Hepatology, and Nutrition updated guidelines for management of Helicobacter pylori in children, adjusting the previous diagnostic and therapeutic approaches in response to changing epidemiology and antibiotic resistance patterns. In this study, we assessed knowledge, practice habits of H. pylori management, and adherence to new guideline recommendations among one state’s community pediatric providers. The majority of the surveyed community pediatric providers are not following the new pediatric guidelines for H. pylori management. An evidence-practice gap for diagnosis and treatment of H. pylori disease can lead to poor resource utilization, inadequate antibiotic usage, increased antibiotic resistance, and prolonged symptoms in patients. By understanding pediatric provider practices, pediatric gastroenterologists can assist in addressing the gap through development of educational interventions for community pediatric providers.

Antibiotic Resistance among Enteric Fever Pathogens in a Tertiary Care Children Hospital of Bangladesh

Background: Enteric fever, a public health problem endemic in Bangladesh involves multiple systems. Fluoroquinolones and third generation cephalosporins are first line drugs used in treatment, which has led to increased minimal inhibitory concentration (MIC) of ciprofloxacin causing therapeutic failure. In recent years using these drug some treatment failure found.&#x0D; Objectives: To study the antibiotic resistance among enteric fever pathogens in young children and to study the isolation rate of S. typhi and S. paratyphi among different age groups of children.&#x0D; Methods: A prospective study was done in Pediatric Infectious &amp; Community Pediatrics Department of Dhaka shishu (Children) Hospital among admitted children age 1 to 15 years from January 2018 to January 2019. During this period 62 blood culture samples with growth of S.typhi &amp; S.paratyphi were processed. The antibiotic susceptibility was done by modified Kirby disk diffusion.&#x0D; Results: During this 1 year from 72 admission days, 216 suspected enteric fever children admitted in Pediatric Infectious &amp; Community Pediatric Department. Out of these 216 patients, isolation rate of enteric fever pathogens by blood cultures was 62 (28.7%). Majority of the isolates were S. typhi (75.8%) and S. paratyphi A were 24.2%. Among them 40(64.5%) isolates were from 5 to 15 years of age. Antibiotic resistance pattern was Ampicillin 37.1%, Chloramphenicol 30.64%, Co-trimoxazole 35.48%, Ceftriaxone (0%), Azithromycin (19.35%), resistance or reduced susceptibility to Ciprofloxacin was found in 77.41%, Nalidixic acid 100%, ten isolates (16.12%) were MDR. The most susceptible antibiotic was ceftriaxone while most resistant was nalidixic acid.&#x0D; Conclusion: The increasing numbers of enteric fever pathogens with decreasing susceptibility to ciprofloxacin and azithromycin is a concern. Increasing dependency to ceftriaxone and cefixime may cause resistance to these drugs near future. So, we can choose older drugs again in some cases.&#x0D; DS (Child) H J 2019; 35(1) : 55-58

Protecting the American Dream: a Pediatric Imperative.

* Abbreviations: AAP — : American Academy of Pediatrics VVN — : Vital Village Network The American dream is a fundamental ethos of the nation passed from generation to generation. In 1931, James Truslow Adams coined the term as “that dream of a land in which life should be better and richer and fuller for everyone.” Most Americans across all incomes still believe their children and grandchildren will achieve the American dream.1 Yet, in reality, it is out of most children’s reach. The American dream is intrinsically tied to the capacity for upward mobility, whereby children can grow up to surpass their parent’s income level. The groundbreaking work of Harvard Professor of Public Economics Dr Raj Chetty reveals that there is less upward mobility in the United States today than at any other time, likely because of lower overall economic growth and greater inequality in its distribution. Specifically, Chetty et al2 found that, since 1940, the fraction of children who earn more than their parents has fallen from >90% to ∼50%. However, the decline in the American dream is not equally distributed across the United States. Chetty et al3 has revealed great variation in upward mobility, with significant differences even among neighborhoods within the same city. Higher–upward-mobility areas are associated with less residential segregation and income inequality and greater … Address correspondence to Arvin Garg, MD, MPH, Department of Pediatrics, University of Massachusetts Medical School, 55 Lake Avenue North, Worcester, MA 01655. E-mail: Arvin.Garg{at}umassmemorial.org

Adolescent Interviews for the Bio-Psycho-Social Model in a Community Pediatric Clinic

Adolescent Interviews for the Bio-Psycho-Social Model in a Community Pediatric Clinic

Comparison of early surgical outcomes following anoplasty and limited PSARP for perineal fistula

Background: To present the early surgical outcomes of two different surgical methods for the treatment of perineal fistula in patients with anorectal malformation. Material and Methods: Retrospective chart analysis of patients treated with any of the two surgical approaches for perineal fistula treatment during the newborn period, without a colostomy at Academic and Community Pediatric Surgery Reference Hospital during October 1st, 2015 to December 31st, 2018. Results: Twenty-six out of 57 patients of our database met inclusion criteria during the study period. 15 in the anoplasty group and 11 in the Minimal Posterior Sagittal Anorectoplasty (MPSARP); the anoplasty group had more rate of anoplasty dehiscence (4 partial, 6 total – requiring additional stitches, p = 0.027), versus zero in the MPSARP group, albeit there was 1 superficial perineal dehiscence. All surgeries were performed without a previous colostomy. There were no other surgical complications reported, and there was no difference in age, weight, sacral ratio, and associated malformations. Conclusion: Minimal PSARP can be safely done in the newborn patient with a patent perineal fistula.

Career Motivators for Community Pediatric Hospitalists.

Within the field of pediatric hospital medicine, physicians can choose to work at community-based or university-based centers. The factors that motivate pediatric hospitalists to work specifically at community sites have not yet been fully explored. Our objective with this study was to elucidate the motivators for pediatric hospitalists to begin and continue work at community sites. A qualitative study was performed via phone-based focus groups. Physicians were included if they were able to attend 1 of the offered group sessions and they self-identified as spending the majority of their time working as community-based pediatric hospitalists. Data were analyzed through a constant comparative analysis. Five themes emerged regarding factors that motivate pediatricians to begin and continue their careers as hospitalists in the community. The themes were (1) professional impact, (2) scope of practice, (3) personal and professional satisfaction, (4) community involvement, and (5) job availability. This study reveals the key factors that motivate community pediatric hospitalists to begin and continue working in the community.

Development of a QI Program Within a Community Pediatric Emergency Department

The growth of community hospital based pediatric emergency departments has created an opportunity to develop locally formulated quality improvement processes. Inherent challenges, resource and solutions are explored. Building a well-defined QI infrastructure, one that promotes multidisciplinary buy-in and ownership among invested participants, is central to success.

Community Pediatric Hospitalist Workload: Results from a National Survey.

As a newly recognized subspecialty, understanding programmatic models for pediatric hospital medicine (PHM) programs is vital to lay the groundwork for a sustainable field. Although variability has been described within university-based PHM programs, there remains no national benchmark for community-based PHM programs. In this report, we describe the workload, clinical services, employment, and perception of sustainability of 70 community-based PHM programs in 29 states through a survey of community site leaders. The median hours for a full-time hospitalist was 1,882 hours/year with those employed by community hospitals working 8% more hours/year and viewing appropriate morning pediatric census as 20% higher than those employed by university institutions. Forty-three out of 70 (63%) site leaders perceived their programs as sustainable, with no significant difference by employer structure. Future studies should further explore root causes for workload discrepancies between community and academic employed programs along with establishing potential standards for PHM program development.

Independent Host Factors and Bacterial Genetic Determinants of the Emergence and Dominance of Escherichia coli Sequence Type 131 CTX-M-27 in a Community Pediatric Cohort Study.

The recent emergence and diffusion in the community of Escherichia coli isolates belonging to the multidrug-resistant and CTX-M-27-producing sequence type 131 (ST131) C1-M27 cluster makes this cluster potentially as epidemic as the worldwide E. coli ST131 subclade C2 composed of multidrug-resistant isolates producing CTX-M-15. Thirty-five extended-spectrum beta-lactamase (ESBL)-producing ST131 isolates were identified in a cohort of 1,885 French children over a 5-year period. They were sequenced to characterize the ST131 E. coli isolates producing CTX-M-27 recently emerging in France. ST131 isolates producing CTX-M-27 (n = 17), and particularly those belonging to the C1-M27 cluster (n = 14), carried many resistance-encoding genes and predominantly an F1:A2:B20 plasmid type. In multivariate analysis, having been hospitalized since birth (odds ratio [OR], 10.9; 95% confidence interval [CI], 2.4 to 48.8; P = 0.002) and being cared for in a day care center (OR, 9.4; 95% CI, 1.5 to 59.0; P = 0.017) were independent risk factors for ST131 CTX-M-27 fecal carriage compared with ESBL-producing non-ST131 isolates. No independent risk factor was found when comparing CTX-M-15 (n = 11)- and CTX-M-1/14 (n = 7)-producing ST131 isolates with ESBL-producing non-ST131 isolates or with non-ESBL-producing isolates. Several factors may contribute to the increase in fecal carriage of CTX-M-27-producing E. coli isolates, namely, resistance to multiple antibiotics, capacity of the CTX-M-27 enzyme to hydrolyze both cefotaxime and ceftazidime, carriage of a peculiar F-type plasmid, and/or capacity to colonize children who have been hospitalized since birth or who attend day care centers.