Pediatric Infectious Disease Physicians Research Articles

Child Health Needs and the Pediatric Infectious Diseases Workforce: 2020-2040.

Pediatric infectious diseases (PID) physicians prevent and treat childhood infections through clinical care, research, public health, education, antimicrobial stewardship, and infection prevention. This article is part of an American Board of Pediatrics Foundation-sponsored supplement investigating the future of the pediatric subspecialty workforce. The article offers context to findings from a modeling analysis estimating the supply of PID subspecialists in the United States between 2020 and 2040. It provides an overview of children cared for by PID subspecialists, reviews the current state of the PID workforce, and discusses the projected headcount and clinical workforce equivalents of PID subspecialists at the national, census region, and census division levels over this 2-decade period. The article concludes by discussing the education and training, clinical practice, policy, and research implications of the data presented. Adjusting for population growth, the PID workforce is projected to grow more slowly than most other pediatric subspecialties and geographic disparities in access to PID care are expected to worsen. In models considering alternative scenarios, decreases in the number of fellows and time spent in clinical care significantly affect the PID workforce. Notably, model assumptions may not adequately account for potential threats to the PID workforce, including a declining number of fellows entering training and the unknown impact of the COVID-19 pandemic and future emerging infections on workforce attrition. Changes to education and training, clinical care, and policy are needed to ensure the PID workforce can meet the future needs of US children.

Accuracy of identifying pediatric acute bacterial sinusitis diagnoses in outpatient claims data.

Acute bacterial sinusitis is among the most frequent outpatient infections in children and adolescents and is well suited to study in large healthcare utilization databases, but the validity of International Classification of Diseases, 10th Revision (ICD-10) codes together with antibiotic prescriptions to identify cases of acute bacterial sinusitis has not been established. We aimed to evaluate the validity of ICD-10 codes combined with antibiotic prescriptions to identify new diagnoses of acute bacterial sinusitis among pediatric patients evaluated in the outpatient setting. Children and adolescents aged 17 years and younger with an outpatient diagnosis of acute sinusitis along with an antibiotic prescription from an ambulatory facility affiliated with the Mass General Brigham health system were identified via a clinical data warehouse. Patients were stratified by age (0-5 years, 6-11 years, and 12-17 years), and 50 cases per age group were randomly sampled. Medical records were independently reviewed by two pediatric infectious diseases physicians to assess for the documentation of a clinician-defined diagnosis of acute bacterial sinusitis. Positive predictive values (PPVs) and 95% confidence intervals (CIs) were calculated. A total of 150 patients were included in the final cohort. Frontal, maxillary, and "unspecified" sinuses accounted for 88% of the diagnoses. The positive predictive value of the algorithm to identify clinician-defined diagnoses of acute bacterial sinusitis was 92% (95% CI 87%, 95%). The PPVs were consistent across age strata. ICD-10 codes for acute sinusitis, when paired with a same-day antibiotic prescription, have a high positive predictive value among a cohort of pediatric patients, suggesting that they can be used to study new acute bacterial sinusitis diagnoses with claims.

A Cross-Sectional Survey of Pediatric Infectious Disease Physicians' Approach to Congenital Cytomegalovirus Infection.

Congenital cytomegalovirus (cCMV) continues to be a major public health care issue due to its high prevalence throughout the world. However, there is a paucity of studies evaluating how providers manage this infection. This study surveyed North American Pediatric Infectious Disease (PID) physicians to elicit their approach towards the evaluation and treatment of this condition. Thirty-two PID physicians responded to this survey. Institutional testing and screening for cCMV were infrequently reported. The respondents in general agreed upon most laboratory and diagnostic testing except for neuroimaging. For those tests, there was a disparity in indications for head ultrasound versus brain MRI imaging. Most (68.8%) agreed with the clinical practice of starting valganciclovir in an infant less than 1 month of age with one sign or symptom of disease, and 62.5% would do so for an infant with isolated sensorineural hearing loss. However, only 28.1% would treat cCMV-infected infants older than 1 month of age. In conclusion, few healthcare institutions represented by PID physicians in this cohort had a cCMV screening or testing initiative, yet most respondents would test at a much higher level based on their clinical practice. While there is general consensus in evaluation and treatment of these children, there are disparities in practices regarding neuroimaging and indications for antiviral treatment with respect to age and severity of disease. There is a great need for an evidence based policy statement to standardize cCMV workup and treatment.

Defining Variability in Evaluation and Management of Children with Chronic Osteomyelitis.

Pediatric chronic osteomyelitis is a rare, debilitating condition lacking management guidelines. In a national survey of 162 pediatric infectious disease physicians through the Emerging Infections Network, tremendous variability in diagnostic approaches and management was noted, highlighting a need for a prospective study to better define the spectrum of pathogens and disease.

1314. Defining Variability in the Evaluation and Management of Children with Chronic Osteomyelitis

Abstract Background Pediatric chronic osteomyelitis (COM) is an uncommon, poorly defined, debilitating disorder often requiring multiple surgeries and prolonged antibiotic courses. Serious long-term sequelae may occur. As accepted diagnostic criteria do not exist, assessments of disease incidence, medical/surgical approach to management and outcomes are lacking. Methods We created a 14-question web-based survey sent to 390 pediatric infectious disease (PID) physician members of the Emerging Infections Network of the Infectious Diseases Society of America. With no standard definition of COM, respondents were asked to conceptualize this disease as they would during routine clinical practice. Of the 148 (38%) survey respondents so far (Table 1), 126 (85%) reported caring for children with COM. We assessed provider characteristics, diagnostic approach, and site-standard surgical and antibiotic management (including oral and intravenous [IV] antimicrobial choice and duration). We performed descriptive statistics on survey results. Results Of the 126 respondents, most were >5 years post-fellowship training and nearly half reported managing 3-6 cases of COM per year (Table 2). Prolonged duration of symptoms (79%), normal inflammatory markers (45%), and abnormal plain films (44%) were the most common findings used for diagnosis; however, diagnostic criteria varied. The most common risk factor was orthopedic implants (44%). Management choices and duration are in Figure 1. Most treated with IV antibiotics for < 2 weeks (34%), continuing oral antibiotics for at least 3-6 months (55%). In COM with retained orthopedic implant, most physicians (48%) use oral therapy until implant removal. Considerations for transition from IV to oral antibiotics included improved physical examination (60%), inflammatory markers (52%), extent of disease (55%), causative organism (41%) and location of infection (38%). Though 85% reported being comfortable diagnosing and managing COM, practices varied widely. Reported approaches to surgical management (a), duration of IV antibiotics (b), and duration of oral antibiotics (c) in children with COM, and management of COM in patients with implanted hardware (d) Responses from 126 pediatric infectious diseases physician participating in an Emerging Infections Network survey regarding diagnosis and management of chronic osteomyelitis (COM). Figure 1a) missing data for 2 respondents; figure 1b) missing data for 5 respondents; figure 1c) missing data for 2 respondents; figure 1d) missing data for 9 respondents. COM: Chronic osteomyelitis; IV: intravenous; abx: antibiotics. Conclusion Pediatric COM is a complex infection. Formal diagnostic criteria and future prospective studies for medical/surgical management by pathogen/site of infection and presence of foreign material are needed to optimize care and outcomes. Disclosures Daniel Benjamin, Jr., MD PhD MPH, Allergan: Advisor/Consultant|Melinta Therapuetics: Advisor/Consultant|Syneos Health: Advisor/Consultant.

Infectious Disease Teleconsultation to the Deployed U.S. Military From 2017-2022.

The ADvanced VIrtual Support for OpeRational Forces (ADVISOR) program is a synchronous telemedicine system developed in 2017 to provide 24/7 remote expert support to U.S. Military and NATO clinicians engaged in medical care in austere locations. Infectious disease (ID) remains the highest consulted service since 2018 and is currently staffed by 10 adult and pediatric ID physicians within the Military Health System. We conducted a retrospective review of the ID ADVISOR calls between 2017 and 2022 to identify trends and better prepare military ID physicians to address urgent ID consultations in overseas settings. Health records of the ID consultations between July 2017 and January 2022 were reviewed for local caregiver and patient demographics, case descriptions, consultant recommendations, and outcomes. A "not research" determination was made by the Brooke Army Medical Center Human Research Protections Office. ID physicians received 57 calls for 60 urgent patient consultations. Most calls were from countries in the Middle East or in Southwest Asia (United States Central Command (USCENTCOM)), followed by countries in Africa (United States Africa Command (USAFRICOM)). The majority of patients were active duty U.S. Military and were generally male with median age of 25 years. All consults involved an initial phone consultation and 30% continued over email. Ninety percent of the calls were initiated by physicians, and the median time from injury or illness-onset to consult was 3 days. Seventy percent of the consult questions involved treatment and further diagnostics, but one-third of cases required assistance with management of disease prevention. Multidrug-resistant or nosocomial infections, animal or bite exposure, malaria and malaria prevention, febrile illness, and blood-borne pathogen exposure accounted for 63% of the consults. Collaboration with other specialties took place in a minority of cases, and follow-up contact was recommended 20% of the time. Most recommendations involved adjusting drug regimens or further testing. Medical evacuation was only recommended in five of the cases. Although there was limited ability for follow-up, no known deaths occurred. A high proportion of calls to the ID ADVISOR line are relevant to the overlapping content areas of infection prevention, force protection, and outbreak response. Most patients requiring urgent ID consultation were managed successfully without evacuation. The current military-unique ID fellowship curriculum is consistent with the encountered diagnoses per the ID ADVISOR line, and high-yield individual topics have been identified.

Pediatric infectious disease physician perceptions of antimicrobial stewardship programs.

Pediatric antimicrobial stewardship programs (ASPs) improve antibiotic use for hospitalized children. Prescriber surveys indicate acceptance of ASPs, but data on infectious diseases (ID) physician opinions of ASPs are lacking. We conducted a survey of pediatric ID physicians, ASP and non-ASP, and their perceptions of ASP practices and outcomes.

When All Is Not as It Seems: Recurrent Fever and New-onset Joint Pain in a 17-Month-old Girl.

When All Is Not as It Seems: Recurrent Fever and New-onset Joint Pain in a 17-Month-old Girl.

Characteristics and antimicrobial choice of pediatric bacterial enteritis in the Kanto region of Japan: A multicenter retrospective observational study

IntroductionThere are few reports on the causative microorganisms of bacterial enteritis in children in Japan in recent years. The distribution of causative microorganisms is important for estimating pathogens and making decisions regarding the treatment plan, as antimicrobial agents are not required for mild bacterial enteritis cases but are used for severe cases or immunocompromised patients. MethodsWe retrospectively surveyed pediatric patients who underwent stool culture at eight hospitals in the Kanto region of Japan from 2014 to 2019 for patient characteristics, causative microorganisms, and prescribed antimicrobial agents. ResultsA total of 4,475 stool cultures were submitted, and the positivity rate for bacterial enteritis was 11%. The causative microorganisms were Campylobacter spp. in 338 cases (67.3%), Salmonella spp. in 85 cases (16.9%), enterohemorrhagic Escherichia coli O157 in 23 cases (4.6%), and Yersinia spp. in 45 cases (9.0%). Hospitals with pediatric infectious disease physicians had a lower rate of antimicrobial therapy for Campylobacter enteritis than hospitals without pediatric infectious disease physicians. ConclusionsCampylobacter spp. are the most common causative agent for bacterial enteritis in this study, and the presence of pediatric infectious disease physicians may promote the appropriate use of antimicrobial agents.

1191. Pediatric Long Haul Post COVID-19: Is New Jersey’s Experience Different?

BackgroundCOVID-19 impacted nearly 4 million children, accounting for 14% of total cases in the US, 1.3-3.2% of total reported hospitalizations and less than 1% deaths attributed to COVID-19. Many studies report persistent symptoms in adults several months after acute COVID-19. Similar findings have been reported from a small cohort of children in Italy. To date there are no studies reviewing long haul symptoms in children in the US.MethodsWith the goal of defining long haul in pediatric population, and providing comprehensive care to these patients, RWJBarnabasHealth launched a post-COVID CARE program in October 2020 for children. The program has provided care for approximately 16 patients with COVID related Multisystem Inflammatory Syndrome (MIS-C) and 48 pediatric patients with COVID. The goal of the Pediatric Post-COVID CARE program was to provide a multidisciplinary approach for children ages 0-21 years impacted with COVID-19. This included patients who experienced ongoing symptoms >4 weeks from initial COVID-19 illness. All children were assessed by a pediatric infectious disease physician and triaged to appropriate subspecialties, all part of the long-haul care team. In addition, physical therapy and psychology support services were provided to facilitate return to normalcy.ResultsTo date, our program has evaluated 64 patients. 28% experienced at least 1 symptom 4 weeks after acute COVID-19. Median age was 14 years and 77.8% were female. The follow-up study was conducted from October 2020 to May 2021. Data was collected 2 weeks, 6 weeks, 3 months, and 6 months post discharge or initial evaluation in clinic. 28% of patients were antibody positive, 55.6% experienced fatigue, 50% experienced shortness of breath or cough, 50% experienced ‘brain fog’,33% chest pain and 44.4% experienced anxiety and/or depression.ConclusionEarly identification of patients and comprehensive protocols may facilitate return to normalcy for children with lingering somatic symptoms worsened by impact of social isolation, economic stresses, lost parental jobs, and food insecurity among many other contributing factors. Further research is needed to determine why children of certain ethnicities are impacted differently.Disclosures All Authors: No reported disclosures

1136. Effect of Weekly Antibiotic Rounds as a Core Strategy of the Antimicrobial Stewardship Program on Antibiotic Utilization in a Terciary-care Neonatal Intensive Care Unit, Medellin, Colombia

BackgroundAntibiotics are among the most prescribed drugs in the neonatal intensive care unit (NICU), but frequently are used inappropriately exposing preterm neonates to additional harm. Antibiotic stewardship programs (ASP) have demonstrated impact on antibiotic use in the hospital setting, but implementation in neonatal units is challenging. We sought to determine the effects of weekly antibiotic rounds on overall antibiotic consumption in the NICU. MethodsSingle-center, retrospective observational study. In November 2014, we implemented weekly antibiotic rounds in a 60-bed tertiary-care NICU, led by a pediatric infectious disease physician. Antibiotic therapy decisions were made in collaboration with neonatologists. Data collected included the proportion of patients receiving antibiotics, irrespective of the indication. Multimodal ASP was implemented hospital-wide in 2015. Antibiotic consumption was measured with days of therapy (DOT). Data on costs and in-hospital mortality were obtained from pharmacy and hospital records. ResultsFrom November 2014 to December 2020, we evaluated 13609 neonates admitted to the NICU during rounds. Of those, 3607 (27%) were receiving at least one antibiotic. Overall, the proportion of patients with antibiotics decreased from 31% to 19% during the study period (p< 0.001). In 2017, an outbreak of neonatal necrotizing enterocolitis (NEC) occurred. Specific countermeasures as well as reinforcement of ASP were implemented. Despite Antibiotic usage by DOT increased in 2017 driven by empiric treatment with piperacillin tazobactam in patients with NEC, overall antibiotic consumption decreased from 254.4 DOT/1000 patient days (PD) to 162.4 DOT/1000 PD (Figure 1). Annual costs from antibiotic prescriptions were US&23,161 in 2015 and decreased to US&12.046 in 2020 saving over US&3,800/year (fig 2a). During the study period, we did not observe an increase in crude in-hospital mortality rate (Figure 2b). Primary Y axis indicates the proportion of patients with at least one antibiotic prescription during rounds. Secondary Y axis indicates antibiotic consumption by days of therapy metrics.Antibiotic prescription costs and NICU mortality rates during study period A. Annual antibiotic prescription costs; B. NICU mortality rateConclusionWeekly antibiotic rounds led to a significant decrease in antibiotic utilization in our NICU. This strategy is relatively simple and low-cost, saves hospital resources and has a large impact on antibiotic use. Hence, its implementation is encouraged as part of successful antimicrobial stewardship programs. Disclosures All Authors: No reported disclosures

1127. Validation of an Adult and Pediatric Beta-Lactam Allergy Risk Stratification Tool

Abstract Background Penicillin allergies are commonly reported, yet more than 95% of these patients can tolerate β-lactams. A comprehensive allergy history is essential when determining which patients can safely receive a β-lactam but is rarely obtained. When available, interpretation of the history is often limited by lack of comfort in determining risk of an allergic reaction. Our antimicrobial stewardship and allergy team created a standardized allergy history questionnaire and risk stratification tool. The purpose of this study was to validate this tool by comparing risk levels assigned by various clinicians to that assigned by an allergist. Methods We prospectively identified 50 adult and 50 pediatric patients hospitalized between July 1, 2020 and March 31, 2021 with an allergy to penicillin, amoxicillin, ampicillin, or cephalexin. Patients with severe non-IgE mediated reactions were excluded. All patients (or caregivers) were interviewed by the same pharmacist using the allergy questionnaire. Clinicians from various subspecialties, including an adult and pediatric allergist, an adult and pediatric infectious diseases (ID) physician, an adult and pediatric hospitalist, and an adult and pediatric ID pharmacist, received anonymized completed questionnaires and the risk stratification tool, but were blinded to other clinicians’ responses. The primary endpoint was overall concordance in risk stratification between non-allergists and allergists. Results Overall concordance was 66% (33/50) in adult and 90% (45/50) in pediatric patients (Table 1). Concordance between individual clinicians and the allergist are shown in Figure 1. In adults, anaphylaxis, difficulty breathing, and angioedema were associated with less severe stratification by non-allergists than allergists. No clinicians stratified any pediatric patient into a lower risk category than the allergist. Table 1. Clinician Agreement with Allergist Figure 1. Risk Stratification Severity Compared to Allergist Conclusion Use of a β-lactam allergy risk stratification tool led to agreement with allergist assessment in the majority of patients. Variation in risk assignment was greater in adult patients; however, non-allergist pediatric providers assigned all patients at the same or more severe level as the allergist, indicating safety in this population. Disclosures All Authors: No reported disclosures

477. Increased Referrals for New PFAPA (Aphthous Stomatitis, Pharyngitis, Adenitis) Diagnosis During the COVID-19 Pandemic

BackgroundCOVID-19 pandemic caused by SARS-CoV-2 resulted in a global health crisis in 2020. Quarantining, wearing masks and physical distancing- key infection prevention strategies implemented to stop the spread of COVID-19, also led to dramatic decreases in rates of common respiratory viral infection seen in young children. Due to lack of school and daycare exposure, we evaluated a larger than usual number of patients with periodic fevers without any known infectious contacts. Based on this observation, we conducted an analysis of all suspected cases of periodic fevers seen at our institution during the COVID-19 lockdown compared to prior seasons.MethodsThe clinical charts were queried for all patients presenting to any Lurie Children’s Hospital outpatient specialty clinic or laboratory with ICD diagnosis code of MO4.1 and MO4.8 (all recurrent and periodic fever syndromes) from June 1, 2020 through September 30, 2020, and compared to similar months the previous 2 years (2018 and 2019). Each patient chart was reviewed by the lead investigator to verify all new diagnoses of PFAPA. The number of new patients with PFAPA diagnosis were tallied and analyzed. Statistical comparisons were made using Kruskal-Wallis tests for monthly distributions in different years. ResultsWe noted a significant increase in patients with new PFAPA diagnosis between June through August 2020 compared to similar months in 2018 and 2019 (Figure1). Experienced pediatric infectious disease physicians and rheumatologists diagnosed majority of the cases. During these months, a monthly median (IQR) of 13 (11.5, 14.5) patients were diagnosed among different Lurie specialty clinics, which is more than 2.5 folds increase in new PFAPA patients from the previous two years which were about 5 (3.5, 6) (Figure 2).Number of Patients with New PFAPA Diagnosis There was a significant increase in number of new patients diagnosed with PFAPA between June through August 2020 compared to similar months in 2018 and 2019.Monthly Distribution Summary for New PFAPA Diagnosis Statistical comparisons were made using Kruskal- Wallis tests for monthly distributions in different yearsConclusionWe observed a significant increase in PFAPA patients referred to our institution soon after introduction of public health measures to slow spread of COVID-19. Given that most children were not in daycare, schools, or camps, we suspect that parents and pediatricians were able to recognize patterns of periodic fevers in children much quicker than preceding years, when fevers would typically be attributed to an infectious process. Disclosures Ravi Jhaveri, MD, AstraZeneca (Consultant)Dynavax (Consultant)Elsevier (Other Financial or Material Support, Editorial Stipend as Co-editor in Chief, Clinical Therapeutics)Seqirus (Consultant)

109. Develop and Implement a Novel Pediatric Antimicrobial Stewardship Program in a Non-Freestanding Children’s Hospital Located in an Adult-Centered Community Hospital in San Joaquin Valley, California

BackgroundA pediatric-specific antimicrobial stewardship program (Ped ASP) has been shown to optimize antimicrobial use, improve patient outcomes, and reduce healthcare expenditures in this population. Opportunities and challenges exist when developing a Ped ASP for a children’s hospital within an adult-centered medical center primarily due to mixed infrastructure. The objective of this study is to provide process and outcome data of a new Ped ASP in a non-freestanding children’s hospital within an adult-centered tertiary hospital.MethodsA pediatric infectious disease physician and four pediatric pharmacists designed a Ped ASP utilizing direct and indirect patient care activities to optimize pediatric antimicrobial use in 21 bed-pediatric services within a 685-bed, adult-centered medical center. Implemented in 2020, Ped ASP activities include thrice weekly chart reviews followed by handshake rounds and quarterly reviews of documented interventions. The Ped ASP team also developed policies, education, and other resources to further guide appropriate antimicrobial use, in collaboration with the adult team.ResultsPed ASP was initiated on general pediatric (PED) and pediatric intensive care (PICU) units. In 2020, a total of 286 charts were reviewed with 199 antibiotic interventions provided, including optimization of antimicrobial selection (23%), IV-to-PO conversion (15%), and antimicrobial dosage adjustment (13%). Annual average antibiotic length and days of therapy per 1000 patient-days were 241 and 290 respectively in PED, and 388 and 432 in PICU. The overall trend from 2020 to 2021 decreased in PED but increased in PICU (Fig. 1). The ratio of narrow to broad spectrum antibiotic use increased for both PED and PICU (Fig. 2). Simultaneously, a pediatric-specific antibiogram, extended-infusion protocol of beta-lactams, and neonatal sepsis treatment algorithm were developed and implemented. Antibiotic Days of Therapy per 1000 Patient Days Ratio of Narrow: Broad Spectrum Antibiotic UsageConclusionA Ped ASP was successfully developed in a non-freestanding children’s hospital. Continual metrics served as an important tool to identify areas for improvement. Future goals include expansion of Ped ASP to other service lines, enhanced ASP education and development of additional pediatric antimicrobial treatment pathways.Disclosures All Authors: No reported disclosures

American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID-19 Pandemic: Version 2.

To provide clinical guidance to rheumatology providers who treat children with pediatric rheumatic disease (PRD) in the context of the coronavirus disease 2019 (COVID-19) pandemic. The task force, consisting of 7 pediatric rheumatologists, 2 pediatric infectious disease physicians, 1 adult rheumatologist, and 1 pediatric nurse practitioner, was convened on May 21, 2020. Clinical questions and subsequent guidance statements were drafted based on a review of the queries posed by the patients as well as the families and healthcare providers of children with PRD. An evidence report was generated and disseminated to task force members to assist with 3 rounds of asynchronous, anonymous voting by email using a modified Delphi approach. Voting was completed using a 9-point numeric scoring system with predefined levels of agreement (categorized as disagreement, uncertainty, or agreement, with median scores of 1-3, 4-6, and 7-9, respectively) and consensus (categorized as low, moderate, or high). To be approved as a guidance statement, median vote ratings were required to fall into the highest tertile for agreement, with either moderate or high levels of consensus. To date, 39 guidance statements have been approved by the task force. Those with similar recommendations were combined to form a total of 33 final guidance statements, all of which received median vote ratings within the highest tertile of agreement and were associated with either moderate consensus (n=5) or high consensus (n=28). These guidance statements have been generated based on review of the available literature, indicating that children with PRD do not appear to be at increased risk for susceptibility to SARS-CoV-2 infection. This guidance is presented as a "living document," recognizing that the literature on COVID-19 is rapidly evolving, with future updates anticipated.

#97: Rapid, Noninvasive Detection of Kingella kingae Pediatric Vertebral Infections Using a Microbial Cell-free DNA Sequencing Test for Pathogen Identification

Abstract Background Kingella kingae is a recognized cause of bone and joint infections (BJI) in infants. The diagnosis of Kingella kingae BJI can be challenging due to its fastidious growth with conventional culturing methods even when infected tissue is obtained. Kingella kingae spinal infections are likely an underdiagnosed entity given the limitations of culture-based methods and the reluctance to biopsy spinal locations of infection (in favor of empiric treatment). This approach often necessitates MRSA coverage. A sensitive, rapid, noninvasive diagnostic approach to pediatric vertebral infections would enable targeted therapy. Detection of circulating microbial cell-free DNA (mcfDNA) in the plasma originating from areas of sequestered infection through next-generation sequencing (NGS) has shown utility in pediatric pneumonia (Farnaes et al. DMID 2019) and a wide variety of infections in the immunocompromised host (Rossoff et al. OFID 2019) and potentially offers promise in resolving the etiology of pediatric vertebral infections. Methods The Karius test is a CLIA-certified/CAP-accredited NGS plasma test that detects circulating mcfDNA in the blood. After mcfDNA is extracted and NGS performed, human sequences are removed and remaining sequences are aligned to a curated pathogen database of &amp;gt;1400 organisms. Organisms present above a statistical threshold are reported and quantified. The time to result reporting is on average 24 hours from sample receipt. Karius Test results over the prior 2 years were reviewed for detections of Kingella kingae in the context of spinal infections. Clinical chart review was performed by the treating pediatric infectious diseases physicians at each participating institution after IRB notification and approval. Results Six cases of Kingella kingae pediatric vertebral infections were identified across five institutions; clinical data were available for five cases across four institutions (see Table). Four cases were male; the average age was 15.3 months. Four of five cases had an antecedent URI. The clinical presentations were characterized by decreased mobility and relatively bland inflammatory response (lack of fever, bland inflammatory markers). The lumbar region was the most commonly affected vertebral location (80%). Blood cultures were negative in all cases; empiric anti-MRSA therapy was initiated in all cases. The time to result of Kingella kingae mcfDNA detection in the plasma was one day from sample receipt in all cases. McfDNA from co-pathogens were detected in 66.7% of cases (Haemophilus influenzae was the most common). The detection of Kingella kingae by the Karius test influenced a decision to narrow coverage in 80% of cases and a decision to forego biopsy in 60% of cases. Conclusion Plasma NGS for circulating mcfDNA offers a rapid, noninvasive means of detecting Kingella kingae pediatric vertebral infection. This culture-independent approach may enable specific diagnosis despite antibiotic pretreatment and obviate the need for an invasive procedure. Accurate identification of Kingella kingae has important implications on antibiotic stewardship enabling targeted therapy without the reliance on empiric MRSA coverage. Given the capacity to detect over 1400 organisms from a single sample NGS for mcfDNA offers a means to detect a broad variety of pathogens known to have predilection to cause pediatric spine infection.

A cluster randomized stepped-wedge trial to de-implement unnecessary post-operative antibiotics in children: the optimizing perioperative antibiotic in children (OPerAtiC) trial

BackgroundAntibiotic-resistant infections have become a public health crisis that is driven by the inappropriate use of antibiotics. In the USA, antibiotic stewardship programs (ASP) have been established and are required by regulatory agencies to help combat the problem of antibiotic resistance. Post-operative antibiotic use in surgical cases deemed low-risk for infection is an area with significant overuse of antibiotics in children. Consensus among leading public health organizations has led to guidelines eliminating post-operative antibiotics in low-risk surgeries. However, the best strategies to de-implement these inappropriate antibiotics in this setting are unknown.Methods/designA 3-year stepped wedge cluster randomized trial will be conducted at nine US Children’s Hospitals to assess the impact of two de-implementation strategies, order set change and facilitation training, on inappropriate post-operative antibiotic prescribing in low risk (i.e., clean and clean-contaminated) surgical cases. The facilitation training will amplify order set changes and will involve a 2-day workshop with antibiotic stewardship teams. This training will be led by an implementation scientist expert (VRM) and a pediatric infectious diseases physician with antibiotic stewardship expertise (JGN). The primary clinical outcome will be the percentage of surgical cases receiving unnecessary post-operative antibiotics. Secondary clinical outcomes will include the rate of surgical site infections and the rate of Clostridioides difficile infections, a common negative consequence of antibiotic use. Monthly semi-structured interviews at each hospital will assess the implementation process of the two strategies. The primary implementation outcome is penetration, which will be defined as the number of order sets changed or developed by each hospital during the study. Additional implementation outcomes will include the ASP team members’ assessment of the acceptability, appropriateness, and feasibility of each strategy while they are being implemented.DiscussionThis study will provide important information on the impact of two potential strategies to de-implement unnecessary post-operative antibiotic use in children while assessing important clinical outcomes. As more unnecessary medical practices are identified, de-implementation strategies, including facilitation, need to be rigorously evaluated. Along with this study, other rigorously designed studies evaluating additional strategies are needed to further advance the burgeoning field of de-implementation.Trial registrationNCT04366440. Registered April 28, 2020, https://clinicaltrials.gov/ct2/show/NCT04366440.

P0567 / #2026: CENTRAL LINE DRESSING QUALITY IMPROVEMENT INITIATIVES REDUCE CLABSI RATE IN THE PICU

Aims & Objectives: The purpose of this project was to reduce the incidence of CLABSIs in a 24-bed Pediatric ICU. Our goal was to decrease from a count of 6 and standardized infection ratio (SIR) 1.3 in fiscal year (FY) 2019, to count to ≤ 4 and SIR to ≤ 0.5 in FY 2020. Methods: Our quality improvement project was devised by a nurse-driven, multidisciplinary HAI prevention committee consisting of PICU bedside nurses, a clinical nurse specialist, nurse manager, infection prevention nurse specialist, pediatric critical care and infectious disease physicians. This group conducted a root cause analysis (RCA) of our unit’s CLABSIs from 2017 to 2019. The RCA data identified central line dressing maintenance as an area for potential improvement. The committee subsequently reviewed the literature on evidence-based CLABSI prevention practices related to central line dressings and inquired about practices used at similar-acuity PICUs. Based on our findings, we devised 3 quality improvement interventions to reduce CLABSIs in the PICU: 1) initiation of daily central line dressing audits of every central line in our unit, 2) standardization of dressing supplies and 3) designation of specially-trained nurses to maintain all central line dressings. Results: The primary outcome was a reduction in CLABSI count and SIR in the post-intervention period compared to pre-intervention. For FY 2019, our PICU CLABSI count was 6 and SIR was 1.3. For FY 2020, the CLABSI count and SIR decreased to 2 (67%) and 0.458 (65%) respectively. Conclusions: CLABSI reduction occurs with the implementation of quality improvement interventions focused on central line dressings.

355. Variability in the Current Evaluation and Management of Pediatric Encephalitis: Survey Results from an Emerging Infections Network Survey

BackgroundChildhood encephalitis causes severe morbidity and mortality. Difficulty identifying causative organisms and a lack of effective therapies leads to variability in management. The recent emergence of novel diagnostic tools and the increased recognition of auto-immune encephalitides has the potential to change the approach to this disease. Our objective was to assess the current evaluation and management of childhood encephalitis.MethodsAn 11-question confidential, web-based survey was distributed by the Emerging Infections Network (EIN) of the Infectious Disease Society of America to 370 Pediatric Infectious Disease (ID) physicians between January 29th and February 17th, 2020. Respondents were characterized by practice region, experience since fellowship, place of employment and primary hospital type. Responses were analyzed with SAS, v 9.4.ResultsResponses were obtained from 222 of 370 members (60%) (Table). Of the 222 respondents, 196 (88%) reported caring for children with suspected encephalitis and form the basis for this report. Multi-plex PCR testing of cerebrospinal fluid (CSF) in the initial evaluation of most children with suspected encephalitis was reported by 56% (with 65% of these respondents reporting the use of pathogen-specific confirmatory testing). CSF metagenomic next generation sequencing (mNGS) had been used by 47%, with 74% of all respondents stating they would use this test if likely diagnoses were excluded via standard testing (and 64% of these only using the test if the child was not improving). Variability in the interpretation of negative CSF mNGS results was reported (Fig 1a). Primary involvement of ID physicians in the diagnostic evaluation of auto-immune encephalitis was reported by 33%, yet only 55% of ID physicians reported feeling comfortable diagnosing this condition. Marked variation existed regarding criteria for the use of immunomodulating agents (Fig 1b) and the need for testing for autochthonous tropical viruses in the U.S. (Fig 1c). Background of 222 Respondents to an Emerging Infections Network Survey Assessing the Evaluation and Management of Pediatric Encephalitis. ID=Infectious Disease; VA=Veterans Affairs; DOD=Department of Defense *Respondents were significantly more likely than non-respondents to have <5 years of ID experience (p=0.04).Figure 1 Approaches to the Interpretation of CSF mNGS Results, Use of Immunomodulating Agents and Testing for Autochthonous Tropical Viral Pathogens in Children with Encephalitis ConclusionVariation exists in the evaluation and management of childhood encephalitis, including the application of new diagnostic modalities and management of autoimmune encephalitides. Updated standardized management guidelines may improve implementation of advances in this realm.Disclosures All Authors: No reported disclosures

Variability in the Use of Novel Diagnostic Technology in Children With Suspected Encephalitis and in the Management of Emerging Encephalitides by Pediatric Infectious Disease Providers.

We surveyed pediatric infectious disease physicians through the Infectious Disease Society of America's Emerging Infections Network regarding the diagnosis and management of encephalitis. We identified practice variations, particularly with the use of new diagnostic modalities and management of autoimmune encephalitides. These findings may inform the creation of updated management guidelines.