Pediatric Infectious Diseases Research Articles

Consensus document of the Spanish Society of Paediatric Infectious Diseases and the Advisory Committee on Vaccines of the Spanish Association of Pediatrics for vaccination of immunosuppressed individuals

The number of people with immunosuppression is increasing considerably due to their greater survival and the use of new immunosuppressive treatments for various chronic diseases. This is a heterogeneous group of patients in whom vaccination as a preventive measure is one of the basic pillars of their wellbeing, given their increased risk of contracting infections. This consensus, developed jointly by the Sociedad Española de Infectología Pediátrica (Spanish Society of Pediatric Infectious Diseases) and the Advisory Committee on Vaccines of the Asociación Española de Pediatría (Spanish Association of Paediatrics), provides guidelines for the development of a personalised vaccination schedule for patients in special situations, including general recommendations and specific recommendations for vaccination of bone marrow and solid organ transplant recipients, children with inborn errors of immunity, oncologic patients, patients with chronic or systemic diseases and immunosuppressed travellers.

Are the first 1,000 days of life a neglected vital period to prevent the impact on maternal and infant morbimortality of infectious diseases in Latin America? Proceedings of a workshop of experts from the Latin American Pediatric Infectious Diseases Society, SLIPE

While the first 1,000 days of life are a critical period in child's development, limited information on the main determinants affecting this period in the Latin America and the Caribbean (LAC) region is available. Therefore, the Latin American Pediatric Infectious Diseases Society (SLIPE) held an ad hoc workshop in May 2022 with an expert panel designed to analyze the main factors impacting the development of childhood in the region during this period and the main causes of maternal infant morbimortality. The aim was to identify priorities, generate recommendations, and advise practical actions to improve this situation. Considerations were made about the challenges involved in bridging the gap that separates the region from more developed countries regarding an optimal early childhood and maternal care. Extensive discussion was conducted to reach consensus recommendations on general strategies intended to reduce maternal and infant mortality associated with infections and immune-preventable diseases during the first 1,000 days of life in LAC.

National survey in Switzerland calls for improved diagnosis and treatment in children with scabies.

The global prevalence of scabies is estimated to be up to 200 million cases annually, with young children particularly affected. In Europe, most cases are thought to originate in migrant populations. Scabies management is challenging in children. To identify knowledge gaps and research needs, we aimed to descriptively evaluate the management of children with scabies by different Swiss healthcare providers. An invitation for an anonymous online survey (36 questions) was sent to members of Swiss societies of dermatologists, general practitioners, paediatricians, paediatric dermatologists, paediatric infectious diseases specialists, and tropical medicine specialists, inviting clinicians to participate from 25thMay to 8thAugust 2020. One reminder invitation was sent. Hospital pharmacies and the distributor of permethrin were contacted to report consumption trends of scabicides in 2018 and 2019. The survey was completed by 248 clinicians: 146 (59%) paediatricians, 47 (19%) dermatologists, 28 (11%) general practitioners, 6 (2%) paediatric dermatologists, 13 (5%) paediatric infectious diseases specialists, and 8 (3%) tropical medicine specialists. Most consulted up to 10 scabies cases within a 16-month period, with similar numbers in migrant and Swiss children. Dermoscopy was used by 24% of non-dermatologists. Non-dermatologists did not consider co-treatment of close contacts in up to 59% of cases. While permethrin was the first-line treatment, treatment failures were frequently reported in children aged <5 years. Up to 67% of paediatric dermatologists regularly used oral ivermectin off-label in children weighing <15 kg. None of the paediatric dermatologists, 15% of the dermatologists, and 9% of the non-dermatologists used only one treatment cycle.Scabicide consumption increased. Treatment studies on ivermectin use in children weighing <15 kg had the highest research priority. In Switzerland, scabies is a frequent dermatosis in migrant and Swiss children. While accessible, optimal diagnostics are underutilised, and treatment is suboptimal. Permethrin resistance appears to be an increasing problem. Dermatologists regularly use ivermectin off-label in children weighing <15 kg. Treatment studies on ivermectin use in children weighing <15 kg, user-friendly diagnostic tools, new treatment protocols, and child-friendly dosage forms are needed to improve the diagnosis and treatment of children with scabies.

Documento de consenso de la Sociedad Española de Infectología Pediátrica y el Comité Asesor de Vacunas de la Asociación Española de Pediatría para la vacunación en inmunodeprimidos

The number of people with immunosuppression is increasing considerably due to their greater survival and the use of new immunosuppressive treatments for various chronic diseases. This is a heterogeneous group of patients in whom vaccination as a preventive measure is one of the basic pillars of their wellbeing, given their increased risk of contracting infections. This consensus, developed jointly by the Sociedad Española de Infectología Pediátrica (Spanish Society of Pediatric Infectious Diseases) and the Advisory Committee on Vaccines of the Asociación Española de Pediatría (Spanish Association of Paediatrics), provides guidelines for the development of a personalised vaccination schedule for patients in special situations, including general recommendations and specific recommendations for vaccination of bone marrow and solid organ transplant recipients, children with inborn errors of immunity, oncologic patients, patients with chronic or systemic diseases and immunosuppressed travellers.

885. Promoting Diversity, Equity and Inclusion with a quarterly virtual Grand Rounds for the Pediatric Infectious Diseases Society

Abstract Background The Inclusion, Diversity, Access and Equity (IDA&amp;E) Taskforce was created by the Pediatric Infectious Diseases Society (PIDS) in 2020. A 2021 survey of the PIDS membership to assess perceptions of diversity, equity and inclusion (DEI) revealed several areas of concern: perceptions of bias against and lack of support for international medical graduates (IMGs); lack of diversity in PIDS leadership; and perceived exclusivity in PIDS social and networking events. There is evidence that implicit bias can be alleviated by education that both increases awareness and provides bias reduction strategies. The Taskforce introduced a quarterly virtual Grand Rounds for the PIDS membership to provide DEI education. This abstract describes the first year of this initiative. Methods A proposal for a quarterly IDA&amp;E Grand Rounds was approved by the PIDS Executive Committee in February 2022. A member of the IDA&amp;E Taskforce assumed the role of course director. Four webinars were held in March, June, and September 2022, and January 2023. The topics addressed were under-representation in Pediatric Infectious Diseases, career challenges faced by IMGs, leadership development, and career pathways within Pediatric Infectious Diseases. A feedback survey link was provided to attendees of each Grand Rounds. Results The four Grand Rounds had an average of 172 registrants (range 130-204). Feedback survey completion was low (average 8 per webinar, range 4-18). Survey respondents reported affirmation of personal experiences; increased awareness of the topic discussed; and desire for more content related to career pathways, and IMG and visa-related concerns. Respondents commented on low attendance by division heads and fellowship program directors and recommended promotion of Grand Rounds attendance among persons in leadership positions. Conclusion Specialty-specific DEI education can be provided at the national level by a medical society through periodic webinars. The hour-long virtual format is limited in ability to address topics in-depth and should be the bare minimum of the work needed by institutions, training programs, and individual practitioners to support workforce diversity in Pediatric Infectious Diseases. Disclosures Tanya Rogo, MD, AstraZeneca: Grant/Research Support|Pfizer: Advisor/Consultant|Pfizer: Grant/Research Support

2323. Pediatric Infectious Diseases Outpatient Telehealth Services During the COVID-19 Pandemic: Single Center Experience

Abstract Background Telehealth (TH) offers valuable opportunities to improve healthcare delivery that may translate to better health outcomes. Utilization of TH by pediatric subspecialty programs has been successful in inpatient settings. Limited data is available on its applicability to outpatient Pediatric Infectious Diseases during the pandemic. We aim to assess the differences between in person vs TH services in a pediatric infectious disease practice. Methods This retrospective cohort study included patients aged 0 to 21 evaluated in a pediatric infectious disease clinic from 1/1/2019 – 12/31/2022 across 5 locations in Southwest Florida. Data was collected for new or established unduplicated patients seen in consultation for an acute, subacute, or chronic pediatric infectious disease condition. All encounters were characterized by in-person or TH modality. Clinic encounters related to research were excluded. Results Altogether, 2,207 patients made 6,905 appointments. Of those appointments, 1,034 (15%) were TH visits, and 5,871 (85%) were in-person visits. New patient TH visits represented 17% vs 22% for in-person. There was a significant difference between the TH and in-person groups in mean age (10 years in TH vs 11 years in-person, p-value=0.01), race (Black 29% in TH vs 42% in-person, p&amp;lt; 0.001), ethnicity (Hispanic/Latino 34% in TH vs 23% in-person, p&amp;lt; 0.001), and type of insurance (Commercial 29% in TH vs 24% in-person, p&amp;lt; 0.001). There was no significant difference in gender (Female 49% in TH vs 47% in-person, p=0.217). The most frequent diagnoses are described in Figure 1. Physicians provided 77% of the TH visits vs 44% for the in-person visits. Cancellation/no-show rate was significantly lower for TH vs in-person visits (21% vs 27% respectively, p&amp;lt; 0.001). Mean traveled distance for in-person visits was 21 miles vs 30 miles avoided for TH encounters. Conclusion TH offered a valuable option for pediatric infectious diseases patients during the COVID-19 pandemic. Availability of mobile connectivity, distance to appointment, and type of diagnosis may play a role in the selection of the appointment modality. TH holds promise for improving access to pediatric subspecialty services, allowing patient convenience and potential better health outcomes while delivering comparable care. Disclosures Claudia M. Espinosa, MD, MSc, AstraZeneca: Grant/Research Support|Enanta: Grant/Research Support|Jansen and Jansen: Advisor/Consultant|Kentucky Rural Health Association: Honoraria|Merck: Grant/Research Support|Sanofi: Advisor/Consultant|Sanofi: Grant/Research Support|Sanofi: Honoraria|Sobi: Dinner Amol Purandare, MD, Caribou: Stocks/Bonds|Intellia: Stocks/Bonds|Merck: Grant/Research Support|Moderna: Grant/Research Support|Pfizer: Grant/Research Support Carina A. Rodriguez, MD, Gilead: Grant/Research Support|Moderna: Grant/Research Support|Novavax: Grant/Research Support

Impact of preoperative bloodstream infection on outcomes of pediatric liver transplant recipients treated for acute liver failure.

Acute liver failure (ALF) is a component of multisystem organ failure that causes severe liver dysfunction in patients without underlying chronic liver disease. The patients with ALF are prone to have infections, including bacteremia. However, studies of the infectious impact for post liver transplantation (LT) in pediatric ALF are limited. We aimed to evaluate our current practice for pediatric LT cases of ALF with preoperative bacteremia. The records of all patients under 18 years old undergoing LT for ALF in our center from November 2005 to December 2021 were collected. They were divided into two groups: those with a preoperative bloodstream infection (BSI) and those without (NBSI). We compared the preoperative status and also reviewed the details of the BSI group. Intraoperative course and postoperative outcomes were also compared. There were 19 BSI patients and 66 NBSI patients. One BSI case was detected on the day of LT. This patient had no changes in vital signs and general condition. After evaluation and therapeutic intervention by pediatric infectious disease specialists, LT was performed on the same day. Five cases developed septic shock at the time of detection of BSI. All BSI patients were in stable condition on the operation day with proper interventions. There were no significant differences in mortality and hospital stay between both groups. LT might be able to be performed for pediatric ALF even with positive blood cultures. In addition, appropriate therapeutic intervention by specialists and patient's stable condition before LT are essential.

Viral Load Pattern of HIV Positive Children and Adolescents Attending a Paediatric Infectious Diseases Clinic in Owerri, Nigeria

Background: The Viral load (VL) test measures the number of copies of HIV RNA in one milliliter of blood and is the preferred antiretroviral therapy (ART) monitoring strategy. Viral suppression is defined as patients having ≤ 1000 copies of viral RNA/ml of blood.&#x0D; Methods/Materials: This study involved the retrospective review of viral load test result of patients aged 2-19years living with HIV/AIDS and enrolled in the treatment programme of the Paediatric infectious diseases clinic of the Federal University Teaching hospital Owerri.&#x0D; Results: 117 patients met the inclusion criteria and 103 were virally suppressed giving a suppression rate of 88%. Majority of those virally suppressed were in the 15-19 age group. A logistic regression analysis to ascertain the impact of age, gender, drug regimen, and duration on ARTs on the likelihood of viral suppression showed that age, gender, and drug regimen were not significant predictors of viral suppression (p &gt; 0.05). However, duration on ARTs was a significant predictor (p &lt; 0.01), with patients who had been on ARTs for greater than 24 months having higher odds of viral suppression (OR = 5.42, 95% CI = 1.84-15.93) compared to those who had been on ARTs for 0-6 months.&#x0D; Conclusion: Our study provides important insights into the viral load pattern of children and adolescents living with HIV/AIDS in Owerri. It highlights the importance of early initiation of ART, adherence to ART regimen, and routine viral load monitoring to achieve and maintain viral suppression.

Clinical Implementation and Value of Plasma Metagenomic Sequencing in Immunocompromised Pediatric Patients

Abstract Background Metagenomic next-generation sequencing (mNGS) of cell-free DNA from plasma is emerging as a promising diagnostic tool in immunocompromised hosts but its performance characteristics in specific patient populations and clinical syndromes have not been systematically compared. Here, we describe the implementation and clinically utility of plasma mNGS in a large cohort of pediatric patients who are immunocompromised. Methods We performed retrospective review of all plasma mNGS testing (Karius®) performed at University of Minnesota between December 2017 – December 2022. Study design was reviewed by UMN IRB and determined to be nonhuman subjects research. For this study, we performed a nested subgroup secondary analysis of all patients aged &amp;lt;18 years at time of mNGS test who had underlying conditions that included hematologic malignancy, solid organ malignancy, hematopoietic stem cell transplantation or solid organ transplantations. Electronic medical records were reviewed for each mNGS test, recording patient demographics, underlying conditions, indications, and conventional microbiological results within 30 days of mNGS. The primary endpoint was change in clinical management as defined by Hogan et al and adjudicated by 2 independent reviewers. Secondary end points included sensitivity, time to mNGS order and time to diagnosis. Results We identified 71 unique pediatric patients with an immune compromised state who had 104 plasma mNGS tests performed between them. Fever was the most common indication for plasma mNGS (66%, 69/104), followed by Pulmonary Syndrome/Infiltrate/Lesion (23%, 22/104). The median time to plasma mNGS ordering from symptom onset was 8 days (IQR 3-17). Pediatric Infectious Diseases was consulted 70% (73/104) of the time. In cases where a microbiological cause(s) were identified, plasma mNGS identified the organism 48% of the time compared to 74% in conventional testing. Plasma mNGS led to a change in clinical management in 14 cases (13%,14/104) ordered in 13 unique patients. In 8 cases this led to a new diagnosis not confirmed by conventional microbiological testing or an earlier diagnosis, later confirmed by conventional testing. The new or earlier diagnoses cases included detection of invasive fungal/mold infections, anaerobic infections, and parasitic infections and were ordered on average within 2 days of symptom onset. Negative or DNA virus results on the plasma mNGS led to de-escalation of antimicrobials in 28% (4/13) of the positive impact cases. Conclusions Here, we describe the implementation of plasma mNGS in large immunocompromised pediatric cohort. Plasma mNGS led to a change in clinical management in a minority of cases (13%). However, these cases demonstrate that when ordered early in the clinical syndromes, plasma mNGS testing can detect difficult to diagnose organisms and promote antimicrobial stewardship. More prospective studies with early implementation of plasma mNGS in immunocompromised pediatric patients will be informative of the clinical value of this powerful diagnostic tool.

Pediatric Outpatient Parenteral Antimicrobial Therapy (OPAT): Experience of Families During Implementation of the Program

Abstract Background Experience with ambulatory intravenous antimicrobial therapy in pediatrics is reported since 1973. This modality avoids hospitalization or helps for early discharge in a patient who, in addition to antibiotics, has no other criteria to remain hospitalized. Even though it reduces the risks and costs that hospitalization entails and allows the patient to remain inserted in his family its use is not widespread in Latin America. We report the experience of families during the implementation of outpatient parenteral antibiotic therapy (OPAT) in pediatric oncologic patients at Solca Guayaquil. Methods A pilot program for outpatient parenteral antibiotic therapy (OPAT) was started in March 2022. We included patients with a permanent central venous access (port-a-cath) who were otherwise clinical stable (afebrile &amp;gt; 48h, increasing absolute neutrophil count (&amp;gt;500 in hematologic malignancies, &amp;gt;100 in solid tumors), no transfusion requirement) and completed a social questionnaire described previously (SUAU C, Thelma et al) with a score &amp;gt; 9. Patients had follow up with pediatric infectious diseases once a week during therapy and received a certificate of completion on their last day with a QR code to complete an anonymous online survey regarding their experience with the program. Results From March to November 2022 there were 6 patients enrolled. Their mean age 9.6 years, 3 (50%) were male and mean duration of therapy 7.7 days. Response rate was 100%. Ronald Mc. Donald's house hosted 5 (83%) patients while 1 (17%) was staying at home. There was 1 (16.7%) readmission 72h after completion of the program. No disfunction of catheter, secondary infection or deaths were reported. Return to regular activities was possible for 4 (67%) of patients. The experience was considered excellent, good or average in 3(50%), 2(33%) and 1(17%) cases. Quality of care during OPAT was perceived as exceeding expectations, meeting expectations and no opinion in 2(33%), 3(50%), and 1(17%) respectively. Support received by hospital staff was pondered excellent and good in 3 (50%) each. All of the patients agreed that OPAT was better than staying admitted however 1 (17%) declared that would not take this modality again (referred as "stressful"). Conclusion The newly implemented OPAT program was perceived overall as a positive experience for patients and their families, there were no major complications. The feedback provided helped to improve the logistics of the program.

Impact of the Implementation of a Fever and Neutropenia Management Algorithm in the Detection of Microbiologically Confirmed Infections in Mexican Children

Abstract Background Fever and neutropenia is a medical emergency in children with cancer. Microbiological identification of the febrile focus is estimated to occur in 20-30% of cases. Algorithms that implement evaluation and treatment strategies help institutions to standardize the appropriate clinical and microbiological diagnosis and management of these episodes, thus improving the rate of confirmed infections. In this study we aimed to report the impact in the identification rates of microbiologically confirmed infections before and after implementing a management algorithm for children with fever and neutropenia which included obtaining blood and urinary cultures, antibiotic administration in the first hour upon arrival, and the evaluation of patients by a pediatric infectious diseases team. Methods We performed an ambispective cohort study including children aged 1 to 16 years, with ≥1 episodes of fever and neutropenia admitted to Hospital Universitario “Dr. José Eleuterio González” to assess changes in microbiological identification before and after the implementation of a management algorithm. Demographic and clinical data of episodes from February 1st, 2017 to December 31st, 2021 were gathered information from clinical records. Qualitative variables were expressed in frequency and percentages, quantitative variables in mean and standard deviation or median and interquartile range. Results A total of 343 episodes were recorded, 122 (35.6%) pre-algorithm, and 221(64.4%) post-algorithm. Microbiologically confirmed infection occurred in 18 (14.7%) episodes pre-algorithm vs 79 (35.7%) post-algorithm. The most frequently microbiologically confirmed infection pre-algorithm was bacteremia (n=10, 8.2%), and viral respiratory tract infections (n=36, 16.3%) in the post-algorithm group. Of those children with bacteremia in the pre-algorithm group, 50% (n=13) were Gram-positive bacteria, and Coagulase-negative Staphylococci were the most prevalent (n=4, 40%). Bacteremia in the post-algorithm group was reported in 23 (10.4%) episodes, of which 56.3% (n=13) were Gram-negative bacteria, and Escherichia coli was the most prevalent (n=5, 21.7%). Respiratory viral infections were reported in 1 (0.8%) in the pre-algorithm vs 36 (16.3%) in post-algorithm group. Influenza viruses accounted for most respiratory infections in the post-algorithm group 33.3% (n=12), and co-infection with 2 or more viruses was reported in 8 (22.2%) isolations. Conclusions The implementation of a fever and neutropenia management algorithm increased the rate of microbiologically confirmed infections in children, also increasing the rate of detection of clinically confirmed infections other than bacteremia, such as urinary, respiratory, and invasive fungal infections. Viral respiratory infections accounted for most of post-algorithm episodes, and its detection was greatly improved by the introduction of the management algorithm. TABLE 1. RATES OF MICROBIOLOGICALLY CONFIRMED INFECTIONS PRE AND POST-ALGORITHM

Socioeconomic circumstances, health-related behaviours and paediatric infections: a mediation analysis

ObjectiveTo examine how the effect of disadvantaged socioeconomic circumstances on the risk of paediatric infections is mediated by pregnancy smoking, excess weight during pregnancy and breast feeding in children under...

World Society for Pediatric Infectious Diseases calls for action to ensure fair prices for vaccines

World Society for Pediatric Infectious Diseases calls for action to ensure fair prices for vaccines

High burden of acute respiratory tract infections leading to hospitalization at German pediatric hospitals: fall/winter 2022-2023.

Given reduced immunity levels for seasonally occurring respiratory infections and the experience of an unusually early, severe wave of RSV infections during 2021, a preexisting clinician-led reporting system (CLRS) was updated to prospectively monitor the anticipated high burden of respiratory infections (ARI) in German pediatric hospitals during fall/winter 2022-2023. From September 13, 2022 through March 31, 2023, children hospitalized with ARI as a primary diagnosis were monitored via a national CLRS established by the German Society for Pediatric Infectious Diseases (DGPI). Once a week, the CLRS collected overall number of new hospital admissions, ARI-related admissions according to pathogen (SARS-CoV-2, RSV, influenza, and other), plus number of patients admitted to ICU with ARI as a primary diagnosis. With a high participation among children's hospitals across Germany (22.8%), 76 centers submitted 1,053 survey reports. ARI-related hospital admissions showed a steep rise starting in late September 2022 and reached their highpoint in early December 2022 (50.1% of all admissions). In parallel, the average number of newly admitted patients (aNA) with RSV (3.6) peaked, as did those with influenza (2.1) one week later. The average highpoint of ARI patients on ICU (aICU) (2.9) was reached shortly thereafter. Again, RSV (1.6) und influenza (1.2) were predominant pathogens. In fall/winter 2022-2023, German hospitals reported a sharp increase in patients with ARIs. While RSV and influenza represented the greatest proportion of ARI, SARS-CoV-2 played a less significant role. Systematic, dynamic collection of ARI data is critical for assessing real burdens on the health care system.

Long-term outcomes of an educational paediatric antimicrobial stewardship programme: a quality improvement study

Background and objectivesAntimicrobial stewardship programmes (ASPs) have resulted in antimicrobial consumption (AMC) reduction and quality of prescription (QOP) improvement. However, evidence of ASP impact in paediatrics is still limited. This...

Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics.

This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.

Exploring the Integration of Case-Based Learning (CBL) with a Flipped Classroom Approach in Teaching Leadership in Pediatric Infectious Diseases

Purpose: This study aims to investigate the potential benefits of combining case-based learning (CBL) with a flipped classroom approach in the context of education in the infection ward. Methods: The study involved the selection of 50 intern students from hospital infection wards between January 2021 and December 2022. A random computer selection was employed to divide the students into two groups: the control group (n = 25) which received traditional teaching, and the research group (n = 25) which received CBL combined with a flipped classroom approach. The teaching outcomes of the two groups were subsequently compared and analyzed. Results: The research group demonstrated significantly higher scores in both basic theoretical knowledge and practical operation assessments compared to the control group (P &lt; 0.05). Additionally, the research group reported higher levels of satisfaction with the teaching method than the control group (P&lt; 0.05). Conclusion: The implementation of CBL combined with a flipped classroom approach for interns in the infection ward was found to be an effective method for improving interns’ theoretical knowledge and practical operation scores, as well as achieving higher levels of teaching satisfaction. These findings have significant clinical value.

Reduction of acute kidney injury in pediatric patients after bone marrow transplant: A prospective analysis after quality improvement implementation.

371 Background: Hematopoietic cell transplantation (HCT) is a curative therapy for malignant and non-malignant diseases. Acute kidney injury (AKI) is a common complication after HCT secondary to use of nephrotoxic medications (NTMx) prescribed for conditioning and prophylaxis. A recently published meta-analysis estimates the incidence of AKI after HCT to be 55.1%, with Stage 3 occurring in 8.3% of patients. Nephrotoxic medication–associated AKI (NAKI) affects 19%–31% of children who receive an intravenous aminoglycoside, with NAKI rates doubling with receipt of ≥ 3 nephrotoxic medications on the same day. We hypothesized that reducing NTMx exposure in pediatric HCT patients would be associated with lower all causes AKI incidence in the HCT unit. Methods: Single-center harm-preventing measures have been implemented at our center since 2019 to 2023. A multi-phased approach was used to increase education and recognition surrounding NTMx exposures in the HCT unit and role in subsequent AKI. We identified champions in the Pediatric HCT and Infectious Disease Host Defense teams. Five educational sessions took place from November 2022-June 2023 and an informational handout was created and distributed to HCT providers. Notifications to attending physicians of patients meeting NTMx exposure criteria, with acceptable alternatives to commonly used nephrotoxic drugs, and suggestions for AKI monitoring took place during daily rounds by the clinical pharmacist. Data on exposures and NAKIs’ was collected and reviewed every 3 months. Results: The cohort included 79 unique patients with 3547 patient days admitted to the HCT unit at Nationwide Children’s Hospital between January 1 2022 and March 31 2023. A total of 210 NTMx exposures were identified and resulted in 22 NAKI events. We reduced the rates of nephrotoxic medication exposure by 51% from 14.36 to 7 per month per 1000 patient days and NAKIs by 21% from to 1.27 to 1 per month per 1000 patient days since the start of our interventions. Conclusions: Successful interventions to decrease AKI in patients admitted to the HCT unit require a multi-disciplinary, iterative, and continuous approach, including recurrent education efforts to providers and pharmacy-driven daily physician alerts. Organizational implementation of these interventions is still ongoing.

Averting a Crisis: Innovating Pediatric Infectious Diseases Recruitment and Training.

Averting a Crisis: Innovating Pediatric Infectious Diseases Recruitment and Training.

Unmeasurable capillary C-reactive protein as one of the diagnostic clues of severe hematological pathologies in children in primary settings: Case series.

The manuscript aimed to show that an unmeasurable capillary C-reactive protein (CRP) should be a red flag that can indicate a possible severe hematological pathology. The authors present 3 case reports of children with fever examined at the pediatric emergency department. Fever is among the most frequently exhibited symptoms of acute pediatric infectious diseases. However, sometimes fever can be the manifestation of other serious noninfectious diseases. CRP is a marker widely used in clinical pediatric practice to help us evaluate inflammation and possible bacterial infection. All mentioned patients had unmeasurable CRP from capillary blood, even though venous CRP ranged from 14 to 21 mg/L. All of the patients were consequently diagnosed with severe hemato-oncological disease. Possible explanations are that a change in blood viscosity or an elevation of circulating immune complexes in the blood of patients with leukemia leads to malfunctioning immunoturbidimetry measurement. Although these findings are very interesting and could lead to faster recognition of acute leukemia in pediatric clinical practice, further prospective study is needed for their confirmation.