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Objectives We evaluated the length of time immunocompromised children (ICC) remain positive for severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), identified factors associated with viral persistence, and determined cycle threshold (C T) values of children with viral persistence as a surrogate of viral load. Methods We conducted a retrospective cohort study of ICC at a pediatric hospital from March 2020 to March 2021. Immunocompromised status was defined as primary, secondary, or acquired due to medical comorbidities/immunosuppressive treatment. The primary outcome was time to first of two consecutive negative SARS‐CoV‐2 polymerase chain reaction (PCR) tests at least 24 hours apart. Testing of sequential clinical specimens from the same subject was conducted using the Centers for Disease Control (CDC) 2019‐nCoV real‐time reverse transcriptase (RT)‐PCR Diagnostic Panel assay. Descriptive statistics, Kaplan–Meier curve median event times and log‐rank tests were used to compare outcomes between groups. Results Ninety‐one children met inclusion criteria. Median age was 15.5 years (interquartile range [IQR] 8–18), 64% were male, 58% were White, and 43% were Hispanic/Latinx. Most (67%) were tested in outpatient settings and 58% were asymptomatic. The median time to two negative tests was 42 days (IQR 25.0–55.0), with no differences in median time by illness presentation or level of immunosuppression. Seven children had more than one sample available for repeat testing, and five of seven (71%) children had initial C T values of 6 weeks and moderate to high viral load.

Introduction/Objectives: We evaluated the length of time immunocompromised children (ICC) remain positive for SARS-CoV-2, identified factors associated with viral persistence and determined cycle threshold (CT) values of children with viral persistence as a surrogate of viral load. Methods: We conducted a retrospective cohort study of ICC at a pediatric hospital from March 2020-2021. Immunocompromised status was defined as primary, secondary or acquired due to medical comorbidities/immunosuppressive treatment. The primary outcome was time to first-of-two consecutive negative SARS-CoV-2 Polymerase chain reaction (PCR) tests at least 24 hours apart. Testing of sequential clinical specimens from the same subject was conducted using the Centers for Disease Control (CDC) 2019-nCoV Real-Time RT-PCR Diagnostic Panel assay. Descriptive statistics, Kaplan-Meier curve median event times and log-rank-sum tests were used to compare outcomes between groups. Results: Ninety-one children met inclusion criteria. Median age was 15.5 years (IQR 8-18 yrs), 64% were male, 58% were white, and 43% were Hispanic/Latinx. Most (67%) were tested in outpatient settings and 58% were asymptomatic. The median time to two negative tests was 42 days (IQR 25.0,55.0), with no differences in median time by illness presentation or level of immunosuppression. Seven children had >1 sample available for repeat testing, and 5/7 (71%) children had initial CT values of 6 weeks and moderate to high viral load.

BackgroundMultiple blood cultures have been shown to improve pathogen yield and antimicrobial stewardship for adult patients with suspected serious bacterial infection (SBI). For children, the use of multiple blood cultures is less common and volume recommendations are more complicated, often resulting in single cultures with low volume.MethodsIn 2010, Children’s Hospital Colorado instituted electronic medical record (EMR) decision support to recommend collection of 2 blood cultures before administration of antibiotics for suspected SBI. Recommended blood culture volumes were calculated by age rather than weight. We evaluated all children admitted to inpatient units between 2008 and 2009 (pre-intervention) and 2011 and 2013 (postintervention) who received antibiotics in the hospital after having blood cultures drawn in the emergency department, excluding those with a length of stay >8 days. We compared blood culture yield, isolate classification (pathogen vs contaminant), and antimicrobial modifications before and after the interventions.ResultsA total of 3948 children were included in the study. EMR guidelines were associated with a significantly higher number of children with multiple blood cultures drawn before antibiotic administration (88.0% vs 12.3%; P ConclusionsMultiple blood cultures with age-based volumes taken before starting antibiotics increase pathogen isolation rates and appropriate modification of antimicrobial treatment in children.

Outbreaks involving the transmission of bloodborne pathogens or other microbial pathogens to patients in various types of health care settings due to unsafe injection, infusion, and medication vial practices are unacceptable. Each of the outbreaks could have been prevented by the use of proper aseptic technique in conjunction with basic infection prevention practices for handling parenteral medications, administration of injections, and procurement and sampling of blood. This document provides practice guidance for health care facilities on essential safe injection, infusion, and vial practices that should be consistently implemented in such settings.

To evaluate whether the implementation of a multiplex gastrointestinal pathogen panel (GIP) was associated with changes in Clostridioides difficile (C difficile) testing and detection rates.We conducted an observational study using interrupted time series analysis and included pediatric patients with testing capable of detecting C difficile. From 2013 to 2015 ("conventional diagnostic era"), stool testing included C difficile-selective polymerase chain reaction and other pathogen-specific tests. From 2015 to 2017 ("GIP era"), C difficile polymerase chain reaction was available along with the GIP, which detected 22 pathogens including C difficile, and replaced the need for additional tests. Outcomes included C difficile testing and detection rates in ambulatory, emergency department, and inpatient settings.There were 6841 tests performed and 1214 C difficile positive results. Across the 3 settings, GIP era had significantly higher C difficile testing (1.7-2.3 times higher) and C difficile detection rates (1.9-3.4 times higher) compared with conventional diagnostic era. After adjusting for the number of tests performed, detection rates were no longer significantly different. Of C difficile positive GIPs, 31% were coinfected with another organism. With GIP testing, patients 1 year of age had a significantly higher C difficile percent positivity than 2-year-old (P = .02) and 3- to 18-year-old children (P .01). Younger children with C difficile were more likely to be coinfected (P .01).Introducing a multiplex panel led to increased C difficile testing, which resulted in increased C difficile detection rates and potential identification and treatment of colonized patients. This highlights an important target for diagnostic stewardship and the challenges associated with multiplex testing.

Transmission of bacterial and viral infections to patients from improper anesthesia infection prevention and control practices continues to be reported. "Recommendations for Infection Control for the Practice of Anesthesiology" were recently revised. The process used to develop an anesthesia infection prevention assessment tool is described. The tool is intended to encourage collaboration between infection preventionists and anesthesia providers in an effort to assess infection prevention and control practices in various health care anesthesia settings.

Object The objective of this investigation was to review the clinical characteristics of recurrent CSF shunt infections in a large pediatric neurosurgical practice and to assess the safety and efficacy of reusing original ventricular entry sites for external ventricular drainage during treatment of infections and for subsequent reinsertion of shunts. Methods Prospectively accrued clinical data on all patients treated at Children's Hospital Colorado for CSF shunt infections within a 10.5-year span were retrospectively investigated. Results One hundred twenty-one consecutive cases of CSF shunt infection met inclusion criteria. Recurrent shunt infection attributable to the management of these infections occurred in 14 cases (11.6%). Three recurrent infections were with their original organisms, 7 were organisms different from the original organisms, and 4 were indeterminate. Conclusions Half or more of recurrent shunt infections were with organisms different from the original organism, and hence were new-type infections introduced during the management of the original infections. Incomplete eradication of original pathogens accounted for 3 (21.4%) of the 14 recurrent infections. Reusing recently infected or contaminated ventricular entry sites, both for CSF drainage during treatment and for implantation of new shunts, was as safe, with regard to risk of recurrent infection, as switching to new entry sites. Prior evidence of shunt infection is not, alone, a sufficient reason to change to a previously well-functioning site, and reuse of contaminated ventricular entry sites avoids all risks associated with making new ventricular entries.

Background Central line–associated blood stream infections (CLABSIs) are a source of high morbidity and mortality in children with acute myelogenous leukemia (AML). Procedure To understand the epidemiology and risk factors associated with the development of CLABSI in children with AML. Methods We retrospectively reviewed all patients with AML over a 5-year period between 2007 and 2011 at the Children's Hospital Colorado. Cases and controls were classified on the basis of the presence of a CLABSI as defined by the National Healthcare Safety Network. Results Of 40 patients in the study, 25 (62.5%) developed at least one CLABSI during therapy. The majority of CLABSIs were due to oral or gastrointestinal organisms (83.0%). Skin organisms accounted for 8.5%. In a multivariable analysis, the strongest risk factors associated with CLABSI were diarrhea (odds ratio [OR] 6.7, 95% confidence interval [CI] 1.6–28.7), receipt of blood products in the preceding 4–7 days (OR 10.0, 95%CI 3.2–31.0), not receiving antibiotics (OR 8.3, 95%CI 2.8–25.0), and chemotherapy cycle (OR 3.5, 95%CI 1.4–8.9). CLABSIs led to increased morbidity, with 13 cases (32.5%) versus two controls (1.9%) requiring transfer to the pediatric intensive care unit (P < 0.001). Three (7.5%) of 40 CLABSI events resulted in or contributed to death. Conclusions Intensified line care efforts cannot eliminate all CLABSIs in the patients with AML. Exploring the role of mucosal barrier breakdown and/or the use of antibiotic prophylaxis may be effective strategies for further prevention of CLABSIs, supporting ongoing trials in this patient population.

An adult immunization strategy called "cocooning" is a relatively new concept, referring to immunizing close contacts of infants and high-risk children, thereby limiting pathogen exposure. This report explores the adoption of free vaccine programs in US children's hospitals and shares our own institutions' experiences in implementing free vaccine programs for close contacts of our patients.

Objective.To determine the source ofBurkholderia cepaciacomplex associated with a hospital outbreak and describe the measures taken to identify and confirm the source.Setting.A 250-bed, tertiary care pediatric hospital in Denver, Colorado.Methods.An epidemiologic investigation was used to identify possible causes for an apparent outbreak ofB. cepaciacomplex in pediatric patients who had new positive cultures with this organism from December 2003 to February 2004. Chart review, microbiology reports, surgical records, site visits, literature review, staff interviews, and cultures of common products and equipment were performed to determine a source of contamination. Random amplified polymorphic DNA and pulsed-field gel electrophoresis typing, performed by 2 independent laboratories, were used for molecular typing of patient and source isolates.Results.Five pediatric patients had new positiveB. cepaciacomplex cultures from either the sinus or the respiratory tract, and all 5 patients had prior exposure to 0.05% oxymetazoline hydrochloride Major Twice-A-Day 12-hour nasal spray (Proforma, Miami, FL). Four of the 5 patients had isolates that were identical to theB. cepaciacomplex isolates recovered from the unopened Twice-A-Day 12-hour nasal spray.Conclusions.Intrinsic contamination of Major Twice-A-Day 12-hour nasal spray withB. cepaciacomplex resulted in nosocomial transmission to 4 patients at our facility and resulted in a voluntary product recall by the manufacturer.B. cepaciacomplex species are common contaminants of an increasing variety of nonsterile medical products. Enhanced culture techniques may be useful in evaluating possible product contamination, suggesting additional measures that should be considered to assure the safety of products that may be used in high-risk patients.

Object The goal of this study was to evaluate the problems encountered in monitoring CSF shunt infection, including the collection, analysis, and reporting of data. The authors propose a system that would produce more accurate, and hence more meaningful, information on shunt infection than do the methodologies and customs now in common use. Methods The authors reviewed and analyzed 19 years of quarterly records of a committee that has addressed CSF shunt infection in an ongoing manner. Results There are strong incentives, political and otherwise, to identify low rates of CSF shunt infection. Details of the composition and operation of a multidisciplinary approach to CSF shunt infection are summarized. Many factors affect the occurrence of shunt infection and its accurate assessment and reporting. Easily accessible sources for the identification of cases of shunt infections and for the assessment of an at-risk population often contain discrepancies in significant numbers. Conclusions Multidisciplinary oversight of the entire matter of CSF shunt infection enhances the chances for collecting accurate data, identifying causes of infection, and developing effective preventative strategies. Valid data require a mechanism for finding all individuals within the at-risk pool; the accurate identification of patients who had shunt infections; standard, pragmatic, and robust criteria for diagnosis of shunt infection; and multidisciplinary oversight of the entire process.

Objective To assess the safety, efficacy, and relative expense of a nurse-led fecal microbiota transplantation (FMT) program for the treatment of recurrent Clostridium difficile infection (CDI). Study design Retrospective cohort study design in children aged 1-18 years with recurrent CDI. The intervention was an intragastric FMT with stool derived from a donor stool bank. Primary outcome was resolution of diarrhea at 3 months post-transplantation. A secondary analysis compared charge data associated with FMT by intragastric delivery vs administration by colonoscopy or nasoduodenal tube. Results A total of 47 intragastric FMT procedures were performed in 42 children (median age 9 years) with recurrent CDI. Response to treatment varied by disease status, with 94% success in previously healthy children, 75% in medically complex children, and 54% in children with inflammatory bowel disease (P = .04). FMT via intragastric delivery showed lower facility and professional charges by 85% and 78% compared with delivery via colonoscopy and radiology-placed nasoduodenal tube, respectively. The use of stool derived from a donor stool bank decreased charges by 49% compared with charges associated with the use of a donor who was a relative. Conclusion A nurse-led intragastric FMT procedure using stool derived from a donor stool bank is a relatively inexpensive and efficacious treatment for recurrent CDI in children. Intragastric FMT success in children was attenuated by the presence of underlying disease, particularly inflammatory bowel disease.

Background We investigated an increase in Clostridium difficile infection (CDI) among pediatric oncology patients. Methods CDI cases were defined as first C difficile positive stool tests between December 1, 2010, and September 6, 2012, in pediatric oncology patients receiving inpatient or outpatient care at a single hospital. A case-control study was performed to identify CDI risk factors, infection prevention and antimicrobial prescribing practices were assessed, and environmental sampling was conducted. Available isolates were strain-typed by pulsed-field gel electrophoresis. Results An increase in hospital-onset CDI cases was observed from June-August 2012. Independent risk factors for CDI included hospitalization in the bone marrow transplant ward and exposure to computerized tomography scanning or cefepime in the prior 12 weeks. Cefepime use increased beginning in late 2011, reflecting a practice change for patients with neutropenic fever. There were 13 distinct strain types among 22 available isolates. Hospital-onset CDI rates decreased to near-baseline levels with enhanced infection prevention measures, including environmental cleaning and prolonged contact isolation. Conclusion C difficile strain diversity associated with a cluster of CDI among pediatric oncology patients suggests a need for greater understanding of modes and sources of transmission and strategies to reduce patient susceptibility to CDI. Further research is needed on the risk of CDI with cefepime and its use as primary empirical treatment for neutropenic fever.

Surveillance testing for Clostridium difficile among pediatric oncology patients identified stool colonization in 29% of patients without gastrointestinal symptoms and in 55% of patients with prior C. difficile infection (CDI). A high prevalence of C. difficile colonization and diarrhea complicates the diagnosis of CDI in this population.

Antibiotic-resistant bacteria are an important cause of morbidity and mortality among hospitalized patients throughout the world. Controlling the emergence and spread of these organisms in healthcare settings requires multiple strategies, including strict attention to hand hygiene, vigilant disinfection of equipment and the environment, efforts to promote antimicrobial stewardship, and adherence to evidence-based bundles of care practices to prevent infections associated with the use of invasive devices such as central venous catheters and ventilators. Multiple studies have demonstrated that identification of patients who are colonized with organisms such as methicillin-resistant Staphylococcus aureus (MRSA)7 and vancomycin-resistant enterococci (VRE), in conjunction with the use of contact precautions when caring for those who are colonized, can reduce rates of colonization and infection with these bacteria. Active-surveillance cultures (ASCs) for these organisms are currently recommended for hospitalized patients at high risk of carriage. Questions remain, however, regarding which specific populations should be screened, the optimal screening method, and which organisms should be targeted for ASC. In this Q&A, 5 experts with different roles in infection prevention and microbiology [including adult (S.S.H.) and pediatric (A.M.M.) hospital epidemiologists from the US and Europe (S.H.), an infection preventionist (S.A.D.), and a microbiology laboratory director (A.J.M.)] have been asked to comment on several unresolved issues regarding the use of ASC as a strategy to prevent the transmission of multidrug-resistant organisms (MDROs) in hospitals. The 2006 Healthcare Infection Control Practices Advisory Committee guideline for the management of MDROs in healthcare settings notes that the target populations for ASC are not well defined. In what patient populations do ASCs make the most sense, and why are there differences between the “search and destroy” approach used in Europe and what is typically done in the United States? Susan Huang: ASC has been shown to be beneficial in high-risk hospitalized populations where …

Treatment with continuous intravenous (IV) prostanoids (ie, epoprostenol and treprostinil) has been shown to improve exercise capacity,1-3 hemodynamics,1-3 and survival rates1,2 in patients with pulmonary arterial hypertension (PAH). Administration of IV formulations of prostanoids involves continuous infusion of medication through a central venous catheter (CVC).4 Although CVCs are common vehicles for drug delivery (an estimated 5 million CVCs are implanted annually in the United States), they are associated with a risk of complications.5 Indeed, more than 15% of patients with CVCs develop catheter-related complications, including mechanical, thrombotic, and infectious complications.5 Catheter-related bloodstream infections (CR-BSIs) are caused by a wide range of opportunistic pathogens, including gram-negative and gram-positive bacterial species.4,6 The mean rate of CR-BSI in medical intensive care units is 2.9 infections per 1,000 catheter-days,7 and the reported incidence of CR-BSI among patients with long-term, indwelling CVCs for various diseases and conditions ranges from 0.3 infections per 1,000 catheter-days to 9.1 infections per 1,000 catheter-days.6,8-10 The use of CVCs in patients with PAH has been associated with CR-BSI rates reportedly ranging from 0.1 infections per 1,000 catheter-days to 1.1 infections per 1,000 catheter-days.6,11,12 In the largest review of patients with PAH and CR-BSI, the Centers for Disease Control and Prevention conducted a retrospective evaluation of CR-BSIs in patients who had received IV prostanoids from 7 major PAH centers.12 A total of 57 CR-BSIs were identified during 51,183 catheter-days among patients receiving IV treprostinil, and 87 CR-BSIs were noted during 201,158 catheter-days among patients receiving IV epoprostenol. Thus, CR-BSI rates were found to be higher among patients receiving treprostinil than among patients receiving epoprostenol (1.11 infections per 1,000 catheter-days vs 0.43 infections per 1,000 catheter-days; pooled incidence rate ratio [IRR], 2.57; 95% confidence interval [CI], 1.81–3.64). However, the incidence of CR-BSI at individual centers varied widely; reported CR-BSI rates ranged from 0.28 to 2.10 infections per 1,000 catheter-days for treprostinil and from 0.23 to 1.02 infections per 1,000 catheter-days for epoprostenol, reflecting an approximate 2-fold difference between centers. The increased incidence of CR-BSI with treprostinil may be associated with higher rates of infection caused by gram-negative pathogens.4,12 The Centers for Disease Control and Prevention report identified a significantly higher pooled mean rate of CR-BSI caused by gram-negative pathogens among patients who received treprostinil than among patients who received epoprostenol (0.76 infections per 1,000 catheter-days vs 0.06 infections per 1,000 catheter-days; pooled IRR, 12.77; 95% CI, 6.55–26.80).12 Higher rates of CR-BSI and the increased frequency of infection caused by gram-negative pathogens associated with treprostinil, compared with epoprostenol, were also reported in a separate publication detailing CR-BSI rates at 2 of the 7 PAH centers and that retrospectively evaluated a total of 224 patients during 146,093 catheter-days.4 Thus, CR-BSIs are rare but significant events in PAH, and infections caused by gram-negative pathogens are more commonly associated with IV treprostinil. The catheter hub is generally the suspected point of entry for pathogens causing CR-BSI in patients receiving long-term treatment.13,14 Akagi et al11 evaluated the effect of adopting a closed-hub system on CR-BSI rates among 20 patients with PAH who were receiving continuous IV epoprostenol. Eleven patients started to receive epoprostenol therapy before introduction of the closed-hub system. During the 6.5-year study period, a total of 7 CR-BSIs occurred in 6 patients, resulting in a CR-BSI rate of 1.2 infections per 1,000 catheter-days in the non–closed-hub system group. Thirteen patients received IV epoprostenol via a closed-hub system, including 4 patients who were switched from the non–closed-hub system. Catheter-related BSIs in the closed-hub system group included 2 infections that occurred in 1 patient, and the CR-BSI rate in this patient population was 0.23 infections per 1,000 catheter-days. Thus, the closed-hub system significantly reduced the risk for CR-BSI among patients with PAH who were receiving IV epoprostenol (P = .04). The infusion line connections also may represent a point of entry for bacterial pathogens present in tap water or transferred from the shower head. Therefore, interventions designed to prevent the exposure of infusion system connections to tap water, such as during bathing, may further reduce the risk of CR-BSI. In this context, the objective of the current study was to evaluate whether the incidence of CR-BSI among patients with PAH receiving IV prostanoids could be reduced through the introduction of 2 new preventive measures: the introduction of a closed-hub system and the waterproofing of catheter hub connections during showering.

Objectives To use a large national comparative database to measure the internal effect of a set of evidence-based bronchiolitis/viral pneumonia clinical care guidelines on clinical practice at a children's hospital, and to compare these changes with those at other children's hospitals. Design Prospective cohort study with retrospective and concurrent (other hospital) controls. Setting The Children's Hospital, Denver, Colo. Participants Hospitalized children with bronchiolitis and/or viral pneumonia. Interventions Our clinical guidelines focused on clear admission and discharge criteria, individualized transition-anticipating orders, and "prove it or don't use it" criteria for the use of respiratory syncytial virus testing, bronchodilators, chest physiotherapy, and ribavirin. Main Outcome Measures The effect of guideline implementation was determined by comparative measurement of internal changes in utilization and outcome (nosocomial infection rate) across time and by external comparison with other children's hospitals using standardized data from the Pediatric Health Information System database of the Child Health Corporation of America (Shawnee Mission, Kan). Results Overall, 10 636 bronchiolitis/viral pneumonia cases were studied: 1302 at the index hospital and 9334 at the 7 comparison hospitals. Internally, the index hospital's residents and attending physicians responded favorably to the bronchiolitis/viral pneumonia care guidelines, resulting in decreases in targeted resource utilization. There were no fatalities, and the number of days in the intensive care unit decreased even though the mean severity of admitted cases increased significantly. Targeted utilization was favorably affected, whereas untargeted utilization was not. Nosocomial infections did not increase with a decreased use of respiratory syncytial virus testing. The index hospital differed favorably from other children's hospitals in several categories. Conclusion Evidence-based care guidelines can successfully influence utilization and clinical outcome.

Bronchiolitis: A Four-Year Comparative Evaluation of the Impact of a Clinical Care Pathway on Patient Outcome and Resource Utilization Using a Large National Dataset