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Background Prophylaxis with levofloxacin to prevent bacteremia in certain high-risk oncologic populations has been standard of care since the 2018 publication from the Children’s Oncology Group (JAMA 2018; 320(10)). This study only had susceptibility data for a minority of isolates and did not assess unit-wide impact on development of resistance, an important outcome given fluoroquinolones (FLQs) lead to resistance not only to FLQs but other drug classes, and not only for patients receiving fluoroquinolones rather unit wide. Our objective was to evaluate the development of resistance unit wide after implementing FLQ prophylaxis in our high-risk oncology patients, in addition to evaluating the overall impact on bacteremia. Methods A 6-year (1/2016-12/2021) single-center, retrospective review rates of bacteremia and susceptibility data from the Children’s Hospital Colorado Center for Cancer and Blood Disorders, encompassing the FLQ prophylaxis initiation date of 11/2018. All positive blood cultures were extracted from Meditech® or EPIC Beaker®, and susceptibility data from Microscan® or Sensititer®, with Institutional review board approval. Repeat cultures were not included. All data was analyzed using descriptive statistics performed in Excel®. Results Within the defined study period, there were 199 total blood cultures. These data were normalized per 1000 central line days, and analysis suggests there has been no significant change in bacteremia rates after implementing levofloxacin prophylaxis. Organisms reported nonsusceptible to levofloxacin or ciprofloxacin rose from over 11% in 2016 to almost 46% in 2021. Comparison of trends before and after the 2018 change reveals a significant difference in percent nonsusceptibility for those antibiotics (p = 0.02). Ceftriaxone or cefotaxime and cefepime were also analyzed and while not statistically significant there was a trend toward increasing resistance for ceftriaxone or cefotaxime (Figures). Conclusion Bacteremia on the oncology unit did not decrease after the implementation FLQ prophylaxis in November 2018. Additionally, resistance to FLQ and other antimicrobial classes is increasing, calling into question the benefit of this practice. Disclosures All Authors: No reported disclosures.

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.

The FilmArray Blood Culture Identification Panel was validated for nonblood sterile site specimens with clinical impact of rapid identification compared to conventional diagnostics. The panel accurately identified target organisms from 98% of positive broth cultures a median 1.1 day faster than conventional techniques (P 0.0001) with potential clinical impact in 22% of cases.

We analyzed in parallel 27 pediatric Clostridium difficile isolates by repetitive sequence-based polymerase chain reaction (RepPCR), pulsed-field gel electrophoresis (PFGE), and whole-genome next-generation sequencing. Next-generation sequencing distinguished 3 groups of isolates that were indistinguishable by RepPCR and 1 isolate that clustered in the same PFGE group as other isolates.

Background Rapid diagnostic technologies for infectious diseases have the potential to improve clinical outcomes, but guideline-recommended antimicrobial stewardship (AS) strategies are not currently optimized for rapid intervention. We evaluated the clinical impact and provider acceptability of implementing real-time AS decision support for children with positive blood culture results according to the FilmArray blood culture identification panel (BCID [BioFire Diagnostics]) at Children's Hospital Colorado. Methods A pre-post quasi-experimental design was used to compare the outcomes of 100 postintervention children with positive blood culture results matched with 200 preintervention control children. Causative organisms in the preintervention group were identified using conventional microbiologic techniques and communicated to providers by a microbiology technologist. Postintervention organisms were identified by the BCID and communicated by an AS provider in real time with interpretation and antimicrobial recommendations. The primary outcome was time to optimal antimicrobial therapy (time from blood culture collection to start of predetermined pathogen-specific regimen or antimicrobial discontinuation for contaminants) compared by a log-rank test and Kaplan-Meier analysis. Provider acceptability of the intervention was assessed via E-mailed surveys. Results The median time to optimal therapy decreased from 60.2 hours before intervention to 26.7 hours after intervention (P = .001). Among children with blood cultures that contained true pathogens, the time to effective antimicrobial therapy decreased from 6.9 to 3.4 hours (P = .03). Unnecessary antibiotic initiation for children with a culture that contained organisms considered to be contaminants decreased from 76% to 26% (P < .001). Providers reported a change in management as a result of BCID results in 73% of the cases and a mean overall satisfaction rating of 4.8 on a 5-point Likert scale. Conclusions Real-time AS decision support for rapid diagnostics is associated with improved antimicrobial use and high satisfaction ratings by providers.

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.

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.

Background.Bacillusspecies have caused healthcare-associated outbreaks of invasive disease as well as pseudo-outbreaks. We report an outbreak investigation of blood cultures positive forBacillus cereusassociated with alcohol prep pads (APPs) contaminated withB. cereusandBacillusspecies resulting in a rapid internal product recall and subsequent international product recall.Design.Epidemiologic and microbiologic outbreak investigation.Setting.A 300-bed tertiary care children's hospital in Aurora, Colorado.Patients.Patients with blood or cerebrospinal fluid cultures positive forB. cereus.Methods.Three patients with blood cultures positive forB. cereuswere identified in late 2010. Breaches in procedural and surgical techniques, common interventions, and products were explored. The following 3 common products were cultured: sterile saline syringes, chlorhexidine/alcohol skin preparation solution, and APPs. Repetitive sequence-based polymerase chain reaction (Rep-PCR) was used to compare isolates obtained from patients and from APPs and was confirmed by independent pulsed-field gel electrophoresis.Results.There appeared to be a significant increase in blood cultures positive forB. cereusduring 2009-2010.B. cereusand otherBacillusspecies were cultured from the internal contents of 63.3% of APPs not labeled as sterile, and 8 of the 10 positive lots were manufactured after 2007. None of the isolates obtained from the patients matched strains isolated from the APPs. However, some lots of APPs had strains that were indistinguishable from one another.Conclusions.APPs that were not labeled as sterile were contaminated withBacillusspecies. The product was immediately recalled internally and replaced with APPs from another manufacturer that were labeled as sterile. On January 3, 2011, the manufacturer voluntarily recalled its APPs. Healthcare facilities, healthcare providers, and users of APPs should avoid the use of APPs not specifically labeled as sterile.

Probiotic agents are increasingly used for the treatment and prevention of a variety of infectious and inflammatory conditions. They are generally safe, but complications of probiotic use can occur. In this report, we describe bacteremia after ingestion of a Lactobacillus rhamnosus GG probiotic tablet in a child with short gut syndrome. We used sequencing of the ribosomal operon region and strain typing with pulsed field electrophoresis of the isolates to show identity between the tablet and bloodstream isolates.