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Objective. The increasing prevalence of infections caused by extended-spectrum [beta]-lactamase--producing Escherichia coli and Klebsiella species (ESBLEK) has become a growing concern in the hospitalized patient population. Previous studies on risk factors for infection with ESBL-EK have mainly focused on adult populations, and these findings may not be relevant among the pediatric population that experiences a unique set of health care exposures and underlying conditions. The objective of this study was to define the risk factors and outcomes associated with ESBL-EK bloodstream infections in children. Methods. We conducted a nested case-control study using data from the Children's Hospital of Philadelphia from May 1, 1999, to September 30, 2003. Eligible patients were identified from the hospital database of microbiology laboratory records. All patients with ESBL-EK bloodstream infections were compared to a random sample of patients with non-ESBL-EK bloodstream infections. Risk factors analyzed included prior antimicrobial use, comorbid conditions, and demographic characteristics. Pulsed-field gel electrophoresis was performed to determine genetic relatedness of the ESBL-EK isolates. Results. Thirty-five cases and 105 control subjects were included in the study. The median age among the cases was 2 years (interquartile range: 0-11), compared with 1 year (interquartile range: 0-8) among control subjects. Patients with ESBL-EK infections were 5.8 times (95% confidence interval: 1.9-17.7) more likely to have had exposure to an extended-spectrum cephalosporin in the 30 days before infection than those with non-ESBL-EK infections. Other independent predictors of ESBL-EK infection were being female, infection with a Klebsiella species, and steroid use in the 30 days before infection. All ESBL-EK isolates were susceptible to carbapenem antibiotics. Pulsed-field gel electrophoresis analysis revealed that the ESBL-EK isolates were polyclonal. Although a substantially higher proportion of children with ESBL-EK died (in-hospital mortality: 36% vs 13%), this difference was not statistically significant. Conclusions. Receipt of extended-spectrum cephalosporins in the 30 days before infection by an Escherichia coli or Klebsiella species is significantly associated with having an ESBL-EK infection in hospitalized children. Curtailed use of cephalosporins among high-risk groups may reduce the occurrence of ESBL-EK infections. Future studies on identifying high-risk children and investigating the impact of curtailed third-generation cephalosporin use to limit additional emergence of ESBL-EK infections should be undertaken. Pediatrics 2005;115:942-949; antibiotic resistance, bloodstream infection, children, risk factors, extended spectrum [beta]-lactamases., ABBREVIATIONS. ESBL, extended spectrum [beta]-lactamase; ESBL-EK, extended-spectrum [beta]-lactamase-producing Escherichia coli and Klebsiella species; CHOP, Children's Hospital of Philadelphia; PFGE, pulsed-field gel electrophoresis. Extended-spectrum [beta]-lactamase (ESBL)-producing enteric Gram-negative bacilli with resistance [...]

Hospitalizations appear to be an opportune time to vaccinate under-immunized preschool children. Vaccination status was verified and compared at admission and discharge among 2,006 hospitalized children under 2 years of age. Efforts made to vaccinate under-immunized children during their hospital stay resulted in an improved full vaccination rate from 44% upon entering the hospital to 70% when leaving. Only 4% of the eligible children had medical reasons to not complete their vaccination schedule. Children with some type of medical insurance were less likely to be under-immunized than those with no insurance., Objective. The Standards for Pediatric Immunization Practices suggest that hospitalization be viewed as an opportunity to vaccinate children. The purpose of the present study is 1) to determine the immunization status of an urban population of hospitalized preschool-aged children, 2) to study the impact of an immunization program designed to vaccinate hospitalized 0 to 2-year-old children who are underimmunized at admission, and 3) to make immunization a routine part of care for the hospitalized child. Methods. Prospective evaluation of the immunization status of hospitalized 0 to 2-year-old residents of Philadelphia admitted to an urban children's hospital was performed. With verification of the child's immunization record through the primary care provider (PCP), needed immunizations were given and records were forwarded to notify the PCP. Educational information was provided to families and health care providers. Main Outcome Measure. The percentage of children fully immunized on admission compared with the percentage at the time of discharge. Results. Two thousand three hundred twenty-nine children from 0 to 2 years of age were hospitalized during the 22-month study period. Immunization records were verified in 86% (2006), requiring an average of 1.5 phone calls to the PCP. The mean patient age was 10 months. Average hospital length of stay was 4 days. On admission, 49% (980) of the 2006 study patients were fully immunized. The remaining 51% (1026) were eligible for vaccination. Immunizations were delayed greater than or equal to 2 months in 18% (355) of the children. Neither type of health care insurance nor site of primary care affected the immunization status of those evaluated at the time of admission. Sixty-six percent (N = 674) of eligible patients received at least one vaccination before hospital discharge. Medical contraindications accounted for only 4% of the reasons eligible patients were not immunized. Of the 2006 children evaluated, the percentage of those fully vaccinated for age increased significantly from 44% on admission to 70% on discharge. Conclusion. As a result of this program, there was a significant improvement in vaccination percentage at the time of hospital discharge in this group of urban preschool-aged children. The development of an immunization program to vaccinate hospitalized preschool children is an opportunity to immunize in the urban setting where there is a high prevalence of underimmunization. In addition, it provides an opening for educational programs for families, nurses, and housestaff and linkage to the community PCPs. Pediatrics 1997;100:192--196; immunization rates, hospitalization, underimmunization, preschool age children., ABBREVIATIONS. CDC, Centers for Disease Control and Prevention; PCP, primary care provider; OPV, oral polio vaccine; MMR, measles-mumps-rubella. Despite some improvement over the last 5 years, vaccine coverage for preschool-aged [...]

Providing routine immunizations to young children in the emergency department (ED) may increase the total number of children that have been fully vaccinated by age two. Medical records of 100 children were evaluated for immunizations, emergency room use and primary care visits. Their records were compared to those of 91 children (control group). The study group had more visits to the emergency room than the control group. Children in the study group were medically eligible to receive vaccines for diptheria, pertussis, tetanus (DPT) and the oral poliovirus vaccine (OPV) at 67% percent of ED visits. They were also eligible to receive booster DPT/OPV and measles, mumps and rubella vaccines at 63% of ED visits. Missed vaccination opportunities were higher in the study group with 7.5 missed chances in every 100 visits versus 4.6 per 100 in the control group. If vaccination opportunities were not missed in the ED, the average number of immunizations would have increased by 20% when compared to the percentage of clinic vaccinations., ABSTRACT. Objective. To determine whether the use of an urban pediatric emergency department (ED) to immunize pre-school-age children would result in an improvement in the percentage fully vaccinated by the end of the second year of life. Design. A retrospective cohort study of two groups: (1) 100 consecutive children (ED group) enrolled at one of two hospital-affiliated primary care clinics were chosen from the ED patient logs if their second birthday occurred in the 12 months prior to November 1990; and (2) 91 age-matched control children (control group) were chosen at random from the same hospital-affiliated clinic's enrollment logs without regard to ED use. The health care provided during the first 2 years of life for each group was compared. Results. The mean number of visits to the ED in the first 2 years of life by the ED group was significantly greater than that of the control group (2.9[SD] [+ or -] 2.5 vs 1.1 [+ or - ] 1.4; P Conclusion. Routine vaccinations in the ED would significantly increase immunization percentages in children enrolled in two hospital-affiliated clinics. Close linkage and coordination between the ED and hospital-affiliated clinics may improve preventive health care in urban children who use EDs. Pediatrics 1994;93:99-103; preschool immunizations, emergency department, missed opportunities, vaccinations.

Feverish infants under two months of age can be successfully treated as outpatients without antibiotics and at significant cost savings if they are first carefully screened for serious illnesses. Complete medical histories, physical examinations and laboratory tests for bacterial infections were conducted on 747 infants with fevers of at least 38.2 degrees Celsius. Based on these results, 139 infants were assigned to outpatient-observation without antibiotics, 148 infants to inpatient-observation without antibiotics and 460 to inpatient-antibiotic therapy. Ninety-nine percent of the infants who were negative according to initial screening did not develop serious bacterial illnesses. The inpatient-antibiotic group averaged $5,532 in hospital and treatment costs. In contrast, the outpatient group averaged only $784. Withholding antibiotic treatment when appropriate saved about $600 per patient. Outpatient observation saved an additional $2,500 in hospital costs for each infant.

* Objective. - To provide an approach toward the diagnosis of children with human immunodeficiency virus (HIV) infection in the acute care setting. Design. - Patient reports and review of recent literature. Setting. - Emergency departments or acute care clinics. Selection Procedures. - Analysis of important recent clinical publications. Interventions. - None. Results and Conclusions. - The clinical and historical findings associated with pediatric HIV infection are occasionally subtle and differ from those findings in adults. In this article, we have divided the first presentation of HIV in the acute care setting into five categories: recurrent bacterial infections, failure to thrive, unexplained organomegaly, adolescents with HIV, and late presentation of perinatally acquired HIV. Each category is illustrated by a patient treated in the acute care setting. Recognition of these categories of presentation will hopefully assist acute care physicians in the early diagnosis of HIV infection., Clinical and historical findings related to pediatric human immunodeficiency virus (HIV) infections can sometimes be subtle and unlike similar findings in adults. This study sought to develop an approach toward the diagnosis of children seen with HIV in the acute care setting. Patient reports and literature reviews were used to divide the first observation of HIV in the acute care setting, such as an emergency department or acute care clinic, into five categories: (1) recurrent bacterial infections; (2) failure to thrive; (3) unexplained organomegaly; (4) adolescents with HIV and (5) late presentation of HIV that was acquired perinatally. It is hoped that recognition of these categories will aid the acute care physician in making an early diagnosis of HIV infection.