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Background Immunocompromised individuals are considered higher risk for severe COVID-19 disease. Much of this data was collected from adults with limited pediatric reporting, although a recent study showed no worse outcome in immunocompromised children. In this study, we characterize our experience of immunocompromised children who were hospitalized with acute SARS-CoV-2 infection and aimed to identify a sub-group of patients who had worse outcomes. Methods We reviewed charts of all immunocompromised children hospitalized with SARS-CoV-2 RT-PCR positive results at our hospital from March 2020-April 2022. Disease severity was characterized according to the NIH COVID-19 guidelines. Clinical characteristics and outcomes were assessed. Individuals were grouped into solid organ transplant recipients, solid tumors, liquid tumors, and stem cell transplant recipients. Proportions were calculated per group in addition to the exact binomial confidence intervals (95%). Results We identified 39 pediatric aged patients ranging from 7 months to 20 years of age with a median age of 10. 35.9% (14/39) of individuals were solid organ transplant recipients, 25.6% (10/39) had solid tumors, 33% (13/39) had liquid tumors, and 5% (2/39) were stem cell transplant recipients. 17.9% were asymptomatic, 66.7% had mild disease, and 15.4% had severe/critical COVID-19 disease. The median time of positive SARS CoV-2 RT-PCR was 32 days. Six children had prolonged SARS-CoV-2 RT-PCR positive testing between 29-97 days with a mean of 49 days. Viral strand specific RNA testing for replicating virus was also persistently positive. Six experienced severe/critical disease resulting in death of three. Most of the patients were treated with predominantly T cell depleting agents (∼74%). However, four patients who had prolonged active critical infection were treated with B cell depleting agents or had known B cell dysfunction. Conclusion The majority of the immunocompromised children in our cohort had mild COVID-19 disease. A subset of individuals experienced ongoing prolonged RT-PCR positivity and testing indicating persistent viral replication, with three demonstrating an inability to control the virus and resulting in death. Worse outcomes may be related to their immune dysfunction and use of B cell depleting agents. Disclosures All Authors: No reported disclosures.

OBJECTIVES Pediatric hospitalization rates are used as a marker of coronavirus disease 2019 (COVID-19) disease severity in children but may be inflated by the detection of mild or asymptomatic infection via universal screening. We aimed to classify COVID-19 hospitalizations using an existing and novel approach and to assess the interrater reliability of both approaches. METHODS This retrospective cohort study characterized severity of illness and likelihood of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection as the cause of hospitalization in pediatric patients RESULTS Of 117 hospitalizations, 46 (39.3%) were asymptomatic, 33 (28.2%) had mild to moderate disease, 9 (7.7%) had severe illness, and 15 (12.8%) had critical illness (weighted κ: 0.82). A total of 14 (12%) patients had multisystem inflammatory syndrome in children. A total of 53 (45%) admissions were categorized as unlikely to be caused by SARS-CoV-2 (κ: 0.78). CONCLUSIONS Although COVID-19 has considerable associated morbidity and mortality in children, reported hospitalization rates likely lead to overestimation of the true disease burden.

Among 287 US hospitals reporting data between 2015 and 2018, annual pediatric surgical site infection (SSI) rates ranged from 0% for gallbladder to 10.4% for colon surgeries. Colon, spinal fusion, and small-bowel SSI rates did not decrease with greater surgical volumes in contrast to appendix and ventricular-shunt SSI rates.

In the midst of the coronavirus disease 2019 (COVID-19) pandemic, we are seeing widespread disease burden affecting patients of all ages across the globe. However, much remains to be understood as clinicians, epidemiologists, and researchers alike are working to describe and characterize the disease process while caring for patients at the frontlines. We describe the case of a 6-month-old infant admitted and diagnosed with classic Kawasaki disease, who also screened positive for COVID-19 in the setting of fever and minimal respiratory symptoms. The patient was treated per treatment guidelines, with intravenous immunoglobulin and high-dose aspirin, and subsequently defervesced with resolution of her clinical symptoms. The patient’s initial echocardiogram was normal, and she was discharged within 48 hours of completion of her intravenous immunoglobulin infusion, with instruction to quarantine at home for 14 days from the date of her positive test results for COVID-19. Further study of the clinical presentation of pediatric COVID-19 and the potential association with Kawasaki disease is warranted, as are the indications for COVID-19 testing in the febrile infant.

BackgroundThe COVID-19 pandemic has resulted in multiple logistical and communication challenges in the face of ever-changing guidance, disease prevalence and increasing evidence.MethodsAt Stanford Children’s Health (SCH), we felt physician input was an important element of pandemic response infrastructure, given our lens into patient care across its continuum. We formed the COVID-19 Physician Liaison Team (CPLT) consisting of representative physicians across the care continuum. The CPLT met regularly and communicated to the SCH’s COVID-19 task force responsible for the ongoing organisation pandemic response. The CPLT problem-solved around various issues including testing, patient care on our COVID-19 inpatient unit and communication gaps.ResultsThe CPLT contributed to conservation of rapid COVID-19 tests for critical patient care needs, decreased incident reports on our COVID-19 inpatient unit and helped enhance communication across the organisation, with a focus on physicians.ConclusionIn retrospect, the approach taken was in line with a distributed leadership model with physicians as integral members contributing to active lines of communication, continual problem-solving and new pathways to provide care.

BackgroundDistribution of mRNA-based SARS-CoV-2 vaccines to healthcare personnel (HCP) in the United States began in December 2020, with efficacy>90%. However, breakthrough infections in fully vaccinated individuals have been reported. Meanwhile, multiple SARS-CoV-2 variants of concern have emerged worldwide, including the B.1.427/B.1.429 variant first described in California. Little is known about the real-world effectiveness of the mRNA-based SARS-CoV-2 vaccines against novel variants including B.1.427/B.1.429.MethodsIn this quality improvement project, post-vaccine SARS-CoV-2 cases (PVSCs) were defined as individuals with positive SARS-CoV-2 nucleic acid amplification test (NAAT) after receiving at least one dose of a SARS-CoV-2 vaccine. Chart extraction of demographic and clinical information was performed, and available specimens meeting cycle threshold value criteria were tested for L452R, N501Y and E484K mutations by RT-PCR.ResultsFrom December 2020 to March 2021, 189 PVSCs were identified out of 22,729 healthcare personnel who received at least one dose of an mRNA-based SARS-CoV-2 vaccine. Of these, 114 (60.3%) occurred within 14 days of first vaccine dose (early post-vaccination), 49 (25.9%) within 14 days of the second vaccine dose (partially vaccinated), and 26 (13.8%)>14 days after the second dose (fully vaccinated). Of 115 samples available for mutation testing, 42 were positive for L452R alone, presumptive of B.1.427/B.1.429; three had N501Y mutation alone and none were found with E484K mutation. Though on univariate analysis partially- and fully-vaccinated PVSCs were more likely than early post-vaccination PVSCs to be infected with presumptive B.1.427/B.1.429, when adjusted for community prevalence of B.1.427/B.1.429 at the time of infection, partially- and fully-vaccinated PVSC did not have statistically significantly elevated risk ratios for infection with this variant (RR 1.40, 95% CI 0.81-2.43 and RR 1.13, 95% CI 0.59-2.16, respectively).ConclusionsThe great majority of PVSCs occurred prior to the expected onset of full, vaccine-derived immunity. Although the B.1.427/B.1.429 variant did not represent a significantly higher proportion of PVSCs than expected, numbers were small and there was a trend towards higher representation in the partially- and fully-vaccinated subset. Continued infection control measures in the workplace and in the community including social distancing and masking, particularly in the early days post-vaccination, as well as continued variant surveillance in PVSCs, is imperative in order to anticipate and control future surges of infection.

Background Although mRNA-based severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccines report >90% efficacy, breakthrough infections occur. Little is known about their effectiveness against SARS-CoV-2 variants, including the highly prevalent B.1.427/B.1.429 variant. Methods In this quality improvement project, we collected demographic and clinical information from post-vaccine SARS-CoV-2 cases (PVSCs), defined as healthcare personnel (HCP) with positive SARS-CoV-2 nucleic acid amplification test after receiving ≥1 vaccine dose. Available specimens were tested for L452R, N501Y, and E484K mutations using reverse-transcription polymerase chain reaction. Mutation prevalence was compared among unvaccinated, early post-vaccinated (≤14 days after dose 1), partially vaccinated (positive test >14 days after dose 1 and 14 days after dose 2) PVSCs. Results From December 2020 to April 2021, ≥23 090 HCP received ≥1 dose of an mRNA-based SARS-CoV-2 vaccine, and 660 HCP cases of SARS-CoV-2 occurred, of which 189 were PVSCs. Among the PVSCs, 114 (60.3%), 49 (25.9%), and 26 (13.8%) were early post-vaccination, partially vaccinated, and fully vaccinated, respectively. Of 261 available samples from vaccinated and unvaccinated HCP, 103 (39.5%), including 42 PVSCs (36.5%), had the L452R mutation presumptive of B.1.427/B.1.429. When adjusted for community prevalence of B.1.427/B.1.429, PVSCs did not have significantly elevated risk of B.1.427/B.1.429 compared with unvaccinated HCP. Conclusions Most PVSCs occurred prior to expected onset of full, vaccine-derived immunity. Presumptive B.1.427/B.1.429 was not more prevalent in post-vaccine cases than in unvaccinated SARS-CoV-2 HCP. Continued infection control measures, particularly

We developed an assay that detects minus-strand RNA as a surrogate for actively replicating severe acute respiratory syndrome coronavirus 2. We detected minus-strand RNA in 41 persons with coronavirus disease up to 30 days after symptom onset. This assay might inform clinical decision-making about patient infectiousness.

Objective:We assessed the magnitude of unidentified coronavirus disease 2019 (COVID-19) in our healthcare personnel (HCP) early in the COVID-19 pandemic, and we evaluated risk factors for infection to identify areas for improvement in infection control practice in a northern California academic medical center.Methods:We reviewed anti–severe acute respiratory coronavirus virus 2 (SARS-CoV-2) receptor-binding domain (RBD) IgG serologic test results and self-reported risk factors for seropositivity among 10,449 asymptomatic HCP who underwent voluntary serology testing between April 20 and May 20, 2020.Results:In total, 136 employees (1.3%) tested positive for SARS-CoV-2 IgG. This included 41 individuals (30.1%) who had previously tested positive for SARS-CoV-2 by nasopharyngeal reverse-transcription polymerase chain reaction (RT-PCR) between March 13 and April 16, 2020. In multivariable analysis, employees of Hispanic ethnicity (odds ratio [OR], 2.01; 95% confidence interval [CI], 1.22–3.46) and those working in environmental services, food services, or patient transport (OR, 4.81; 95% CI, 2.08–10.30) were at increased risk for seropositivity compared to other groups. Employees reporting a household contact with COVID-19 were also at higher risk for seropositivity (OR, 3.25; 95% CI, 1.47–6.44), but those with a work, exposure alone were not (OR, 1.27; 95% CI, 0.58–2.47). Importantly, one-third of seropositive individuals reported no prior symptoms, no suspected exposures, and no prior positive RT-PCR test.Conclusion:In this study, SARS-CoV-2 seropositivity among HCP early in the northern California epidemic appeared to be quite low and was more likely attributable to community rather than occupational exposure.

Introduction Central line-associated bloodstream infections (CLABSIs) are the most common hospital-acquired infection in pediatric patients. High adherence to the CLABSI bundle mitigates CLABSIs. At our institution, there did not exist a hospital-wide system to measure bundle-adherence. We developed an electronic dashboard to monitor CLABSI bundle-adherence across the hospital and in real time. Methods Institutional stakeholders and areas of opportunity were identified through interviews and data analyses. We created a data pipeline to pull adherence data from twice-daily bundle checks and populate a dashboard in the electronic health record. The dashboard was developed to allow visualization of overall and individual element bundle-adherence across units. Monthly dashboard accesses and element-level bundle-adherence were recorded, and the nursing staff's feedback about the dashboard was obtained. Results Following deployment in September 2018, the dashboard was primarily accessed by quality improvement, clinical effectiveness and analytics, and infection prevention and control. Quality improvement and infection prevention and control specialists presented dashboard data at improvement meetings to inform unit-level accountability initiatives. All-element adherence across the hospital increased from 25% in September 2018 to 44% in December 2019, and average adherence to each bundle element increased between 2018 and 2019. Conclusions CLABSI bundle-adherence, overall and by element, increased across the hospital following the deployment of a real-time electronic data dashboard. The dashboard enabled population-level surveillance of CLABSI bundle-adherence that informed bundle accountability initiatives. Data transparency enabled by electronic dashboards promises to be a useful tool for infectious disease control.

Supplemental Digital Content is available in the text., Introduction: Efforts to reduce central line-associated bloodstream infection (CLABSI) rates require strong microsystems for success. However, variation in practices across units leads to challenges in ensuring accountability. We redesigned the organization’s mesosystem to provide oversight and alignment of microsystem efforts and ensure accountability in the context of the macrosystem. We implemented an A3 framework to achieve reductions in CLABSI through adherence to known evidence-based bundles. Methods: We conducted this CLABSI reduction improvement initiative at a 395-bed freestanding, academic, university-affiliated children’s hospital. A mesosystem-focused A3 emphasized bundle adherence through 3 key drivers (1) practice standardization, (2) data transparency, and (3) accountability. We evaluated the impact of this intervention on CLABSI rates during the pre-intervention (01/15-09/17) and post-intervention (07/18–06/19) periods using a Poisson model controlling for baseline trends. Results: Our quarterly CLABSI rates during the pre-intervention period ranged from 1.0 to 2.3 CLABSIs per 1,000 central line-days. With the mesosystem in place, CLABSI rates ranged from 0.4 to 0.7 per 1,000 central line days during the post-intervention period. Adjusting for secular trends, we observed a statistically significant decrease in the post versus pre-intervention CLABSI rate of 71%. Conclusion: Our hospital-wide CLABSI rate declined for the first time in many years after the redesign of the mesosystem and a focus on practice standardization, data transparency, and accountability. Our approach highlights the importance of alignment across unit-level microsystems to ensure high-fidelity implementation of practice standards throughout the healthcare-delivery system.

Mucormycosis in pediatric oncology patients is a rare invasive fungal infection associated with significant morbidity and mortality. We describe five patients diagnosed with mucormycosis during induction chemotherapy for acute lymphoblastic leukemia at our institution. All of the patients in our series survived, some in spite of having disseminated disease. Most of the patients' chemotherapy was modified with the aim of controlling their leukemia while minimizing immunosuppression until their fungal infection was under control. Although mucormycosis is frequently fatal, rapid diagnosis and a multidisciplinary approach can lead to excellent outcomes, even in patients undergoing intensive chemotherapy.

Importance Central catheter–associated bloodstream infections (CLABSIs) and catheter-associated urinary tract infections (CAUTIs) increase morbidity, mortality, and health care costs in pediatric patients. Objective To examine changes over time in CLABSI and CAUTI rates between 2013 and 2018 in neonatal intensive care units (NICUs) and pediatric intensive care units (PICUs) using prospective surveillance data from community hospitals, children’s hospitals, and pediatric units within general hospitals. Design, Setting, and Participants This time series study included 176 US hospitals reporting pediatric health care–associated infection surveillance data to the National Healthcare Safety Network from January 1, 2013, to June 30, 2018. Patients aged 18 years or younger admitted to PICUs or level III NICUs were included in the analysis. Main Outcomes and Measures The primary outcomes were device-associated rates of CLABSI in NICUs and PICUs and CAUTI in PICUs (infections per 1000 device-days). Secondary outcomes included population-based rates (infections per 10 000 patient-days) and device utilization (device-days per patient-days). Regression models were fit using generalized estimating equations to assess yearly changes in CLABSI and CAUTI rates, adjusted for birth weight (≤1500 vs >1500 g) in neonatal models. Results Of the 176 hospitals, 132 hospitals with NICUs and 114 hospitals with PICUs contributed data. Of these, NICUs reported 6 064 172 patient-days and 1 363 700 central line-days and PICUs reported 1 999 979 patient-days, 925 956 central catheter–days, and 327 599 indwelling urinary catheter–days. In NICUs, there were no significant changes in yearly trends in device-associated (incidence rate ratio [IRR] per year, 0.99; 95% CI, 0.95-1.03) and population-based (IRR, 0.96; 95% CI, 0.92-1.00) CLABSI rates or central catheter utilization (odds ratio [OR], 0.97; 95% CI, 0.95-1.00). Results were similar in PICUs, with device-associated (IRR, 1.03; 95% CI, 0.99-1.07) and population-based (IRR, 1.03; 95% CI, 0.99-1.07) CLABSI rates and central catheter utilization (OR, 0.99; 95% CI, 0.97-1.01) remaining stable. While device-associated CAUTI rates in PICUs also remained unchanged over time (IRR, 0.97; 95% CI, 0.91-1.03), population-based CAUTI rates significantly decreased by 8% per year (IRR, 0.92; 95% CI, 0.86-0.98) and indwelling urinary catheter utilization significantly decreased by 6% per year (OR, 0.94; 95% CI, 0.91-0.96). Conclusions and Relevance Recent trends in CLABSI rates noted in this study among critically ill neonates and children in a large cohort of US hospitals indicate that past gains have held, without evidence of further improvements, suggesting novel approaches for CLABSI prevention are needed. Modest improvements in population-based CAUTI rates likely reflect more judicious use of urinary catheters.

This study uses electronic health record (EHR) data to evaluate differences in central line–associated bloodstream infection (CLABSI) rates by how central line days are counted: once a day at a fixed time for all patients; a sampling-based approximation; or a validated electronic count.

This review aims to provide clinicians engaged in the care of infants and children an update on the current understanding of the epidemiology, etiology, diagnostic evaluation, and clinical management of complicated pneumonia. The review provides timely information surrounding areas of consensus and ongoing research.The epidemiology and etiologies of complicated pneumonia continue to evolve over the past several decades in context of the introduction of new vaccines. We review uncommon and emerging pathogens. Immunocompromised patients are particularly at risk for complications. The 2011 clinical practice guidelines for pediatric community-acquired pneumonia from The Pediatric Infectious Diseases Society/Infectious Diseases Society of America and the British Thoracic Society are changing approaches to evaluation and management. The efficacy of new diagnostic laboratory studies, and imaging techniques, continues to be studied. Antibiotics are the mainstay of treatment, with several new options to consider. Techniques for the drainage of parapneumonic effusions continue to optimize.Although much is known about complicated pneumonia, it remains a significant burden. New diagnostic and therapeutic interventions hold much promise. This review seeks to provide clinicians with evidence that motivates a reasoned approach to the evaluation and management of complicated pneumonia.

A 15-year-old female with a past medical history significant for autoimmune hepatitis on chronic immunosuppressive medications presented to a community hospital with a 24-hour history of shortness of breath, right-sided pleuritic pain, cough, fever, and headache. Review of systems was otherwise negative. She was diagnosed with pneumonia and admitted for empiric treatment with ceftriaxone, clindamycin, azithromycin, and fluconazole. She remained febrile and was transferred after 72 hours to a quaternary children’s hospital. Her past medical history was significant for autoimmune hepatitis diagnosed in 2005, and home medications included 6-mercaptopurine and allopurinol. The patient was born and lives in coastal central California. She traveled 1 month before presentation to Arizona and 1 year prior to visit family in Mexico, both trips were 2 weeks in duration. She had no known sick contacts. Her physical exam upon transfer was notable for a generally well appearance. Her vital signs were as follows: blood pressure 102/67; heart rate 80; respiratory rate 21; SpO2 97% on room air; and temperature 38.1°C. She had decreased breath sounds and dullness to percussion on the right. There was no cervical, axillary, or inguinal lymphadenopathy. Her abdominal exam was benign. The patient was continued empirically on ceftriaxone, clindamycin, azithromycin, and fluconazole. A chest radiograph (Figure 1A) demonstrated a large, free-flowing, right-sided pleural effusion, and a chest computed tomography (Figure 1B) demonstrated the same without parenchymal disease or intrathoracic lymphadenopathy. Her initial laboratory studies demonstrated an elevated c-reactive protein 8.6 (0–0.9 mg/dL) and normal electrolytes, liver function tests, and complete blood count. An infectious laboratory work-up was performed including 2 negative antibody screens for Coccidioides immitis by immunodiffusion, positive tuberculin skin test with 25-mm induration, positive QuantiFERON-Gold IT assay, negative human immunodeficiency virus (HIV) antibody, elevated Mycoplasma pneumoniae serologies immunoglobulin (Ig)M 1:128 and IgG 1:128, and a negative respiratory virus panel. A previous tuberculin skin test in 2006 had 0 mm of induration. On day 5 of illness, a chest tube was placed draining 750 mL of exudative serous fluid with 1240/μL nucleated cells and 92% lymphocytes. The adenosine deaminase was 5.1 U/L (0–9.4). Acid-fast bacilli (AFB), fungal, and bacterial stains were negative as were a mycobacterial and mycoplasma polymerase chain reaction (PCR). Cytology was negative for malignant cells. Her fevers resolved the day after chest tube placement. A pleural biopsy was performed on day 8 of her illness, and fibrinous material was noted in the pleural space intraoperatively. Acid-fast bacilli, fungal, and bacterial stains were negative as was bacterial sequencing, which can identify Mycobacterium tuberculosis complex. Pathology revealed necrotizing granulomatous inflammation but no well formed granulomas. Three induced sputa were AFB smear negative. She remained afebrile and was discharged with presumed latent tuberculosis infection but without a clear diagnosis for her disease after completing a 10-day course of ceftriaxone and 5 days of azithromycin. Fluconazole was also discontinued. On follow-up 1 month after discharge she remained afebrile; however, she had shortness of breath with exertion. Her pleural effusion was unchanged on chest radiograph from the time of discharge. Her M pneumoniae serologies were IgM 1:256 and IgG 1:256 andHistoplasma serologies Case Report