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Nishihara Y, MacBrayne C, Prinzi A, Zenge J, Grover T, Parker SK. 2151. Time to Positivity in Blood Cultures at a Free-Standing Level IV NICU. Open Forum Infect Dis 2022. [DOI: 10.1093/ofid/ofac492.1771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Abstract
Background
In the Neonatal Intensive Care setting, subtle clinical deterioration of the infant combined with the lack of specificity in clinical signs to identify true infection often triggers an evaluation for sepsis. Blood cultures are obtained, and empiric antibiotics are initiated. Limiting the duration of antibiotic exposure has potential benefits in curtailing antimicrobial resistance and reducing unwanted adverse effects. We aimed to determine the time to positivity (TTP) of blood cultures in a level IV NICU over a 6-year period, with the goal to reassess our antimicrobial practice.
Methods
Data were extracted from the Children’s Hospital Colorado data warehouse for all neonates admitted to the NICU with a positive blood culture between Jan 2013 to Dec 2018. These patient’s charts were reviewed for both microbiologic and clinical data. TTP was calculated based on date and time culture was collected, compared to the date and time growth was first reported. Micro-organisms were categorized into absolute pathogens, potential pathogens, common contaminants, yeast and other less frequently identified organisms.
Results
A total of 309 positive blood cultures were identified from 268 neonates. The mean gestational age was 34.7 weeks with an average birthweight of 2353g. Overall TTP median and interquartile range (IQR) was 21.1 (14.4 ,25.4) hours. The median (IQR) TTP for gram-positive absolute pathogens and gram-negative absolute pathogens were 16.3 (13.0, 22.4) and 12.6 (11.3, 14.4) hours, respectively. Of the 309 positive culture results, 295 (95%) had been initiated with antibiotics; 110 (37%) were later deemed as contaminant, and treatment discontinued. Central line associated bacterial infection was documented in 35 cases (11%). Death within 4 weeks of culture positivity was recorded in 25 (9.5%) cases.
Conclusion
The majority of gram-positive and gram-negative pathogens were identified within 24h of blood culture collection. A substantial number of cases were later categorized as contaminants, highlighting the importance of correct sterile technique when obtaining cultures. These findings highlight opportunities for antimicrobial stewardship to limit antibiotic exposure in the NICU. The high mortality within 4 weeks of blood culture positivity warrants further study.
Disclosures
All Authors: No reported disclosures.
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Affiliation(s)
| | | | | | | | | | - Sarah K Parker
- University of Colorado/Children's Hospital Colorado , Aurora, Colorado
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Azar MM, Turbett S, Gaston D, Gitman M, Razonable R, Koo S, Hanson K, Kotton C, Silveira F, Banach DB, Basu SS, Bhaskaran A, Danziger-Isakov L, Bard JD, Gandhi R, Hanisch B, John TM, Odom John AR, Letourneau AR, Luong ML, Maron G, Miller S, Prinzi A, Schwartz I, Simner P, Kumar D. A consensus conference to define the utility of advanced infectious disease diagnostics in solid organ transplant recipients. Am J Transplant 2022; 22:3150-3169. [PMID: 35822346 DOI: 10.1111/ajt.17147] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 06/28/2022] [Accepted: 07/07/2022] [Indexed: 01/25/2023]
Abstract
The last decade has seen an explosion of advanced assays for the diagnosis of infectious diseases, yet evidence-based recommendations to inform their optimal use in the care of transplant recipients are lacking. A consensus conference sponsored by the American Society of Transplantation (AST) was convened on December 7, 2021, to define the utility of novel infectious disease diagnostics in organ transplant recipients. The conference represented a collaborative effort by experts in transplant infectious diseases, diagnostic stewardship, and clinical microbiology from centers across North America to evaluate current uses, unmet needs, and future directions for assays in 5 categories including (1) multiplex molecular assays, (2) rapid antimicrobial resistance detection methods, (3) pathogen-specific T-cell reactivity assays, (4) next-generation sequencing assays, and (5) mass spectrometry-based assays. Participants reviewed and appraised available literature, determined assay advantages and limitations, developed best practice guidance largely based on expert opinion for clinical use, and identified areas of future investigation in the setting of transplantation. In addition, attendees emphasized the need for well-designed studies to generate high-quality evidence needed to guide care, identified regulatory and financial barriers, and discussed the role of regulatory agencies in facilitating research and implementation of these assays. Findings and consensus statements are presented.
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Affiliation(s)
- Marwan M Azar
- Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sarah Turbett
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - David Gaston
- John's Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Melissa Gitman
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Sophia Koo
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kimberly Hanson
- University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Camille Kotton
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fernanda Silveira
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - David B Banach
- University of Connecticut School of Medicine, Farmington, Connecticut, USA
| | - Sankha S Basu
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Lara Danziger-Isakov
- Cincinnati Children's Hospital Medical Center and University of Cincinnati, Cincinnati, Ohio, USA
| | - Jennifer Dien Bard
- Children's Hospital Los Angeles, University of Southern California, Los Angeles, California, USA
| | - Ronak Gandhi
- Department of Pharmacy Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Hanisch
- Children's National Hospital, Washington, District of Columbia, USA
| | - Teny M John
- The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Audrey R Odom John
- Perelman School of Medicine, University of Pennsylvania, Children's Hospital of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Alyssa R Letourneau
- Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Me-Linh Luong
- Department of Microbiology, University of Montreal, Centre de Recherche du Centre Hospitalier de l'Université de Montréal, Montréal, Canada
| | - Gabriela Maron
- St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Steve Miller
- University of California San Francisco School of Medicine, San Francisco, California, USA
| | - Andrea Prinzi
- Infectious Disease Medical Science Liaison, Denver, Colorado, USA
| | - Ilan Schwartz
- Faculty of Medicine and Dentistry, University of Alberta, University of Alberta, Alberta, Canada
| | - Patricia Simner
- John's Hopkins University School of Medicine, Baltimore, Maryland, USA
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Haynes AS, Prinzi A, Silveira LJ, Parker SK, Lampe JN, Kavanaugh JS, Horswill AR, Fish D. Cefadroxil Comparable to Cephalexin: Minimum Inhibitory Concentrations among Methicillin-Susceptible Staphylococcus aureus Isolates from Pediatric Musculoskeletal Infections. Microbiol Spectr 2022; 10:e0103922. [PMID: 35730963 PMCID: PMC9431593 DOI: 10.1128/spectrum.01039-22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 05/25/2022] [Indexed: 11/20/2022] Open
Abstract
Cephalexin and cefadroxil are oral first-generation cephalosporins used to treat methicillin-susceptible Staphylococcus aureus (MSSA) infections. Despite its shorter half-life, cephalexin is more frequently prescribed, although cefadroxil is an appealing alternative, given its slower clearance and possibility for less frequent dosing. We report comparative MIC distributions for cefadroxil and cephalexin, as well as for oxacillin, cephalothin, ceftaroline, and cefazolin, for 48 unique clinical MSSA isolates from pediatric patients with musculoskeletal infections. Both cefadroxil and cephalexin had MIC50 values of 2 μg/mL and MIC90 values of 4 μg/mL. MIC50s for oxacillin, cephalothin, and ceftaroline were ≤0.25 μg/mL, and cefazolin's MIC50 was 0.5 μg/mL. While cefadroxil and cephalexin MICs are higher than those for other active agents, the distributions of MICs for cefadroxil and cephalexin are statistically equivalent, suggesting similar in vitro MSSA activities. Cefadroxil should be further considered an alternative agent to cephalexin, although additional work is needed to identify the optimal dose and frequency of these antibiotics for the treatment of serious MSSA infections. IMPORTANCE Cephalexin and cefadroxil are oral antibiotics that are used to treat serious infections due to the bacteria MSSA. While cephalexin is used more commonly, cefadroxil is excreted from the body more slowly; this generally allows patients to take cefadroxil less frequently than cephalexin. In this study, we compared the abilities of cefadroxil, cephalexin, and several other representative intravenous antibiotics to inhibit the growth of MSSA in the laboratory. Bacterial samples were obtained from children with bone, joint, and/or muscle infections caused by MSSA. We found that cefadroxil and cephalexin inhibited the growth of MSSA at similar concentrations, suggesting similar antibacterial potencies. The selected intravenous antistaphylococcal antibiotics generally inhibited bacterial growth with lower antibiotic concentrations. Based on these results, cefadroxil should be further considered an alternative oral antibiotic to cephalexin, although future research is needed to identify the optimal dose and frequency of these antibiotics for serious infections.
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Affiliation(s)
- Andrew S. Haynes
- Children’s Hospital Colorado, Department of Pediatrics, Section of Pediatric Infectious Diseases, Aurora, Colorado, USA
- University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Andrea Prinzi
- Children’s Hospital Colorado, Department of Pediatrics, Section of Pediatric Infectious Diseases, Aurora, Colorado, USA
- University of Colorado Anschutz Medical Campus, Graduate School, Aurora, Colorado, USA
| | - Lori J. Silveira
- University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Sarah K. Parker
- Children’s Hospital Colorado, Department of Pediatrics, Section of Pediatric Infectious Diseases, Aurora, Colorado, USA
- University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, USA
| | - Jed N. Lampe
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
| | - Jeffrey S. Kavanaugh
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Alexander R. Horswill
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, Colorado, USA
- Department of Veterans Affairs, Eastern Colorado Healthcare System, Aurora, Colorado, USA
| | - Douglas Fish
- University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, USA
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Prinzi A, Parker SK, Thurm C, Birkholz M, Sick-Samuels A. Association of Endotracheal Aspirate Culture Variability and Antibiotic Use in Mechanically Ventilated Pediatric Patients. JAMA Netw Open 2021; 4:e2140378. [PMID: 34935920 PMCID: PMC8696566 DOI: 10.1001/jamanetworkopen.2021.40378] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Endotracheal aspirate cultures are commonly collected from patients with mechanical ventilation to evaluate for ventilator-associated pneumonia or tracheitis. However, the respiratory tract is not sterile, making differentiating between colonization from bacterial infection challenging, and results may be unreliable owing to variable specimen quality and sample processing across laboratories. Despite these limitations, clinicians routinely interpret bacterial growth in endotracheal aspirate cultures as evidence of infection, sometimes regardless of organism significance, prompting antibiotic treatment. OBJECTIVE To assess the variability in endotracheal aspirate culture rates and the association between culture rates and antibiotic prescribing among patients with mechanical ventilation across children's hospitals in the US. DESIGN, SETTING, AND PARTICIPANTS Cross-sectional retrospective analysis of data obtained from the Children's Hospital Association Pediatric Health Information System database between January 1, 2016, through December 31, 2019. Participants were all patients hospitalized with mechanical ventilation aged less than 18 years. EXPOSURES A charge for an endotracheal aspirate culture on a ventilated day. MAIN OUTCOMES AND MEASURES Endotracheal aspirate culture rate and antibiotic days of therapy per ventilated days. For mechanical ventilation, clinical transaction classification codes for mechanical ventilation other unspecified ventilator assistance were used. To identify respiratory cultures, the laboratory test code for aerobic culture was used and relevant keywords (ie, respiratory tract, sputum) were used to identify sources in the hospital charge description master. RESULTS A total of 152 132 patients were identified among 31 hospitals. Among these patients, 79 691 endotracheal aspirate cultures were collected on a ventilator-day (patients aged less than 1 year, 44%; 1-4 years, 27%, 5-11 years. 16%, and 12-18 years, 13%; 3% were Asian; 17% Hispanic; 21% non-Hispanic Black; 45% Non-Hispanic White patients; 14% were other; 56% of patients were male, 44% were female). The overall median rate of culture use was 46 per 1000 ventilator-days (IQR, 32-73 cultures per 1000 ventilator-days). The endotracheal aspirate culture rate was positively correlated with the hospital's antibiotic days of therapy rate (R = 0.46; P = .009). In a multivariable model adjusting for patient-level and hospital-level characteristics and among patients with mechanical ventilation, each additional endotracheal aspirate culture was associated with 2.87 (95% CI, 2.74-3.01) higher odds of receiving additional days of therapy compared with patients who did not receive and endotracheal aspirate culture. CONCLUSIONS AND RELEVANCE In this study, notable variability was found in endotracheal aspirate culture rates across US pediatric hospitals and pediatric intensive care units, and endotracheal aspirate culture use was associated with increased antibiotic use. These findings suggest an opportunity for diagnostic and antibiotic stewardship to standardize testing and treatment of suspected ventilator-associated infections in pediatric patients with mechanical ventilation pediatric patients.
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Affiliation(s)
- Andrea Prinzi
- Department of Infectious Diseases, Children’s Hospital Colorado, Denver
- University of Colorado Anschutz Medical Campus Graduate School, Denver
| | - Sarah K. Parker
- Department of Infectious Diseases, Children’s Hospital Colorado, Denver
- Department of Pediatrics, University of Colorado School of Medicine, Denver
| | - Cary Thurm
- Children’s Hospital Association, Lenexa, Kansas
| | - Meghan Birkholz
- Department of Infectious Diseases, Children’s Hospital Colorado, Denver
| | - Anna Sick-Samuels
- Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Abstract
OBJECTIVES Initiation and continuation of empirical antimicrobial agents for a 48-72-hour observation period is routine practice in the diagnosis and treatment of infants and children with concern for bacteremia. We examined blood cultures at a freestanding pediatric hospital over a 6-year period to determine the time to positivity. METHODS Data were extracted for all patients who were hospitalized and had blood cultures drawn between January 2013 and December 2018. Time to positivity was calculated on the basis of date and time culture was collected compared with date and time growth was first reported. RESULTS Over a 6-year period, 89 663 blood cultures were obtained, of which 6184 had positive results. After exclusions, a total of 2121 positive blood culture results remained, including 1454 (69%) pathogens and 667 contaminants (31%). For all positive blood culture results, the number and percentage positive at 24, 36, and 48 hours were 1441 of 2121 (68%), 1845 of 2121 (87%) and 1970 of 2121 (93%), respectively. One hundred twenty-five (66 pathogens, 59 contaminants) of the 89 663 cultures (0.14%) yielded positive results between 36 and 48 hours, indicating that 719 patients would need to be treated for 48 hours rather than 36 hours to prevent 1 case of antibiotic termination before positive result. Median times to positive result by pathogen and service line are presented. CONCLUSIONS This study reveals that ≤36 hours may be a sufficient period of observation for infants and children started on empirical antimicrobial agents for concern for bacteremia. These findings highlight opportunities for antimicrobial stewardship to limit antimicrobial .
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Affiliation(s)
| | - Manon C Williams
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado
| | | | - Kelly Pearce
- Epidemiology, Children's Hospital Colorado, Aurora, Colorado
| | - Dustin Lamb
- School of Medicine, University of Colorado, Aurora, Colorado
| | - Sarah K Parker
- Department of Pediatric Infectious Diseases, Children's Hospital Colorado and School of Medicine, University of Colorado, Aurora, Colorado.,Epidemiology, Children's Hospital Colorado, Aurora, Colorado
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6
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Prinzi A, Curtis D, Parker S, Ziniel S. 672. The Pediatric Endotracheal Aspirate Culture Survey (Petacs): Examining Practice Variation Across Pediatric Microbiology Laboratories in the United States. Open Forum Infect Dis 2020. [PMCID: PMC7777241 DOI: 10.1093/ofid/ofaa439.865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background In the absence of evidence-based laboratory guidelines, the workup and interpretation of tracheal aspirate (TA) cultures remains controversial and confusing within the fields of clinical microbiology, infectious diseases, and critical care. Methods Between January 22 and February 24, 2020, we conducted a national, web-based survey of microbiology laboratory personnel in free-standing pediatric hospitals and adult hospitals containing pediatric facilities regarding the laboratory practices used for TA specimens. We hypothesized that there would be substantial center-level variability in laboratory processes of TA cultures. Results The response rate for the survey was 48%. There was a high level of variability in the criteria used for all processes including specimen receipt, Gram staining and culture reporting. Nearly a quarter of respondents (23%) reject TA specimens based on Gram stain criteria, and 56% of labs require that a minimum number of Gram stain fields be reviewed prior to reporting results. Overall, non-academic hospital laboratories and pediatric-only laboratories are more likely to identify, report and perform susceptibility testing on organisms from tracheal aspirate cultures, regardless of organism quantity or predominance. Conclusion There is a substantial amount of process variability among pediatric microbiology laboratories that affects TA culture reporting, which is used to make treatment decisions. This variation within and among labs makes clinical outcome studies related to TA cultures very difficult. Research is needed to determine best laboratory practices for TA culture workup and to provide evidence for the development of clinical guidelines. Disclosures All Authors: No reported disclosures
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Affiliation(s)
- Andrea Prinzi
- University of Colorado Graduate School, Denver, Colorado
| | - Donna Curtis
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Sonja Ziniel
- Children’s Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado
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Williams MC, Dominguez SR, Prinzi A, Lee K, Parker SK. Reliability of mecA in Predicting Phenotypic Susceptibilities of Coagulase-Negative Staphylococci and Staphylococcus aureus. Open Forum Infect Dis 2020; 7:ofaa553. [PMID: 33409329 PMCID: PMC7759207 DOI: 10.1093/ofid/ofaa553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 12/10/2020] [Indexed: 12/29/2022] Open
Abstract
The mecA gene is commonly used to identify resistance in Staphylococcus aureus, but historically is not used for coagulase-negative staphylococci (CoNS). Analysis of 412 staphylococcal blood cultures (2014–2018) revealed that the absence of mecA had high concordance (100%) with oxacillin susceptibility for S. aureus and CoNS alike.
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Affiliation(s)
- Manon C Williams
- Section of Pediatric Infectious Diseases, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samuel R Dominguez
- Section of Pediatric Infectious Diseases, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Pathology and Laboratory Medicine, Children's Hospital Colorado, Aurora, Colorado, USA.,Department of Infection Control and Epidemiology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Andrea Prinzi
- Department of Pathology and Laboratory Medicine, Children's Hospital Colorado, Aurora, Colorado, USA.,Clinical Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Kayla Lee
- Department of Pathology and Laboratory Medicine, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Sarah K Parker
- Section of Pediatric Infectious Diseases, Children's Hospital Colorado and the University of Colorado School of Medicine, Aurora, Colorado, USA.,Department of Infection Control and Epidemiology, Children's Hospital Colorado, Aurora, Colorado, USA
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