Incidence of Antimicrobial-Associated Acute Kidney Injury in Children: A Structured Review

Acute kidney injury (AKI) is a commonly reported adverse effect of administration of antimicrobials. While AKI can be associated with poorer outcomes, there is little information available to understand rates of AKI in children exposed to various antimicrobials. We performed a structured review using the PubMed and Embase databases. Articles were included if they provided an AKI definition in patients who were < 19 years of age receiving an antimicrobial and reported the frequency of AKI. Author-defined AKI rates were calculated for each study and mean pooled estimates for each antimicrobial were derived from among all study participants. Pooled estimates were also derived for those studies that reported AKI according to pRIFLE (pediatric risk, injury, failure, loss, end stage criteria), AKIN (acute kidney injury network), or KDIGO (kidney disease improving global outcomes) creatinine criteria. A total of 122 studies evaluating 28 antimicrobials met the inclusion criteria. Vancomycin was the most commonly studied drug: 11,514 courses across 44 included studies. Among the 27,285 antimicrobial exposures, the overall AKI rate was 13.2% (range 0-42.1% by drug), but the rate of AKI varied widely across studies (range 0-68.8%). Cidofovir (42.1%) and conventional amphotericin B (37.0%) had the highest pooled rates of author-defined AKI. Eighty-one studies used pRIFLE, AKIN, or KDIGO AKI criteria and the pooled rates of AKI were similar to author-defined AKI rates. In conclusion, antimicrobial-associated AKI is reported to occur frequently in children, but the rates of AKI varies widely across studies and drugs. Most published studies examined hospitalized patients and heterogeneity in study populations and in author definitions of AKI are barriers to a comparison of nephrotoxicity risk among antimicrobials in children.

The epidemiology of cephalosporin allergy labels in pediatric primary care

Background

Recent studies have sought to understand the epidemiology and impact of beta-lactam allergy labels on children; however, most of these studies have focused on penicillin allergy labels. Fewer studies assess cephalosporin antibiotic allergy labels in children. The objective of this study was to determine the prevalence, factors associated with, and impact of cephalosporin allergy labels in children cared for in the primary care setting.

Methods

Cephalosporin allergy labels were reviewed among children in a dual center, retrospective, birth cohort who were born between 2010 and 2020 and followed in 90 pediatric primary care practices. Antibiotic prescriptions for acute otitis media were compared in children with and without cephalosporin allergies.

Results

334,465 children comprised the birth cohort and 2,877 (0.9%) were labeled as cephalosporin allergic during the study period at a median age of 1.6 years. Third-generation cephalosporins were the most common class of cephalosporin allergy (83.0%). Cephalosporin allergy labels were more common in children with penicillin allergy labels than those without (5.8% vs. 0.6%). Other factors associated with a cephalosporin allergy label included white race, private insurance, presence of a chronic condition, and increased health care utilization. Children with third-generation cephalosporin allergy labels received more amoxicillin/clavulanate (28.8% vs. 10.2%) and macrolides (10.4% vs. 1.9%) and less amoxicillin (55.8% vs. 70.9%) for treatment of acute otitis media than non-allergic peers p < 0.001.

Conclusions

One in 100 children is labeled as cephalosporin allergic, and these children receive different antibiotics for the treatment of acute otitis media compared to non-allergic peers.

The Quality and Management of Penicillin Allergy Labels in Pediatric Primary Care

BACKGROUND AND OBJECTIVES

Penicillin allergy labels are the most common drug allergy label. The objective of this study was to describe the quality and management of penicillin allergy labels in the pediatric primary care setting.

METHODS

Retrospective chart review of 500 of 18 015 children with penicillin allergy labels born from January 1, 2010 to June 30, 2020 randomly selected from an outpatient birth cohort from Texas Children's Pediatrics and Children's Hospital of Philadelphia networks. Penicillin allergy risk classification ("not allergy," "low risk," "moderate or high risk," "severe risk," "unable to classify") was determined based on documentation within (1) the allergy tab and (2) electronic healthcare notes. Outcomes of allergy referrals and penicillin re-exposure were noted.

RESULTS

Half of penicillin allergy labels were "unable to classify" based on allergy tab documentation. Risk classification agreement between allergy tabs and healthcare notes was fair (Cohen's ĸ = 0.35 ± 0.02). Primary care physicians referred 84 of 500 (16.8%) children to an allergist, but only 54 (10.8%) were seen in allergy clinic. All children who were challenged (25 of 25) passed skin testing. Removal of allergy labels was uncommon (69 of 500, 13.8%) but occurred more often following allergy appointments (26 of 54, 48%) than not (43 of 446, 9.6%, P < .001). Children delabeled by primary care physicians were as likely to tolerate subsequent penicillin-class antibiotics as those delabeled by an allergist (94% vs 93%, P = .87).

CONCLUSIONS

Penicillin allergy documentation within the allergy tab was uninformative, and children were infrequently referred to allergists. Future quality improvement studies should improve penicillin allergy documentation and expand access to allergy services.

Impact of Penicillin Allergy Labels on Children Treated for Outpatient Respiratory Infections

BACKGROUND

Penicillin allergy is the most common antibiotic allergy, yet most children labeled as allergic tolerate penicillin. The impact of inaccurate penicillin allergy labels (PALs) on pediatric outpatients is unknown. The objective of this study was to compare outcomes between children with and without a PAL after treatment for outpatient respiratory tract infections (RTI).

METHODS

A retrospective, longitudinal birth cohort study was performed in children who received care in 90 pediatric primary care practices in Philadelphia and Houston metropolitan areas. Prescribing and clinical outcomes of children with a PAL at the time of an RTI were compared to non-allergic children, adjusting for potential confounders.

RESULTS

Antibiotics were prescribed for 663,473 non-recurrent RTIs among 200,977 children. Children with a PAL (5% of cohort) were more likely than non-allergic children to receive broad-spectrum antibiotics (adjusted relative risk (aRR) 3.24, 95% CI 3.22-3.26) and second-line antibiotics (aRR 4.87, 95% CI 4.83, 4.89). Compared to non-allergic children receiving first-line antibiotics, children with a PAL were more likely to return with adverse drug events (aRR 1.28, 95% CI 1.18-1.39). There was no difference in treatment failure between groups (aRR 0.95, 95% CI 0.90-1.00).

CONCLUSIONS

PALs lead to higher rates of broad-spectrum and second-line antibiotic prescribing in children treated for RTIs in primary care and contribute to unnecessary healthcare utilization through increased adverse events. Given the frequency of PALs, efforts to prevent inappropriate penicillin allergy labeling and promote de-labeling of existing inaccurate allergy labels may improve care of children treated for common bacterial infections.

949. Impact of Antimicrobial Stewardship Pharmacist Participation in Pediatric Infectious Diseases Rounds on Prospective Audit and Feedback Recommendations

Background

Prospective audit and feedback (PAF) is a core strategy of antimicrobial stewardship programs (ASPs). To improve communication of PAF recommendations to the inpatient pediatric infectious diseases (ID) consult service, the ASP pharmacists at our hospital were integrated into ID rounds. The purpose of this study was to assess the impact of ASP pharmacy participation in ID rounds on the rate of ASP recommendations.

Methods

Prior to implementation of the ASP pharmacist rounding service, the ASP pharmacist did not routinely attend rounds or communicate PAF recommendations directly to the ID consult service. Starting 1/3/22, the ASP pharmacists had daily (M-F) in-person discussions with the ID team regarding their patients’ antimicrobials. Audits performed between 1/4/21-12/30/21 and 1/3/22-4/29/22 on patients with an ID consult were included in the non-rounding cohort (NRC) and rounding cohort (RC), respectively. We compared PAF recommendation rates, characteristics, and acceptance rates between the two cohorts.

Results

There was an increase in PAF recommendation rate in the RC compared to NRC (188/485 [39%] vs 359/1234 [29%], p < 0.001). Antibiotics were the antimicrobial category mostly likely to have a recommendation and the rate of antibiotic PAF recommendations was higher in the RC compared to the NRC (132/341 [39%] vs. 271/934 [29%], p = 0.001) (Table 1). The most common recommendation types in both cohorts were to optimize the antimicrobial dose and antimicrobial discontinuation. Recommendations were more frequently communicated to the ID team in the RC compared to NRC (125/188 [66%] vs. 107/359 [30%], p < 0.001). The recommendation acceptance rate was similar between the two cohorts (159/188 [85%] RC vs. 290/359 [81%] NRC, p = 0.29).

CNS: Central nervous system; IV: Intravenous; NRC: Non-rounding cohort; PAF: Prospective audit and feedback; PO: Per os, oral; RC: Rounding cohort; SSTI: Skin and soft tissue infection; UTI: Urinary tract infection.

Conclusion

Implementation of a pediatric ASP pharmacist rounding service increased the PAF recommendation rate and improved recommendation communication with the pediatric ID consult service. Participation in rounds may better inform ASP pharmacist PAF recommendations. Future studies describing the potential benefit to the ID team by having an ASP pharmacist present on rounds are warranted. ASPs should consider formal integration of ASP pharmacists as part of the ID consult service to further improve the quality of antimicrobial prescribing.

Disclosures

All Authors: No reported disclosures.

567. The Quality & Management of Penicillin Allergy Labels in a Pediatric Birth Cohort

Background

Penicillin allergy labels (PALs) influence antibiotic prescribing, yet little is known about the quality and management of PALs placed in the pediatric outpatient setting.

Methods

We performed a retrospective chart review of 500 randomly selected children with PALs from a ten-year birth cohort (n=18,015) from Texas Children’s Pediatrics and Children’s Hospital of Philadelphia Primary Care Networks. PALs were classified as “not allergy” (family history, isolated diarrhea), “low risk” (maculopapular rash >24 hours into antibiotic course, no hives or pruritis), “moderate or high risk” (hives or pruritis, maculopapular rash < 24 hours into antibiotic course, anaphylaxis, swelling, or respiratory symptoms), “severe cutaneous reaction” (erythema multiforme, serum sickness), or “unable to classify” (information not available or unspecified rash characteristics or timing) based on 1) information in the allergy tab and 2) encounter notes. We used kappa-statistic measure-of-agreement to determine allergy classification agreement between the allergy tab and notes.

Results

The median age of PAL placement was 1.4 years (IQR 0.9, 2.2). Most (n=303, 63%) PALs were placed by physicians. Half of PALs were categorized as “unable to classify; physicians were just as likely to place ambiguous PALs as other providers (48 vs 53%, p=0.31). Most (80%) children were evaluated at a primary care office within 1 week of their reaction. There was fair agreement between the allergy tab and encounter note documentation (Table 1). Of 54 (11%) children evaluated by an allergist, 25/25 passed an oral amoxicillin challenge. Only 69 (14%) children were de-labeled during the study period, more by an allergist (48%) than in the community (9.6%, p< 0.001). Table 1.

Factors Associated With Penicillin Allergy Labels in Electronic Health Records of Children in 2 Large US Pediatric Primary Care Networks

Importance

Penicillin allergy labels influence clinical decision-making, yet most children who are labeled do not have type 1 hypersensitivity allergic reactions and instead have a history of predictable adverse reactions or unspecified illness symptoms while receiving penicillin for viral infections. Studies describing penicillin allergy labeling in the pediatric outpatient setting are lacking.

Objective

To describe the epidemiology and factors associated with penicillin allergy labels across 2 large US pediatric primary care networks.

Design, Setting, and Participants

This retrospective, longitudinal birth cohort study was conducted in 90 primary care pediatric practices serving a diverse population of children across Houston, Texas, Austin, Texas, Philadelphia, Pennsylvania, and parts of New Jersey. Participants were children born between January 2010 and June 2020 who had a health care visit in the first 14 days of life and at least 2 additional visits in the first year of life at one of 90 primary care pediatric practices. Censoring criteria were additionally applied to exclude data from children no longer seeking health care in the 90 clinics over time. Statistical analysis was performed from February to May 2021.

Exposures

Basic patient demographics, health care utilization, penicillin exposure, and primary clinic location.

Main Outcomes and Measures

Addition of penicillin allergy label in the electronic medical record.

Results

Among 334 465 children in the birth cohort, 164 173 (49.1%) were female; 72 831 (21.8%) were Hispanic, 59 598 (17.8%) were non-Hispanic Black, and 148 534 (44.4%) were non-Hispanic White; the median (IQR) age at censoring was 3.8 (1.7-6.6) years; 18 015 (5.4%) were labeled as penicillin allergic, but the prevalence of penicillin allergy labeling ranged from 0.9% to 10.2% across practices. Children were labeled at a median (IQR) age of 1.3 (0.9-2.3) years. Non-Hispanic White children were more likely to be labeled compared with non-Hispanic Black children after controlling for potential confounders (adjusted odds ratio, 1.7 [95% CI, 1.6-1.8]). There were 6797 allergic children (37.7%) labeled after receiving 1 penicillin prescription and 1423 (7.9%) labeled after receiving 0 penicillin prescriptions.

Conclusions and Relevance

In this cohort study of more than 330 000 children, penicillin allergy labeling was common and varied widely across practices. Children were labeled early in life, and almost half were labeled after receiving 1 or 0 penicillin prescriptions. These findings raise questions regarding the validity of penicillin allergy labels. Future work exploring the fidelity of and outcomes associated with penicillin allergy-labeling in children is warranted.

1135. The Effect of Penicillin Allergy Labels on Antibiotic Prescribing for Children Diagnosed with Upper Respiratory Tract Infections in Two Primary Care Networks

Background

In pediatric inpatient settings, unconfirmed penicillin allergy labels (PALs) are associated with increased broad-spectrum antibiotic use, costs, and adverse events. However, 90% of antibiotics are prescribed in the outpatient setting and 70% of these antibiotics are given for upper respiratory tract infections (URTI.) Little is known about the effect of PALs on antibiotic prescribing in the pediatric outpatient population.

Methods

A retrospective birth cohort was created of children born between January 1^st 2010 and June 30^th 2020 and seen at one of 91 Texas Children’s Pediatrics or Children’s Hospital of Philadelphia primary care clinics. Children with an ICD10 code for an URTI and an antibiotic prescription were stratified into those with or without a penicillin allergy label at the time of the infection. Rates of second-line and broad-spectrum antibiotic use were compared.

Results

The birth cohort included 334,465 children followed for 1.2 million person-years. An antibiotic was prescribed for 696,782 URTIs and the most common diagnosis was acute otitis media. Children with PALs were significantly more likely to receive second-line antibiotics (OR 35.0, 95% CI 33.9-36.1) and broad-spectrum antibiotics (OR 23.9, 95% CI 23.2-24.8.) Children with PALs received more third generation cephalosporins (60% vs. 15%) and more macrolide antibiotics (25% vs. 3%) than those without a PAL. Overall, 18,015 children (5.4%) acquired a PAL during the study period, which accounted for 23% of all second-line antibiotic prescriptions and 17% of all broad-spectrum antibiotic use for URTIs.

Multivariable logistic regression for receipt of second-line antibiotics for upper respiratory tract infections

Conclusion

PALs are common and account for a substantial proportion of second-line and broad-spectrum antibiotic use in pediatric outpatients treated for URTIs. Efforts to de-label children with PALs are likely to increase first-line antibiotic use and decrease broad-spectrum antibiotic use for URTIs, the most common indication for antibiotic prescribing to children.

Disclosures

Debra Palazzi, MD, MEd, AAP (Other Financial or Material Support, PREP ID Editorial Board, PREP ID Course)AHRQ (Research Grant or Support)Elsevier (Other Financial or Material Support, Royalties for writing and editing chapters)JAMA Pediatrics (Board Member)

159. Characterization of Suboptimal Discharge Antimicrobial Prescriptions and Effect of Inpatient Audit and Feedback on Quality of Antimicrobial Prescribing

Background

Approximately 30% of children are discharged from the hospital with an antimicrobial prescription; nearly a third of these prescriptions are suboptimal. Although the best approach to antimicrobial stewardship of discharge prescriptions remains uncertain, prospective audit and feedback (PAF) has improved inpatient antimicrobial use. We aimed to identify and characterize suboptimal discharge antimicrobial prescribing and assess the impact of inpatient PAF on the quality of discharge antimicrobial prescribing at a free-standing children’s hospital.

Methods

A retrospective review of enteral discharge antimicrobial prescriptions between 12/1/20-5/31/21 and parenteral antimicrobial prescriptions sent to our hospital’s infusion pharmacy between 3/1/21-5/31/21 was performed to determine if suboptimal or not. A prescription was determined to be suboptimal if the antimicrobial choice, dose, frequency, duration, formulation, or indication was not consistent with institutional and/or national guidelines. Data collection included the antimicrobial, indication, and prescribing medical service. Prescriptions were evaluated for a corresponding inpatient PAF for the same drug and indication and then stratified based on inpatient PAF completion.

Results

A total of 1192 discharge prescriptions for 698 unique patients over 834 hospital encounters were reviewed. Overall, 243 (20%) prescriptions were identified as suboptimal; reasons were duration (16%), dose (8%), frequency (5%), or antimicrobial choice, formulation, or route (≤1%). Prescriptions for cephalexin had the highest rate of suboptimal prescribing (80/167, 48%), followed by amoxicillin-clavulanate (89/203, 44%). A corresponding inpatient PAF was identified for 675 (57%) of discharge antimicrobial prescriptions. Inpatient PAF prior to discharge resulted in fewer suboptimal discharge prescriptions for the same antimicrobial (8% vs. 36%, p < 0.001).

Conclusion

Antimicrobial prescribing at inpatient discharge was suboptimal in 1 of every 5 prescriptions. Inpatient PAF was associated with improved antimicrobial prescribing at hospital discharge. Antimicrobial stewardship programs should continue to explore ways to capture and intervene on antimicrobials prescribed at discharge.

Disclosures

Hayden T. Schwenk, MD, MPH, Nothing to disclose

Suppurative Intracranial Complications of Pediatric Sinusitis: A Single-Center Experience

BACKGROUND

Suppurative intracranial complications of sinusitis are rare events in children and can lead to harmful neurologic sequelae and significant morbidity. We sought to review the presentation and management of patients admitted at our hospital with these conditions.

METHODS

This was a retrospective study of pediatric patients admitted to a quaternary children's hospital from 2007 to 2019 for operative management of sinusitis with intracranial extension. Clinical characteristics, including surgical and microbiological data, were collected and analyzed.

RESULTS

Fifty-four patients were included; the median age was 11.0 years, and there was a male predominance. Eighty-nine percent of patients had prior healthcare visits for the current episode of sinusitis; 46% of patients had an abnormal neurologic exam on admission. Epidural abscess and subdural empyema were the most common complications, and subdural empyema was associated with repeat surgical intervention. The dominant pathogens were Streptococcus anginosus group organisms (74%). The majority of patients completed treatment parenterally, with a median duration of therapy of 35 days. Neurological sequelae, including epilepsy or ongoing focal deficits, occurred in 22% of patients. History of seizure or an abnormal neurological exam at admission were associated with neurological sequelae.

CONCLUSIONS

Clinicians should consider intracranial complications of sinusitis in patients with symptoms of sinusitis for >1 week. Patients should undergo urgent neuroimaging, as neurosurgical intervention is essential for these patients. Subdural empyema was associated with repeat neurosurgical intervention. Neurological sequelae occurred in 22% of patients, and new onset seizure or an abnormal neurological exam at admission were associated with neurological sequelae.

Characterization of Vibrio parahaemolyticus serotype O3:K6 activation of murine macrophage. (111.27)

Vibrio parahaemolyticus is the leading cause of seafood-related bacterial gastroenteritis in the United States. There is a dearth of literature regarding the host response to, and subsequent elimination of, infection with this pathogen. Here, we have developed an in vitro model using the virulent clinical isolate V. parahaemolyticus RIMD2210633, an O3:K6 serotype. We determined that this isolate could infect RAW264.7 cells, a murine macrophage cell line and bone marrow derived macrophage (BMDM), resulting in the production of the early proinflammatory cytokines interleukin-1 alpha (IL-1α), interleukin 6 (IL-6) and interleukin 10 (IL-10). Additionally, infected RAW264.7 macrophage displayed increased surface CD86, CD40 and class II MHC expression while displaying a decrease in TLR4. Concurrently, we investigated the production of reactive oxygen species (ROS) by both RAW264.7 and BMDM infected with this virulent clinical strain. We report that in response to infection, both types of macrophage demonstrate increased production of ROS. We have determined that infection of macrophage by a virulent clinical isolate of Vibrio parahaemolyticus results in immune activation as demonstrated by increased cell surface molecules and proinflammatory cytokine production. Characterization of this response will provide the foundation to understand elimination of this organism from the infected host.

Generation of a proinflammatory response by macrophage following infection with an O3:K6 serotype of Vibrio parahaemolyticus. (94.3)

Vibrio parahaemolyticus, a Gram-negative bacterium, is the leading cause of seafood-related bacterial gastroenteritis in the United States. This emerging pathogen can causes self-limiting gastrointestinal infection, wound infection, and, in the immunocompromised host, significant systemic disease, leading to death. The CDC has recently reported a 47% increase in the number of culture confirmed V. parahaemolyticus infections since 1996-1998. There is a dearth of literature regarding the host response to, and subsequent elimination of, infection with this pathogen. In order to elucidate the immune response to infection, we have developed an in vitro model using the virulent clinical isolate V. parahaemolyticus RIMD2210633, an O3:K6 serotype. First, we determined that this isolate could infect RAW264.7 cells, a murine macrophage cell line. Additionally, infection resulted in the simultaneous detection of 7-amino-actinomycin D (7-AAD) and annexin-V positive cells, suggesting cell death with a loss of membrane integrity. Lastly, infection resulted in the production of the early proinflammatory cytokines interleukin-1 alpha (IL-1α) and interleukin 6 (IL-6). We a currently investigating the cellular pathways involved in this proinflammatory response and macrophage cell death. Here, we have begun to investigate those aspects of the immune response required to eliminate this gastrointestinal pathogen from infected host tissues.

Disintegrins in health and disease

Few of the proteins isolated and characterized from snake venom have proven to be more chemically diverse, exquisitely specific or promiscuously active than the family known as disintegrins. These small proteins have shown structural homology with hundreds of cell surface molecules from plants and animals other than snakes, and their precise mimicry of native receptor ligands speaks to evolutionary niches related to survival and geographic locale. Over 100 disintegrins have been named and studied, with the most recent efforts into molecular techniques providing significant clues to taxonomic relationships among four different snake families. Investigators have evaluated disintegrin applications in therapies for cancer, asthma, osteopenia and inappropriate angiogenesis. Crystal and NMR studies have confirmed hypotheses regarding ligand-receptor interactions while illuminating the complexities of structure-function evidence. Disintegrin chimeras with viruses, microbubbles and fluorescent labels have become useful tools in many investigations. While many disintegrin studies still involve platelets, previously unexplored interactions with glial cancer, T lymphocytes and the bacteria Yersinia have blazed new trails for this field. This review will summarize disintegrin investigations since 2003.