Navigating Multiple Challenges: Malnutrition and Nephrotoxic Drug Effects in a Non-verbal Child With Autism Spectrum Disorder Requiring Dialysis

Acute kidney injury (AKI) is a common medication adverse event, particularly in patients with pre-existing medical conditions taking nephrotoxic medications. However, little is known about the differences in the risk of nephrotoxic medication-related complications in children with autism spectrum disorder (ASD) compared to the general pediatric population. A nine-year-old non-verbal boy with ASD was hospitalized for scrotal cellulitis requiring vancomycin and piperacillin/tazobactam due to a lack of clinical response to cephalosporins. His history is significant for being an extremely selective eater, and his appetite decreased over four months prior to presentation. Poorly controlled scrotal pain, despite acetaminophen use, was suspected based on his facial expressions and maternal assessment, especially considering his non-verbal status. Consequently, a non-steroidal anti-inflammatory drug was initiated. The hospital course was complicated by the development of a scrotal abscess, minimal enteral intake, hypoalbuminemia-induced intravascular dehydration, oliguria, and generalized edema. His creatinine increased to 5.11 mg/dL from 0.51 mg/dL despite early discontinuation of nephrotoxic medications and fluid resuscitation, which led to hemodialysis due to worsening AKI. Subsequently, urinary output and edema improved. Creatinine improved to <1 mg/dL with careful creatinine monitoring and concomitant furosemide and albumin infusion in the pediatric intensive care unit. Children with comorbidities, such as malnutrition, who require nephrotoxic medications, need extra attention. Implementing clinical decision support tools or quality improvement programs can promote the prevention of nephrotoxic medication exposure and decrease the incidence of AKI. An alert within an electronic health record system for multiple nephrotoxic drugs and daily multidisciplinary huddles during patient-centered rounds could help reduce and eliminate adverse events. In particular, for non-verbal patients or those with limited communication skills, such as children with ASD, rigorous and close monitoring of vital signs, physical condition, pain, medication intake, and lab results, in addition to a nephrotoxic medication screening and notification system, should be key to optimizing patient care.

Lost in Translation: An OSCE-Based Workshop for Helping Learners Navigate a Limited English Proficiency Patient Encounter

INTRODUCTION

Residents have been known to report a lack of self-efficacy in their ability to provide care for limited English proficiency (LEP) patients. Interpreters must be utilized to help navigate these patient encounters, but many institutions do not have a curriculum focused on utilizing interpreters effectively.

METHODS

We created a 3-hour workshop for physician learners working with the pediatric population. It included a panel discussion, best-practices presentation, video demonstration, observing scenarios, and pre- and postworkshop objective structured clinical exams (OSCEs). The first OSCE introduced learners to a scenario (4-day-old with jaundice with an LEP parent) where interpreter use was imperative. The second OSCE allowed learners to perform another case (12-year-old with an abscess with an LEP parent) and practice newly obtained skills from the workshop. Both OSCEs were scored using a 16-item yes/no checklist. All pediatric residents filled out an eight-item survey to evaluate the workshop; a subset of that group performed the pre- and postworkshop OSCEs.

RESULTS

Forty pediatric residents attended the workshop and completed the survey. The workshop was well received, with the majority of residents stating they would change their current interpreter usage practices. Ten pediatric residents performed the pre- and postworkshop OSCEs; all improved their scores.

DISCUSSION

The workshop was effective in improving how residents navigated LEP encounters. It is applicable to learners of all levels who want to improve their communication skills to provide better care for LEP patients and can be tailored to fit the needs of a specific institution.

1449. Comparison of Emergency Department vs. Inpatient Pediatric Treatment for Empiric Community Acquired Pneumonia in Infants and Children over 3 Months of Age

Background

The Infectious Diseases Society of America (IDSA) made guidelines for management of community acquired pneumonia (CAP) in healthy infants and children older than 3 months of age. These were made to assist clinicians in choosing appropriate antimicrobial therapy in order to decrease morbidity and mortality and minimize antimicrobial resistance. Accordingly, narrow-spectrum antibiotics as first-line treatment but inappropriate selection of broad-spectrum antibiotics remains high. Our study investigates the concordance between emergency department (ED) and in-patient prescribers in choosing appropriate antibiotic therapy for CAP.

Methods

This retrospective chart reviews the aforementioned population who were admitted to the inpatient pediatric service via the ED from January 1, 2015–December 1, 2017. Data collection included patient demographics, prior antibiotic use from an outside prescriber, the antimicrobial prescribed in the ED, and the antimicrobial used in the pediatric unit. The primary outcome determined the consistency between the prescribing pattern in the ED and the inpatient. A descriptive statistical analysis was conducted afterward.

Results

A total of 210 patients were admitted to the inpatient pediatric service. The ED prescribed an aminopenicillin to 2.9% of patients or a cephalosporin as monotherapy to 70.9%; 0.9% of patients were started on both types. Once under the hospitalist’s service, the hospitalist continued the cephalosporin in 72.4%, switched to an aminopenicillin in 10.6%, switched to a macrolide in 5.4%, and 8.1% discontinued antimicrobrials altogether. If an aminopenicillin was started in the ED, it was continued by the hospitalist in 83.3% of the cases, with none switching to a cephalosporin, and one patient being switched to a macrolide.

Conclusion

At our local pediatric hospital, there is poor compliance with IDSA guidelines for CAP. There is high concordance between ED and in-patient prescribers since hospitalists were more likely to continue the antimicrobial started in the ED. Guideline adherence might be improved by focus on antibiotic stewardship and creating order sets that adhere to IDSA guidelines. Future studies could investigate if these suggestions improve overall adherence rates.

Disclosures

All authors: No reported disclosures.

Controlled comparison of BacT/ALERT FAN aerobic medium and BATEC fungal blood culture medium for detection of fungemia

Yeasts are an increasingly common cause of nosocomial bloodstream infections. Methods for their detection are many; controlled comparisons are few. The vented FAN aerobic blood culture medium has been shown to be superior to the standard BacT/ALERT aerobic medium for the detection of fungemia as well as bacteremia. The BACTEC selective fungal medium (FM) (BD Biosciences, Sparks, Md.) allowed detection of more episodes of fungemia than did a resin-containing medium with equal volumes of blood cultured. Therefore, we compared vented FAN to FM for the ability to recover fungi from the blood of patients who were at increased risk of having fungemia. From 5,109 cultures processed for which both FAN and FM bottles were adequately filled, fungi were recovered from 87 cultures. Of these, 47 were detected with both bottles, 12 were detected with FAN only, and 28 were detected with FM only (P < 0.05). FAN was the first bottle positive for 36 of the 47 cultures for which both bottles yielded the same fungus, whereas the FM bottle was the first bottle positive for 11 cultures (P < 0.001). A total of 54 episodes of fungemia were identified, with 40 detected by both media, 4 detected only by FAN, and 10 detected only by FM (P value, not significant). We conclude that the vented FAN aerobic bottle is comparable to the FM bottle for detection of episodes of yeast infection but has the added benefit of detecting bacteria.

Controlled clinical comparison of bioMérieux VITAL and BACTEC NR-660 blood culture systems for detection of bacteremia and fungemia in adults

A total of 9,446 blood cultures were collected from adult patients at three university-affiliated hospitals. Of these, 8,943 cultures were received with both aerobic bottles filled adequately; 885 yielded 1,016 microorganisms, including 622 isolates (61%) that were the cause of sepsis, 337 isolates (33%) that were contaminants, and 57 isolates (6%) that were indeterminate as the cause of sepsis. With the exception of Staphylococcus aureus, which was recovered more often from VITAL aerobic bottles, more pathogenic microorganisms were recovered from BACTEC NR6 (aerobic) bottles than from VITAL aerobic bottles. Growth of pathogenic microorganisms was detected earlier in VITAL aerobic bottles. A total of 8,647 blood cultures were received with both anaerobic bottles filled adequately; 655 yielded 740 microorganisms, including 486 isolates (66%) that were the cause of sepsis, 215 isolates (29%) that were contaminants, and 39 isolates (6%) that were indeterminate as the cause of sepsis. More pathogenic microorganisms were recovered from VITAL anaerobic bottles than from BACTEC NR7 (anaerobic) bottles. Growth of pathogenic microorganisms was detected earlier in VITAL anaerobic bottles. In 8,500 sets all four bottles were received adequately filled. When paired aerobic and anaerobic bottle sets (systems) were compared, more pathogenic microorganisms (again with the exception of S. aureus) were recovered from the BACTEC system. For the 304 septic episodes (253 unimicrobial and 51 polymicrobial), significantly more were detected by the BACTEC system. We conclude that VITAL requires modification to improve recovery of pathogenic microorganisms to make it competitive with other commercially available blood culture systems.

Controlled clinical laboratory comparison of BACTEC plus aerobic/F resin medium with BacT/Alert aerobic FAN medium for detection of bacteremia and fungemia

Blood specimens collected from adult patients with suspected sepsis in four medical centers were inoculated into BACTEC Plus/F and BacT/Alert FAN aerobic culture bottles. Both bottles of 7,401 bottle pairs contained the prescribed blood volume of 8 to 12 ml. Bottles were incubated in their respective instruments for a standard 7-day protocol or until the instruments signaled that they were positive. A total of 720 isolates that were judged to represent true infections were recovered from 338 patients; 451 isolates were recovered from both bottles, 143 were recovered from only the Plus/F bottle, and 126 were recovered from only the FAN bottle (P was not significant). Although more Histoplasma capsulatum isolates were recovered from Plus/F bottles (P < 0.005), there were no other statistically significant differences in recovery rates of individual species or groups of organisms between the two systems. Of 329 monomicrobic patient septic episodes, 244 episodes were detected by both blood culture systems, 40 were detected only by the BACTEC system, and 45 were detected only by the BacT/Alert system (P was not significant). There was no significant difference between the two systems in the detection of septic episodes among patients receiving antibiotic therapy at the time of blood cultures. Of the cultures found to be positive within the first 72 h of incubation, detection was on average earlier by the BACTEC system (16.9 h) than by the BacT/Alert system (18.7 h). Larger differences in average time to detection were seen with streptococci (10.7 h by the BACTEC system and 17.9 h by the BacT/Alert system) and yeasts (an average of 29.4 h by the BacT/Alert system versus 37.2 h by the BACTEC system). With the exception of the differences noted above, BACTEC Plus/F aerobic resin and BacT/Alert aerobic FAN blood culture bottles were comparable in their abilities to recover aerobic and facultative organisms.

Clinical importance of increased sensitivity of BacT/Alert FAN aerobic and anaerobic blood culture bottles

Two recent multicenter blood culture studies found that BacT/Alert FAN (FAN) bottles (Organon Teknika, Durham, N.C.) had increased yields in detecting bacteremia and fungemia compared with standard BacT/Alert (STD) bottles. Because the clinical importance of this increase in microbial recovery is unknown, we performed a retrospective analysis to determine the frequency with which FAN bottles were the sole means of detecting an episode of bacteremia. There were 1,047 positive blood cultures in which both study bottles were adequately filled and the organism isolated was judged to be the cause of sepsis: 240 (23%) were positive only in FAN bottles and 73 (7%) were positive only in STD bottles. Of a total of 664 episodes of bacteremia, 126 (19%) were identified only by FAN bottles and 43 (7%) were identified only by STD bottles (P < 0.0001). Episodes detected only by FAN bottles more often were recurrent events (23 of 126, or 18%) than episodes detected only by STD bottles (2 of 43, or 5%) (P < 0.05) and more commonly occurred in patients receiving theoretically effective antibiotic therapy (33 of 126 [26%] versus 4 of 43 [9%]) (P < 0.05). The medical records for patients with 127 of these episodes (92 FAN bottles only; 35 STD bottles only) were available for review. More than half of both FAN bottle-only (60 of 92, or 65%) and STD bottle-only (20 of 35, or 57%) episodes were judged to be clinically important. We conclude that FAN bottles improve the detection of bacteremia and that the majority of the additional episodes detected are clinically important. The benefits of the greater yield in specific patient populations must be balanced against the higher costs of FAN bottles.