William F. Malcolm

Background and Aims: Policymakers need data about the burden of respiratory syncytial virus (RSV) lower respiratory tract infections (LRTI) among infants. This study estimates quality of life (QoL) for otherwise healthy term US infants with RSV‐LRTI and their caregivers, previously limited to premature and hospitalized infants, and corrects for selective testing.Methods: The study enrolled infants n = 11) LRTI‐tested infants (66.4) was lower than that in not‐tested LRTI infants (79.6,p = 0.096). For outpatient LRTI infants (n = 23), median QALYs/1000 losses were 9.8 and 0.25 for their caregivers. RSV‐positive outpatient LRTI infants (n = 6) had significantly milder QALYs/1000 losses (7.0) than other LRTI‐tested infants (n = 5)(21.8,p = 0.030). Visits earlier in the year were more likely to be RSV‐positive than later visits (p = 0.023). Modeled RSV‐positivity (51.9%) was lower than the observed rate (55.0%). Infants’ and caregivers’ QALYs/1000 loss were positively correlated (rho = 0.34,p = 0.046), indicating that infants perceived as sicker imposed greater burdens on caregivers.Conclusions: The overall median QALYs/1000 losses for LRTI (9.0) and RSV‐LRTI (5.6) in US infants are substantial, with additional losses for their caregivers (0.25 and 0.20, respectively). These losses extend equally to outpatient episodes. This study is the first reporting QALY losses for infants with LRTI born at term or presenting in nonhospitalized settings, and their caregivers.

Background: Surveillance in 2020–2021 showed that seasonal respiratory illnesses were below levels seen during prior seasons, with the exception of interseasonal respiratory syncytial virus (RSV). Methods: Electronic health record data of infants aged <1 year visiting the Duke University Health System from 4 October 2015 to 28 March 2020 (pre–COVID-19) and 29 March 2020 to 30 October 2021 (COVID-19) were assessed. International Classification of Diseases-Tenth Revision (ICD-10) codes for RSV (B97.4, J12.1, J20.5, J21.0) and bronchiolitis (RSV codes plus J21.8, J21.9) were used to detail encounters in the inpatient (IP), emergency department (ED), outpatient (OP), urgent care (UC), and telemedicine (TM) settings. Results: Pre–COVID-19, 88% of RSV and 92% of bronchiolitis encounters were seen in ambulatory settings. During COVID-19, 94% and 93%, respectively, occurred in ambulatory settings. Pre–COVID-19, the highest RSV proportion was observed in December–January (up to 38% in ED), while the peaks during COVID-19 were seen in July–September (up to 41% in ED) across all settings. RSV laboratory testing among RSV encounters was low during pre–COVID-19 (IP, 51%; ED, 51%; OP, 41%; UC, 84%) and COVID-19 outside of UC (IP, 33%; ED, 47%; OP, 47%; UC, 87%). Full-term, otherwise healthy infants comprised most RSV encounters (pre–COVID-19, up to 57% in OP; COVID-19, up to 82% in TM). Conclusions: With the interruption of historical RSV epidemiologic trends and the emergence of interseasonal disease during COVID-19, continued monitoring of RSV is warranted across all settings as the changing RSV epidemiology could affect the distribution of health care resources and public health policy.

Objectives The objectives describe the frequency that inadequate oral feeding (IOF) is the reason why moderately preterm (MPT) infants remain hospitalized and its association with neonatal morbidities. Study design Prospective study using the NICHD Neonatal Research Network MPT Registry. Multivariable logistic regression was used to describe associations between IOF and continued hospitalization at 36 weeks postmenstrual age (PMA). Result A total of 6017 MPT infants from 18 centers were included. Three-thousand three-seventy-six (56%) remained hospitalized at 36 weeks PMA, of whom 1262 (37%) remained hospitalized due to IOF. IOF was associated with RDS (OR 2.02, 1.66–2.46), PDA (OR 1.86, 1.37–2.52), sepsis (OR 2.36, 95% 1.48–3.78), NEC (OR 16.14, 7.27–35.90), and BPD (OR 3.65, 2.56–5.21) compared to infants discharged and was associated with medical NEC (OR 2.06, 1.19–3.56) and BPD (OR 0.46, 0.34–0.61) compared to infants remaining hospitalized for an alternative reason. Conclusion IOF is the most common barrier to discharge in MPT infants, especially among those with neonatal morbidities.

Urinary tract infections (UTIs) are common. Antibiotic treatment is usually empirical, with the risk of under-treatment of resistant infections. To characterize risk factors for antibiotic-resistant community urine isolates using routine record-linked health data. Within the NHS Scotland Infection Intelligence Platform, national surveillance patient-level data on community urine isolates (January 2012–June 2015) were linked to hospital activity and community prescribing data. Associations between age, gender, comorbidity, care home residence, previous hospitalizations, antibiotic exposure and resistant (any antibiotic) or MDR (≥1 antibiotic from ≥3 categories) urinary isolates were quantified using multivariable logistic regression. Of 40984 isolates, 28% were susceptible, 45% were resistant and 27% were MDR. Exposure to ≥ 4 different antibiotics in the prior 6 months increased MDR risk (OR 6.81, 95% CI 5.73–8.11). MDR was associated with ≥29 DDD cumulative exposure, in the prior 6 months, for any antibiotic (OR 6.54, 95% CI 5.88–7.27), nitrofurantoin (OR 8.56, 95% CI 6.56–11.18) and trimethoprim (OR 14.61, 95% CI 10.53–20.27). Associations persisted for 10–12 months for nitrofurantoin (OR 2.31, 95% CI 1.93–2.76) and trimethoprim (OR 1.81, 95% CI 1.57–2.09). Increasing age, comorbidity, previous hospitalization and care home residence were independently associated with MDR. For resistant isolates the factors were the same, but with weaker associations. To our knowledge, we have demonstrated, using national capability at scale, the risk of MDR in community urine isolates for the first time and quantified the cumulative and sustained impact of antibiotic exposure. These data will inform the development of decision support tools for UTI treatment.

Day‐night cycled light improves health outcomes in preterm infants, yet the best time to institute cycled light is unclear. The hypothesis of this study was that extremely preterm infants receiving early cycled light would have better health and developmental outcomes than infants receiving late cycled light. Infants born at ≤28 weeks gestation were randomly assigned to early cycled light (ECL) starting at 28 weeks postmenstrual age [PMA] or late cycled light (LCL), starting at 36 weeks PMA. Daylight was 200–600 lux and night was 5–30 lux. Primary outcomes were weight over time and length of hospitalization. Secondary outcomes were hospital costs, sleep development, and neurodevelopment at 9, 18, and 24 months corrected age. Of 121 infants randomized, 118 were included in analysis. Weight gain in the two groups did not differ significantly but increased across time in both groups. In PMA weeks 36–44, the mean weight gain was 193.8 grams in the ECL group compared to 176.3 grams in the LCL group. Effect sizes for weight were Cohen d = 0.26 and 0.36 for 36 and 44 weeks PMA. Infants in the ECL group went home an average of 5.5 days earlier than the LCL group, but this difference was not statistically significant. There were no group differences on neurodevelopmental outcomes. Although statistically non‐significant, clinically important differences of improved weight gain and decreased hospital stay were observed with ECL. The small observed effect sizes on weight during hospitalization should be considered in future cycled light research with extremely preterm infants.

Objectives The objective of this study was to retrospectively analyse patterns of primary care antibiotic prescribing by nurse prescribers in Scotland. Methods Data on dispensed antibiotic prescriptions written by nurse prescribers in 2007–13 were obtained from the Prescribing Information System, a database of all NHS prescriptions dispensed in Scotland. Results Since 2007, there has been a steady increase in the volume of antibiotic prescribing in primary care undertaken by nurse prescribers. There was considerable variability in the frequency of antibiotic prescribing among nurses and across NHS regions. Since 2007, an increasing proportion of antibiotics prescribed by nurses are those recommended for first-line empirical treatment of infection, with a reduction in the proportion of broader-spectrum agents. Other measures of prescribing quality (duration of treatment of adult females with urinary tract infection and use of recommended doses) have improved since 2007. Conclusions This paper is the first, to our knowledge, to present an analysis of data on antibiotic prescribing in primary care by nurse prescribers. Inappropriate prescribing is a problem and, given the impact that antibiotic prescribing has on antimicrobial resistance, it is important that the prescribing behaviour of nurses is explored. This is especially significant as this is a growing body of prescribers who predominately work in the community, where the majority of antibiotics are prescribed. This analysis showed that practice varies across NHS regions and between prescribers and although more information is needed to establish whether nurse prescribers are prescribing appropriately, some quality indicators may suggest that they are following best practice.

Objective: Determine associations between left vocal cord paralysis (LVCP) and poor respiratory, feeding and/or developmental outcomes in extremely low birth weight (ELBW) infants following surgical closure of a patent ductus arteriosus (PDA). Study Design: ELBW infants who underwent PDA ligation between January 2004 and December 2006 were identified. We compared infants with and without LVCP following ligation to determine relationships between LVCP and respiratory morbidities, feeding and growth difficulties and neurodevelopmental impairment at 18 to 22-month follow-up. Student's t-test, Fisher's exact test and multivariable regression analyses were used to determine associations. Result: In all, 60 ELBW infants with a mean gestational age of 25 weeks and mean birth weight of 725 g had a PDA surgically closed. Twenty-two of 55 survivors (40%) were diagnosed with LVCP post-operatively. Infants with LVCP were significantly more likely to develop bronchopulmonary dysplasia (82 vs 39%, P=0.002), reactive airway disease (86 vs 33%, PP<0.0001). Conclusion: LVCP as a complication of surgical ductal ligation in ELBW infants is associated with persistent respiratory and feeding problems. Direct laryngoscopy should be considered for all infants who experience persistent respiratory and/or feeding difficulties following PDA ligation.