Eimear Kitt

Antimicrobial resistance is rampant in low- and middle-income countries. Recent data from Princess Marina Hospital (PMH), Botswana, revealed that 100% of pediatric surgical unit patients received antimicrobials inappropriately. We implemented a quality improvement initiative to improve antimicrobial use in children admitted to PMH's pediatric surgical ward. With key stakeholders, we developed clinical pathways (CPs) to standardize antimicrobial use across common surgical diagnoses. A CP booklet, informed by the World Health Organization (WHO) Access, Watch, and Reserve (AWaRe) guideline, was distributed to prescribers. We conducted weekly prospective antimicrobial use audits over 1 year, from 3 months pre–CP implementation to 9 months post–CP implementation. A total of 1099 pediatric surgical patients were admitted and 374 (34.0%) required antimicrobials. The WHO Access group accounted for 360 antibiotic courses (72.4%) and the Watch group for 137 (27.6%), a total of 497. Overall, appropriate antimicrobial use improved significantly (pediatric surgery, 33 [50.8%] vs 99 [93.4%]; orthopedics, 3 [10.3%] vs 26 [89.7%]; neurosurgery, 5 [27.8%] vs 13 [72.2%]; and ear, nose, and throat, 4 [33.3%] vs 19 [95.0%]; each P < .001) in the postimplementation period except for maxillofacial-dental patients (1 [25.0%] vs 3 [75.0%]; P = .264). Improvements were observed across provider categories and years of experience: medical officers (28 [42.4%] vs 38 [91.0%]), interns (7 [33.3%] vs 20 [87.0%]), and specialists (11 [26.2%] vs 64 [97.0%]); years of experience: 5 years (34 [38.2%] vs 154 [92.2%]) (P < .001 for each). Appropriate antimicrobial use improved post–CP implementation. Expanding CPs with ongoing antimicrobial stewardship education will ensure sustained improvement.

The Emergency Department (ED) represents an ideal location for antimicrobial stewardship (AMS) intervention, given the large volume of antibiotics seen prescribed to a wide variety of patients. This is particularly true in paediatrics, where most infectious presentations are viral in nature. A recent European Society of Clinical Microbiology and Infectious Diseases (ESCMID) position paper addressed four key areas affecting adult ED. This included: (1) the utility of biomarkers or rapid pathogen tests, (2) the impact of blood cultures on antibiotic prescribing, (3) the effect of watchful waiting on clinical outcomes, and (4) the potential for structured follow-up programmes within the ED to impact prescribing. Comparatively, the paediatric ED remains underrepresented in the literature with regard to AMS interventions. In this review article, we review the evidence surrounding the above four key areas as they relate to the paediatric population.

Background: Surgical site infections (SSIs) are a common complication in liver transplant (LT) recipients. Lack of pediatric prophylaxis guidelines results in variation in preventative antibiotic regimens. Methods: We performed a retrospective observational study of LT recipients <18 years old using a merged data set that included data from the Pediatric Health Information System and the United Network for Organ Sharing between 2006 and 2017. The exposure was defined as the antibiotic(s) received within 24 hours of LT, with 6 categories, ranging from narrow (category 1: cefazolin), to broad). The primary outcome was presence or absence of SSI in the index admission. Mixed-effects logistic regression compared the effectiveness of each category in preventing SSI, relative to category 1. Results: Of the 2586 LT, 284 (11%) met SSI criteria. The SSI rate was higher in the younger subcohort (16.2%) than in the older (8.6%), necessitating a stratified analysis. Antibiotics from category 5 were most commonly used. In the younger subcohort, the adjusted risk was increased in all categories compared with the reference, most notably in category 3 (odds ratio [OR], 2.58 [95% confidence interval: .69–9.59]) and category 6 (2.76 [.66–11.56]). In the older subcohort, estimated ORs were also increased for each category, most notably in category 4 (2.49 [95% confidence interval: .99–6.27]). None of the ORs suggested benefit from broader-spectrum prophylaxis. Our E-value assessment suggests that it's unlikely there is unmeasured confounding by indication to the degree necessary to revert ORs to protective. Conclusions: There was wide variation in antibiotic prophylaxis. Adjusted analyses did not reveal a protective benefit of broader-spectrum prophylaxis in either subcohort, suggesting that narrower regimens may be adequate.

This white paper provides clinicians and hospital leaders with practical guidance on the prevention and control of viral respiratory infections in the neonatal intensive care unit (NICU). This document serves as a companion to Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC)’s “Prophylaxis and Screening for Prevention of Viral Respiratory Infections in Neonatal Intensive Care Unit Patients: A Systematic Review.” It provides practical, expert opinion and/or evidence-based answers to frequently asked questions about viral respiratory detection and prevention in the NICU. It was developed by a writing panel of pediatric and pathogen-specific experts who collaborated with members of the HICPAC systematic review writing panel and the SHEA Pediatric Leadership Council to identify questions that should be addressed. The document has been endorsed by SHEA, the American Hospital Association (AHA), The Joint Commission, the Pediatric Infectious Diseases Society (PIDS), the Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), and the National Association of Neonatal Nurses (NANN).

Objectives: Data on triage practices of children admitted to Princess Marina Hospital in Gaborone, Botswana is limited. The inpatient triage, assessment, and treatment score was developed for low resource settings to predict mortality in children. We assess its performance among children admitted to Princess Marina Hospital and their demographic, clinical, and risk factors for death. Methods: This was a secondary data analysis of a prospective cohort study comprising 299 children ages 1 month to 13 years admitted June to September 2018. Descriptive statistics, bivariate analysis, and multivariate logistic regression were used. Sensitivity and specificity data were generated for the inpatient triage, assessment, and treatment score. Results: Thirteen children died (13/284, 4.6%). Comorbidity (adjusted odds ratio 4.0, p = 0.020) and high inpatient triage, assessment, and treatment score (adjusted odds ratio 5.0, p = 0.017) increased odds of death. The area under the receiver operating characteristic curve was 0.81. Using inpatient triage, assessment, and treatment cutoff of 4, the sensitivity, specificity, and likelihood ratio were 31%, 94%, and 5.0, respectively. Conclusion: Implementing the inpatient triage, assessment, and treatment score in low resource settings may improve identification, treatment, and evaluation of the sickest children.

Rotavirus (RV) was a common healthcare-associated infection prior to the introduction of the RV vaccine. Following widespread RV vaccination, healthcare-associated rotavirus cases are rare. We describe an investigation of a cluster of rotavirus infections in a pediatric hospital in which an uncommon genotype not typically circulating in the United States was detected.

Objectives A disproportionate number of neonatal deaths occur in low/middle-income countries, with sepsis a leading contributor of mortality. In this study, we investigate risk factors for mortality in a cohort of high-risk hospitalised neonates in Botswana. Independent predictors for mortality for infants experiencing either a sepsis or a non-sepsis-related death are described. Methods This is a prospective observational cohort study with infants enrolled from July to October 2018 at the neonatal unit (NNU) of Princess Marina Hospital (PMH) in Gaborone, Botswana. Data on demographic, clinical and unit-specific variables were obtained. Neonates were followed to death or discharge, including transfer to another hospital. Death was determined to be infectious versus non-infectious based on primary diagnosis listed on day of death by lead clinician on duty. Results Our full cohort consisted of 229 patients. The overall death rate was 227 per 1000 live births, with cumulative proportion of deaths of 22.7% (n=47). Univariate analysis revealed that sepsis, extremely low birth weight (ELBW) status, hypoxic ischaemic encephalopathy, critical illness and infants born at home were associated with an increased risk of all-cause mortality. Our multivariate model revealed that critical illness (HR 3.07, 95% CI 1.56 to 6.03) and being born at home (HR 4.82, 95% CI 1.76 to 13.19) were independently associated with all-cause mortality. Low birth weight status was independently associated with a decreased risk of mortality (HR 0.24, 95% CI 0.11 to 0.53). There was a high burden of infection in the cohort with more than half of infants (140, 61.14%) diagnosed with sepsis at least once during their NNU admission. Approximately 20% (n=25) of infants with sepsis died before discharge. Our univariate subanalysis of the sepsis cohort revealed that ELBW and critical illness were associated with an increased risk of death. These findings persisted in the multivariate model with HR 3.60 (95% CI 1.11 to 11.71) and HR 2.39 (95% CI 1 to 5.77), respectively. Conclusions High rates of neonatal mortality were noted. Urgent interventions are needed to improve survival rates at PMH NNU and to prioritise care for critically ill infants at time of NNU admission, particularly those born at home and/or of ELBW.