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Objective: To describe patterns of inappropriate antibiotic prescribing at US children’s hospitals and how these patterns vary by clinical service. Design: Serial, cross-sectional study using quarterly surveys. Setting: Surveys were completed in quarter 1 2019–quarter 3 2020 across 28 children’s hospitals in the United States. Participants: Patients at children’s hospitals with ≥1 antibiotic order at 8:00 a.m. on institution-selected quarterly survey days. Methods: Antimicrobial stewardship physicians and pharmacists collected data on antibiotic orders and evaluated appropriateness of prescribing. The primary outcome was percentage of inappropriate antibiotics, stratified by clinical service and antibiotic class. Secondary outcomes included reasons for inappropriate use and association of infectious diseases (ID) consultation with appropriateness. Results: Of 13,344 orders, 1,847 (13.8%) were inappropriate; 17.5% of patients receiving antibiotics had ≥1 inappropriate order. Pediatric intensive care units (PICU) and hospitalists contributed the most inappropriate orders (n = 384 and n = 314, respectively). Surgical subspecialists had the highest percentage of inappropriate orders (22.5%), and 56.8% of these were for prolonged or unnecessary surgical prophylaxis. ID consultation in the previous 7 days was associated with fewer inappropriate orders (15% vs 10%; P < .001); this association was most pronounced for hospitalist, PICU, and surgical and medical subspecialty services. Conclusions: Inappropriate antibiotic use for hospitalized children persists and varies by clinical service. Across 28 children’s hospitals, PICUs and hospitalists contributed the most inappropriate antibiotic orders, and surgical subspecialists’ orders were most often judged inappropriate. Understanding service-specific prescribing patterns will enable antimicrobial stewardship programs to better design interventions to optimize antibiotic use.

The utility of methicillin-resistant Staphylococcus aureus (MRSA) nasal surveillance swabs has not been well-described in children. This retrospective, cohort study yielded a negative predictive value of 99.4% for an initial negative MRSA nasal surveillance swab in 165 hospitalized children with a suspected infection and clinical cultures obtained from a likely site of infection.

Antibiotic use in hospitalized children is highly variable and often unnecessary, which puts children at risk of antibiotic-associated harms including adverse drug events, antibiotic resistance, and long-term chronic health problems. Antimicrobial stewardship programs reduce unnecessary antibiotic use through antimicrobial review, the development of guidelines and clinical decision-support tools, diagnostic stewardship, and other targeted interventions. Future directions for inpatient stewardship include increased collaboration with nurses, utilization of implementation science to close the gap between evidence-based recommendations and practice changes, and the extension of stewardship from large academic centers to smaller hospitals.

Background Antibiotic-associated adverse events (AEs) in hospitalized children have not been comprehensively characterized. Methods We conducted a retrospective observational study of children hospitalized at The Johns Hopkins Hospital receiving ≥24 hours of systemic antibiotics. Consensus regarding antibiotic-associated AE definitions was established by 5 infectious diseases specialists prior to data collection. Two physicians reviewed potential AEs and determined whether they were more likely than not related to antibiotics after comprehensive manual chart review. Inpatient and post-discharge AEs were identified using the Epic Care Everywhere network. AEs evaluated from the initiation of antibiotics until 30 days after antibiotic completion included gastrointestinal, hematologic, hepatobiliary, renal, neurologic, dermatologic, cardiac, myositis, vascular access device-related events, and systemic reactions. Ninety-day AEs included Clostridioides difficile infections, multidrug-resistant organism infections, and clinically significant candidal infections. The impact of AEs was categorized as necessitating additional diagnostic testing, changes in medications, unplanned medical encounters, prolonged or new hospitalizations, or death. Results Among 400 antibiotic courses, 21% were complicated by at least one AE and 30% occurred post-discharge. Each additional day of antibiotics was associated with a 7% increased odds of an AE. Of courses complicated by an AE, 66% required further intervention. Hematologic, gastrointestinal, and renal AEs were the most common, accounting for 31%, 15%, and 11% of AEs, respectively. AEs complicated 35%, 35%, 19%, and 18% of courses of piperacillin-tazobactam, tobramycin, ceftazidime, and vancomycin, respectively. Conclusions More than 1 in 5 courses of antibiotics administered to hospitalized children are complicated by AEs. Clinicians should weigh the risk of harm against expected benefit when prescribing antibiotics.

Background National guidelines recommend 10 days of antibiotics for children with community-acquired pneumonia (CAP), acknowledging that the outcomes of children hospitalized with CAP who receive shorter durations of therapy have not been evaluated. Methods We conducted a comparative effectiveness study of children aged ≥6 months hospitalized at The Johns Hopkins Hospital who received short-course (5–7 days) vs prolonged-course (8–14 days) antibiotic therapy for uncomplicated CAP between 2012 and 2018 using an inverse probability of treatment weighted propensity score analysis. Inclusion was limited to children with clinical and radiographic criteria consistent with CAP, as adjudicated by 2 infectious diseases physicians. Children with tracheostomies; healthcare-associated, hospital-acquired, or ventilator-associated pneumonia; loculated or moderate to large pleural effusion or pulmonary abscess; intensive care unit stay >48 hours; cystic fibrosis/bronchiectasis; severe immunosuppression; or unusual pathogens were excluded. The primary outcome was treatment failure, a composite of unanticipated emergency department visits, outpatient visits, hospital readmissions, or death (all determined to be likely attributable to bacterial pneumonia) within 30 days after completing antibiotic therapy. Results Four hundred and thirty-nine patients met eligibility criteria; 168 (38%) patients received short-course therapy (median, 6 days) and 271 (62%) received prolonged-course therapy (median, 10 days). Four percent of children experienced treatment failure, with no differences observed between patients who received short-course vs prolonged-course antibiotic therapy (odds ratio, 0.48; 95% confidence interval, .18–1.30). Conclusions A short course of antibiotic therapy (approximately 5 days) does not increase the odds of 30-day treatment failure compared with longer courses for hospitalized children with uncomplicated CAP.

National guidelines recommend oral vancomycin over oral metronidazole as first-line treatment for nonsevereWe conducted an observational study of hospitalized children with nonsevere CDI treated with metronidazole versus vancomycin using an inverse probability of treatment-weighted propensity-score analysis. All of the following criteria had to be present for children with positive CDI testing for study eligibility: (1) ≥3 new-onset unformed stools within a 24-hour period; (2) 2-17 years of age; (3) hospitalization for ≥48 hours for CDI; (4) no laxative use ≤48 hours; (5) no alternate etiology for diarrhea; (6) no previous episode of CDI ≤3 months; (7) no concurrent non-CDI-targeted antibiotic therapy, and (8) no severe or fulminant CDI.One hundred ninety-two patients met eligibility criteria; 141 (73.4%) received oral metronidazole and 51 (26.6%) children received oral vancomycin. Baseline characteristics were similar between the 2 groups in the weighted cohort. Of 141 patients, 101 (71.7%) children receiving metronidazole had clinical improvement by day 5, whereas 44 of 51 (86.3%) cases resolved with vancomycin (odds ratio, 0.40; 95% confidence interval, 0.17-0.97;Our study suggests that children with nonsevere CDI have earlier resolution of clinical symptoms when prescribed vancomycin compared with metronidazole. Large interventional studies are necessary to evaluate the reproducibility of our findings.

Objective National guidelines recommend oral vancomycin over oral metronidazole as first-line treatment for nonsevere Clostridioides difficile infection (CDI) in adults. Guidelines recommend metronidazole for children with nonsevere CDI, emphasizing that comparative effectiveness studies comparing the relative efficacy of vancomycin and metronidazole are lacking in children. Method We conducted an observational study of hospitalized children with nonsevere CDI treated with metronidazole versus vancomycin using an inverse probability of treatment-weighted propensity-score analysis. All of the following criteria had to be present for children with positive CDI testing for study eligibility: (1) ≥3 new-onset unformed stools within a 24-hour period; (2) 2–17 years of age; (3) hospitalization for ≥48 hours for CDI; (4) no laxative use ≤48 hours; (5) no alternate etiology for diarrhea; (6) no previous episode of CDI ≤3 months; (7) no concurrent non-CDI–targeted antibiotic therapy, and (8) no severe or fulminant CDI. Results One hundred ninety-two patients met eligibility criteria; 141 (73.4%) received oral metronidazole and 51 (26.6%) children received oral vancomycin. Baseline characteristics were similar between the 2 groups in the weighted cohort. Of 141 patients, 101 (71.7%) children receiving metronidazole had clinical improvement by day 5, whereas 44 of 51 (86.3%) cases resolved with vancomycin (odds ratio, 0.40; 95% confidence interval, 0.17–0.97; P = .04). The odds of CDI recurrence within 12 weeks were similar between the groups. Conclusions Our study suggests that children with nonsevere CDI have earlier resolution of clinical symptoms when prescribed vancomycin compared with metronidazole. Large interventional studies are necessary to evaluate the reproducibility of our findings.

We report the case of a young adolescent male who presented with persistent fevers and rhabdomyolysis and was ultimately diagnosed with acute HIV. Rhabdomyolysis is an unusual manifestation of acute HIV that has been rarely reported. However, in the absence of another etiology we propose that HIV should be considered in the differential for rhabdomyolysis, particularly in association with fever and pharyngitis. Young people, especially men who have sex with men of color and younger adolescents, are at increased risk of HIV, and may not disclose any sexual history. Opportunities to identify risk factors and test for HIV are often missed in young people. A high level of suspicion and routine screening for HIV is needed in youth, especially in light of the benefits of early diagnosis and treatment of acute HIV. Pre-exposure prophylaxis is highly effective for the prevention of HIV and is underutilized in adolescents.

1. Rebecca G. Same, MD* 2. Pranita D. Tamma, MD, MHS* 1. *Division of Pediatric Infectious Diseases, Department of Pediatrics, The Johns Hopkins University School of Medicine, Baltimore, MD * Abbreviations: CDC: : Centers for Disease Control and Prevention CIDT: : culture-independent diagnostic testing GBS: : Guillain-Barre syndrome HIV: : human immunodeficiency virus IBD: : inflammatory bowel disease Ig: : immunoglobulin Campylobacter is one of the 2 most common causes of foodborne illness in the United States. It most commonly occurs in children younger than 5 years of age. Campylobacter species can cause a wide range of syndromes, from asymptomatic infections to severe systemic infections. After completing this article, readers should be able to: 1. Recognize that Campylobacter is a common cause of foodborne illness in the United States and internationally. 2. Understand the indications for testing and the treatment of Campylobacter infection. Campylobacter species are an important cause of infection throughout the world, especially in young children. Campylobacter jejuni is the most common Campylobacter species in the United States, where it is 1 of the top 2 causes of foodborne illness. (1) Other important species include Campylobacter upsaliensis , Campylobacter lari , and Campylobacter fetus , which can cause serious systemic infections in all age groups, particularly in immunocompromised patients. Campylobacter species infections cause gastroenteritis and typically present with diarrhea that may or may not be bloody, emesis, and abdominal pain. Campylobacter infection in children can mimic intussusception, appendicitis, or inflammatory bowel disease (IBD). Immune-mediated complications of Campylobacter infection include reactive arthritis and Guillain-Barre syndrome (GBS). Campylobacter infection is a nationally notifiable disease, and confirmed cases should be reported through the Centers for Disease Control and Prevention (CDC) Foodborne Diseases Active Surveillance Network. Most Campylobacter infections are mild and self-limited and require only supportive care, although some may lead to severe dehydration. Serious infection or infections in immunocompromised hosts may benefit from treatment with macrolide antibiotics. Increasing …

Background The Infectious Diseases Society of America guidelines recommend either 14 days of trimethoprim-sulfamethoxazole (TMP-SMX) or 7 days of ciprofloxacin for the treatment of pyelonephritis. Antibiotic courses of 7 days of TMP-SMX vs 7 days of ciprofloxacin for pyelonephritis have not been previously compared. We evaluated the odds of a subsequent, symptomatic urinary tract infection (UTI) for women with Escherichia coli pyelonephritis receiving a 7-day course of TMP-SMX vs a 7-day course of ciprofloxacin. Methods Women ages 16 years and older with E. coli pyelonephritis presenting to 5 health care facilities in the greater Maryland area between 2010 and 2016 receiving either TMP-SMX or ciprofloxacin were included. Patients were excluded if they met any of the following criteria: (a) pregnancy, (b) dialysis dependency, (c) E. coli not susceptible to the treatment prescribed, (d) polymicrobial urine culture, or (e) >48 hours of antibiotic therapy other than TMP-SMX or ciprofloxacin. Results Of 272 women meeting eligibility criteria, 81 (30%) and 191 (70%) received 7 days of TMP-SMX and 7 days of ciprofloxacin, respectively. In an adjusted model, the likelihood of a recurrent UTI within 30 days for the TMP-SMX and ciprofloxacin groups was similar (adjusted odds ratio 2.30; 95% confidence interval, 0.72-7.42). Conclusions Our findings suggest that 7 days of TMP-SMX therapy may result in similar clinical outcomes compared with 7 days of ciprofloxacin for the treatment of pyelonephritis. Considering the frequency of pyelonephritis and risks of antibiotic resistance and associated toxicities, decreasing the duration of antibiotic therapy for pyelonephritis may impact a large number of women.