Antimicrobial susceptibility patterns across US pediatric healthcare institutions are unknown. A national pooled pediatric antibiogram (1) identifies nationwide trends in antimicrobial resistance, (2) allows across-hospital benchmarking, and (3) provides guidance for empirical antimicrobial regimens for institutions unable to generate pediatric antibiograms.

In January 2012, a request for submission of pediatric antibiograms between 2005 and 2011 was sent to 233 US hospitals. A summary antibiogram was compiled from participating institutions to generate proportions of antimicrobial susceptibility. Temporal and regional comparisons were evaluated using χ² tests and logistic regression, respectively.

Of 200 institutions (85%) responding to our survey, 78 (39%) reported generating pediatric antibiograms, and 55 (71%) submitted antibiograms. Carbapenems had the highest activity against the majority of gram-negative organisms tested, but no antibiotic had more than 90% activity against Pseudomonas aeruginosa. Approximately 50% of all Staphylococcus aureus isolates were methicillin resistant. Western hospitals had significantly lower proportions of S. aureus that were methicillin resistant compared with all other regions tested. Overall, 21% of S. aureus isolates had resistance to clindamycin. Among Enterococcus faecium isolates, the prevalence of susceptibility to ampicillin (25%) and vancomycin (45%) was low but improved over time (P < .01), and 8% of E. faecium isolates were resistant to linezolid. Southern hospitals reported significantly higher prevalence of E. faecium with susceptibilities to ampicillin, vancomycin, and linezolid compared with the other 3 regions (P < .01).

A pooled, pediatric antibiogram can identify nationwide antimicrobial resistance patterns for common pathogens and might serve as a useful tool for benchmarking resistance and informing national prescribing guidelines for children.

Antimicrobial stewardship programs (ASPs) are recommended to optimize antimicrobial use for hospitalized patients. Although mechanisms for the implementation of ASPs have been described, data-driven approaches to prioritize specific conditions and antimicrobials for intervention have not been established. We aimed to develop a strategy for identifying high-impact targets for antimicrobial stewardship efforts.

Retrospective cross-sectional study.

Children admitted to 32 freestanding children's hospitals in the United States in 2010.

We identified the conditions with the largest proportional contribution to the total days of antibiotic therapy prescribed to all hospitalized children. For the 4 highest-using conditions, we examined variability between hospitals in antibiotic selection patterns for use of either first- or second-line therapies depending on the condition. Antibiotic use was determined using standardized probability of exposure to selected agents and standardized days of therapy per 1,000 patient-days, adjusting for patient demographics and severity of illness.

In 2010, 524,364 children received 2,082,929 days of antibiotic therapy. Surgical patients received 43% of all antibiotics. The 4 highest-using conditions—pneumonia, appendicitis, cystic fibrosis, and skin and soft-tissue infection—represent 1% of all conditions yet accounted for more than 10% of all antibiotic use. Wide variability in antibiotic use occurred for 3 of these 4 conditions.

Antibiotic use in children's hospitals varied broadly across institutions when examining diagnoses individually and adjusting for severity of illness. Identifying conditions with both frequent and variable antimicrobial use informs the prioritization of high-impact targets for future antimicrobial stewardship interventions.

Develop a clinical decision support tool comprised of an electronic medical record alert and antimicrobial stewardship navigator to facilitate antimicrobial stewardship.

We analyzed alerts targeting antimicrobial de-escalation to assess the effectiveness of the navigator as a stewardship tool. The alert provides antimicrobial recommendations, then directs providers to the navigator, which includes order management, relevant patient information, evidence-based clinical information, and bidirectional communication capability.

Academic, tertiary care medical center with an electronic medical record.

Alerts containing stewardship recommendations and immediate access to the navigator were created.

Antibiotic use and response data were collected 1 day before stewardship recommendation via the best practice alert (BPA) tool and 1 day after the BPA tool response. A total of 1,285 stewardship BPAs were created. Two hundred and forty-four (18.9%) of the BPAs were created and acted upon within 72 hours for the purpose of de-escalation: 169 (69%) were accepted, 30 (12%) were accepted with modification, and 45 (18%) were rejected. Statistically significant decreases in total antibiotic use as well as in use of broad-spectrum (anti-methicillin-resistant Staphylococcus aureus and anti-pseudomonal) agents occurred when accepted recommendations were compared with rejected recommendations.

We describe the successful development of a clinical decision support tool to perform prospective audit and feedback comprised of an alert and navigator system featuring evidence-based recommendations and clinical and educational information. We demonstrate that this tool improves antibiotic use through our example of de-escalation.

This project was registered at ClinicalTrials.gov (NCT01573195).

To identify risk factors for pediatric Candida central line-associated bloodstream infections (CLABSIs).

Retrospective case-control study.

Freestanding tertiary care children's hospital.

Patients with Candida CLABSI from January 31, 2000, through December 31, 2010, compared with age- and year-matched controls.

Demographics, comorbidities, presence of indwelling foreign bodies, exposure to antibiotics or corticosteroids, total parenteral nutrition (TPN) or blood transfusions, complications, and outcome were evaluated. Bivariate and then logistic regression were used to compare temporal trends and risk factors.

A total of 160 Candida CLABSI patients (median age, 1.96 years) were compared with 457 controls. Those with Candida CLABSIs were more likely to have intestinal failure (adjusted odds ratio [aOR], 6.777 [95% confidence interval (CI), 2.315–19.839]; P < .001), to have a gastrostomy tube in place (aOR, 4.156 [95% CI, 2.317–7.456]; P < .001), and to receive TPN (aOR, 3.897 [95% CI, 2.403–6.319]; P < .001) or blood transfusions (aOR, 2.990 [95% CI, 1.841–4.856]; P < .001), and they had a 3-fold increase in mortality (aOR, 3.543 [95% CI, 1.501–8.364]; P = .004). Candida albicans was most common, but non-albicans strains resistant to amphotericin (C. lusitaniae) and fluconazole (C. glabrata and C. krusei) were also found.

Those patients with intestinal failure, gastrostomy tube presence, and/or receipt of TPN and blood transfusions are at increased risk for development of Candida CLABSI.

To summarize the approaches used to manage exposure of patients to inadequately sterilized neurosurgical instruments contaminated as a result of Creutzfeldt-Jakob disease (CJD).

Information on past CJD exposure incidents reported to the Centers for Disease Control and Prevention (CDC) was aggregated and summarized. In addition, inactivation studies were reviewed, and data from selected publications were provided for reference.

Nineteen incidents of patient exposure to potentially CJD-contaminated instruments were reported to the CDC, including 17 that involved intracranial procedures and 2 that involved ophthalmologic procedures. In more than 50% of incidents, the neurosurgical procedures were performed for diagnostic work up of the index patients. At least 12 of the hospitals had multiple neurosurgical sets, and the CJD-contaminated instruments could not be identified in 11 of 19 hospitals. In 12 of 15 hospitals with neurosurgical incidents, a decision was made to notify patients of their potential exposure.

Neurosurgical instruments used for treatment of patients with suspected or diagnosed CJD or patients whose diagnosis is unclear should be promptly identified and sterilized using recommended CJD decontamination protocols. Inability to trace instruments complicates appropriate management of exposure incidents. The feasibility of instituting instrument tracking procedures should be considered.

To report type and rates of healthcare-associated infections (HAIs) as well as pathogen distribution and antimicrobial resistance patterns from a pilot HAI surveillance system in Egypt.

Prospective surveillance was conducted from April 2011 through March 2012 in 46 intensive care units (ICUs) in Egypt. Definitions were adapted from the Centers for Disease Control and Prevention's National Healthcare Safety Network. Trained healthcare workers identified HAIs and recorded data on clinical symptoms and up to 4 pathogens. A convenience sample of clinical isolates was tested for antimicrobial resistance at a central reference laboratory. Multidrug resistance was defined by international consensus criteria.

ICUs from 11 hospitals collected 90,515 patient-days of surveillance data. Of 472 HAIs identified, 47% were pneumonia, 22% were bloodstream infections, and 15% were urinary tract infections; case fatality among HAI case patients was 43%. The highest rate of device-associated infections was reported for ventilator-associated pneumonia (pooled mean rate, 7.47 cases per 1,000 ventilator-days). The most common pathogens reported were Acinetobacter species (21.8%) and Klebsiella species (18.4%). All Acinetobacter isolates tested (31/31) were multidrug resistant, and 71% (17/24) of Klebsiella pneumoniae isolates were extended-spectrum β-lactamase producers.

Infection control priorities in Egypt should include preventing pneumonia and preventing infections due to antimicrobial-resistant pathogens.

To better understand hospital infection control practices in Ethiopia.

A cross-sectional evaluation of healthcare worker (HCW) knowledge, attitudes, and practices about hand hygiene and tuberculosis (TB) infection control measures.

An anonymous 76-item questionnaire was administered to HCWs at 2 university hospitals in Addis Ababa, Ethiopia. Knowledge items were scored as correct/incorrect. Attitude and practice items were assessed using a Likert scale.

In total, 261 surveys were completed by physicians (51%) and nurses (49%). Fifty-one percent of respondents were male; mean age was 30 years. While hand hygiene knowledge was fair, self-reported practice was suboptimal. Physicians reported performing hand hygiene 7% and 48% before and after patient contact, respectively. Barriers for performing hand hygiene included lack of hand hygiene agents (77%), sinks (30%), and proper training (50%) as well as irritation and dryness (67%) caused by hand sanitizer made in accordance with the World Health Organization formulation. TB infection control knowledge was excellent (more than 90% correct). Most HCWs felt that they were at high risk for occupational acquisition of TB (71%) and that proper TB infection control can prevent nosocomial transmission (92%). Only 12% of HCWs regularly wore a mask when caring for TB patients. Only 8% of HCWs reported that masks were regularly available, and 76% cited a lack of infrastructure to isolate suspected/known TB patients.

Training HCWs about the importance and proper practice of hand hygiene along with improving hand sanitizer options may improve patient safety. Additionally, enhanced infrastructure is needed to improve TB infection control practices and allay HCW concerns about acquiring TB in the hospital.

Prevalence of hepatitis B and C in Pakistan is 2.5% and 4.5%, respectively. Major cause of these infections is reuse of syringes.

To determine a cost-effective, innovative solution to prevent syringe reuse and break the transmission cycle of blood-borne infections.

Analytical study in a tertiary care hospital, Jinnah Postgraduate Medical Centre, Karachi, Pakistan, July 2011 to June 2012.

Healthcare workers from 30 wards included in the study were trained on injection safety, use of needle remover and needle pit, and management of needlestick injuries. Each ward was provided with 2 needle-removing devices, and a pit was constructed for disposal of needles. Usage of the device in wards and pit use were monitored regularly.

In 28 (93.3%) wards, sharp containers were accessible by public and were slack. Syringes were recapped using both hands in 27 (90%) cases; needlestick injury was reported by 30% of paramedics, while 25 (83.3%) of the interviewed staff had not received any formal training in injection safety. Vigilant monitoring and information sharing led to healthcare workers in 28 (96.5%) wards using the device. Needle containers were emptied in 27 (93.1%) wards, and needle pits were used in 26 (96.3%) wards. Needlestick injury was nil in follow-up.

Needle removers permanently disable syringes. The needle pit served as a cost-effective, innovative method for disposal of needles. The intervention resulted in reducing the risk of needlestick injury.