Studies in adults support the use of a negative methicillin-resistant Staphylococcus aureus (MRSA) nares screening (MNS) to help limit empiric anti-MRSA antibiotic therapy. We aimed to evaluate the use of MNS for anti-MRSA antibiotic de-escalation in hospitalized children (<18 years). Records of patients admitted between 1 January 2015 and 31 December 2020 with a presumed infectious diagnosis who were started on anti-MRSA antibiotics, had a PCR-based MNS, and a clinical culture performed were retrospectively reviewed. A total of 95 children were included with a median age (range) of 2 (0–17) years. The top three diagnosis groups were skin and soft tissue infections (n = 38, 40%), toxin-mediated syndromes (n = 17, 17.9%), and osteoarticular infections (n = 14, 14.7%). Nasal MRSA colonization and growth of MRSA in clinical cultures was found in seven patients (7.4%) each. The specificity and the negative predictive value (NPV) of the MNS to predict a clinical MRSA infection were both 95.5%. About half (n = 55, 57.9%) had anti-MRSA antibiotics discontinued in-house. A quarter (n = 14, 25.5%) were de-escalated based on the negative MNS test alone, and another third (n = 21, 38.2%) after negative MNS test and negative culture results became available. A high NPV suggests that MNS may be useful for limiting unnecessary anti-MRSA therapy and thereby a useful antimicrobial stewardship tool for hospitalized children. Prospective studies are needed to further characterize the utility of MNS for specific infectious diagnoses.
BackgroundVentilator-associated tracheitis (VAT) is a common intensive-care unit entity considered in febrile patients with endotracheal intubation or with tracheostomy. Prospective-Audit-And-Feedback activities had identified an overall increased and high inter-provider-variability in the use of antibiotics for VAT. By developing a VAT-specific guideline, we intended primarily to decrease the amount of respiratory fluid cultures (RFCx) submitted, and secondly decrease the overall antibiotic use (AU) in the PICU, while not increasing the incidence of ventilator-associated events (VAE).MethodsA multidisciplinary team developed a guideline for patients with fever or change in baseline respiratory support with endotracheal intubation or with tracheostomy who had no radiographic evidence of pneumonia consisting of three parts: A) When to send an RFCx, B) Diagnosis of VAT, C) Antibiotic management of VAT: A) To obtain a RFCx, patient needed to have an abnormal white cell count (WBC) ( <5 K/uL or >14.5 K/uL) AND purulent or increased amount of endotracheal secretions PLUS either abnormal body temperature (T <36°C or ≥38.3°C) or change in baseline respiratory support. B) A diagnosis of VAT is allowed if RFCx shows Gram stain with ≥+3 WBC AND ≥+3 bacteria. C) Empiric antibiotic treatment with antipseudomonal activity (informed by previous RFCx if exist) to be started after RFCx have been obtained. Reassessment and possible modification at 48H based on final RFCx results. Duration of AU to be limited to 5 days. Guideline education was completed at multiple PICU meetings from September 2017 through June 2018. Manual audits were used to analyze adherence to the guideline. Data on RFCx order utilization, ventilator days, and AU from January 2017 to December 2018 were analyzed.ResultsSince the initiation of the guideline, we observed a downward trend of RFCx orders (Fig1.A) with an average decrease of 19% after guideline implementation. The overall AU (Fig1.B) in PICU decreased by an average of 24% while the incidence of VAE has remained stable.ConclusionEfforts to standardize diagnosis and treatment of VAT in patients with endotracheal intubation or tracheostomy resulted in a decreased number of RFCx, and reduced overall AU without increasing the risk of VAE. Disclosures All authors: No reported disclosures.
Background Empirical antibiotic regimens frequently include treatment for methicillin-resistant Staphylococcus aureus (MRSA). Studies in adults with pneumonia support the use of a negative MRSA nares screening (MNS) to help de-escalate antibiotic therapy. Comparable pediatric data in the literature is scarce. We aimed to evaluate the use of MNS for antibiotic de-escalation in hospitalized children (< 18 years) at a tertiary children’s hospital. Methods A retrospective chart review was conducted of pediatric inpatients (January 01, 2015 to December 31, 2020) with a presumed infectious diagnosis who had a PCR-based MNS test and a clinical culture (i.e. site of infection or blood) performed as part of their diagnostic work up. Those who were screened >5 days since admission or > 48 hours since start of MRSA-active antimicrobials, and those who had antibiotic treatment withdrawn after 48 hours because of negative cultures were excluded. Results A total of 101 children were included with a median age (range) of 2 years (0-17) and about half (n=57, 56.4%) were male. Top three diagnosis groups were skin and soft tissue infections (n=33, 32.7%), toxin-mediated syndromes (n=21, 20.8%), and osteoarticular infections (n=13, 12.9%). Pneumonia accounted for only six (5.9%) patients. The prevalence of nasal MRSA colonization was 6.9% (n=7). The sensitivity of the MNS test to predict a MRSA infection was 42.9% with a specificity of 95.7%. The positive predictive value (PPV) and negative predictive values (NPV) were 42.9% and 95.7%, respectively. In about half (55/95, 57.9%) of patients initiated on anti-MRSA therapy, these agents were discontinued during the admission. A quarter (n=14, 25.5%) were de-escalated based on the negative MNS test alone, and another third (n=21, 38.2%) after negative MNS test and negative culture results became available. Conclusion Pediatric providers at this institution have started to use the MNS to help limit anti-MRSA therapy. We noted a high NPV which suggests that MNS may be useful for timely de-escalation of anti-MRSA therapy and thereby a useful antimicrobial stewardship tool for hospitalized children. Prospective studies to evaluate the utility of MNS for the various infectious syndromes are warranted. Disclosures All Authors: No reported disclosures
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