Publications by authors named "Andi L Shane"

70 Publications

Surgery-Associated Infections among Infants Born Prematurely.

J Pediatr 2021 Aug 27. Epub 2021 Aug 27.

Department of Pediatrics, Emory University School of Medicine and Children's Healthcare of Atlanta, GA, United States; Department of Pediatrics, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, United States.

Objective: To assess the burden of invasive infection following surgery (surgery-associated infections, SAI) among extremely premature infants.

Study Design: This was an observational, prospective study of infants born at gestational age 22-28 weeks hospitalized for >3 days, between April 1, 2011-March 31, 2015 in academic centers of the NICHD Neonatal Research Network. SAI was defined by culture-confirmed bacteremia, fungemia, or meningitis ≤14 days following a surgical procedure.

Results: Of 6573 infants, 1154 (18%) who underwent surgery were of lower GA (mean [SD]: 25.5 [1.6] vs. 26.2 [1.6], p<0.001), lower BW (803 [220] vs 886 [244], P < .001), and more likely to have a major birth defect (10% vs. 3%, p<0.001); 64% had one surgery (range 1-10 per infant). Most underwent gastrointestinal (GI) procedures (873, 76%) followed by central nervous system (CNS) procedures (150, 13%). Eighty-five (7%) infants had 90 SAI (78 bacteremia, 5 fungemia, 1 bacteremia and meningitis, 6 meningitis alone). Coagulase-negative staphylococci (CoNS) were isolated in 36 (40%) SAI and were isolated with another organism in 5 episodes. Risk of SAI or death ≤14 days after surgery was higher after GI compared with CNS procedures [16% vs 7%, adjusted RR (aRR) (95% CI): 1.95 (1.15-3.29), p=0.01]. Death ≤14 days after surgery occurred in 141 of the 1154 infants; 128 deaths occurred after GI surgeries.

Conclusions: Surgical procedures were associated with bacteremia, fungemia, or meningitis in 7% of infants. The epidemiology of invasive post-operative infections as described in this report may inform the selection of empiric antimicrobial therapy and post-operative preventive care.
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http://dx.doi.org/10.1016/j.jpeds.2021.08.064DOI Listing
August 2021

Pediatric Caregiver Behaviors Related to Oral Antibiotic Use.

J Pediatric Infect Dis Soc 2021 Aug 7. Epub 2021 Aug 7.

Division Pediatric Infectious Disease, Department of Pediatrics, Emory School of Medicine, Emory University, Atlanta, Georgia, USA.

In a survey of 396 caregivers of children, 119 (30%) reported requesting antibiotics from clinicians and 65 (16%) had stored antibiotics at home. In addition, 47 (12%) reported past or intended nonprescription antibiotic administration; this finding was associated with household income of ≥$75 000 annually (odds ratio 2.042, 95% confidence interval 1.01-4.14, P = .048).
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http://dx.doi.org/10.1093/jpids/piab020DOI Listing
August 2021

Evaluation of a Clinical Decision Support Strategy to Increase Seasonal Influenza Vaccination Among Hospitalized Children Before Inpatient Discharge.

JAMA Netw Open 2021 07 1;4(7):e2117809. Epub 2021 Jul 1.

Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.

Importance: Hospitalized children are at increased risk of influenza-related complications, yet influenza vaccine coverage remains low among this group. Evidence-based strategies about vaccination of vulnerable children during all health care visits are especially important during the COVID-19 pandemic.

Objective: To design and evaluate a clinical decision support (CDS) strategy to increase the proportion of eligible hospitalized children who receive a seasonal influenza vaccine prior to inpatient discharge.

Design, Setting, And Participants: This quality improvement study was conducted among children eligible for the seasonal influenza vaccine who were hospitalized in a tertiary pediatric health system providing care to more than half a million patients annually in 3 hospitals. The study used a sequential crossover design from control to intervention and compared hospitalizations in the intervention group (2019-2020 season with the use of an intervention order set) with concurrent controls (2019-2020 season without use of an intervention order set) and historical controls (2018-2019 season with use of an order set that underwent intervention during the 2019-2020 season).

Interventions: A CDS intervention was developed through a user-centered design process, including (1) placing a default influenza vaccine order into admission order sets for eligible patients, (2) a script to offer the vaccine using a presumptive strategy, and (3) just-in-time education for clinicians addressing vaccine eligibility in the influenza order group with links to further reference material. The intervention was rolled out in a stepwise fashion during the 2019-2020 influenza season.

Main Outcomes And Measures: Proportion of eligible hospitalizations in which 1 or more influenza vaccines were administered prior to discharge.

Results: Among 17 740 hospitalizations (9295 boys [52%]), the mean (SD) age was 8.0 (6.0) years, and the patients were predominantly Black (n = 8943 [50%]) or White (n = 7559 [43%]) and mostly had public insurance (n = 11 274 [64%]). There were 10 997 hospitalizations eligible for the influenza vaccine in the 2019-2020 season. Of these, 5449 (50%) were in the intervention group, and 5548 (50%) were concurrent controls. There were 6743 eligible hospitalizations in 2018-2019 that served as historical controls. Vaccine administration rates were 31% (n = 1676) in the intervention group, 19% (n = 1051) in concurrent controls, and 14% (n = 912) in historical controls (P < .001). In adjusted analyses, the odds of receiving the influenza vaccine were 3.25 (95% CI, 2.94-3.59) times higher in the intervention group and 1.28 (95% CI, 1.15-1.42) times higher in concurrent controls than in historical controls.

Conclusions And Relevance: This quality improvement study suggests that user-centered CDS may be associated with significantly improved influenza vaccination rates among hospitalized children. Stepwise implementation of CDS interventions was a practical method that was used to increase quality improvement rigor through comparison with historical and concurrent controls.
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http://dx.doi.org/10.1001/jamanetworkopen.2021.17809DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8299313PMC
July 2021

A Vexing Problem: When Visitors Become Vectors of Viruses.

J Pediatric Infect Dis Soc 2021 Jun 26. Epub 2021 Jun 26.

Division of Pediatric Infectious Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia, USA.

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http://dx.doi.org/10.1093/jpids/piab053DOI Listing
June 2021

Neonatal-Perinatal Infections: An Update.

Clin Perinatol 2021 06;48(2):xix-xx

Chief, Division of Pediatric Infectious Disease, Marcus Professor of Hospital, Epidemiology and Infection Control, Emory University School of Medicine and Children's Healthcare of Atlanta, Emory Children's Center, Room 504A, 2015 Uppergate Drive NE, Atlanta, GA 30322, USA. Electronic address:

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http://dx.doi.org/10.1016/j.clp.2021.03.014DOI Listing
June 2021

Triage guideline for immunocompromised children with fever in an emergency centre in Ethiopia.

Afr J Emerg Med 2021 Mar 4;11(1):20-25. Epub 2020 Dec 4.

Division of Emergency Medicine, Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.

Fever in children with neutropenia often portends life-threatening bacteremia that may be ameliorated with early recognition and the rapid administration of antimicrobial therapy. Studies demonstrating this effect have been done in resource-endowed countries, but not in resource-limited settings. We attempted to decrease the time to antibiotics in patients with fever and neutropenia presenting to a paediatric emergency centre at a tertiary care referral hospital in Ethiopia. In 3 phases we performed baseline data collection, instituted triaging and treatment guidelines, and provided antibiotics. We tracked a variety of outcomes, most importantly time from arrival to initiation of antibiotics. While this time was reduced during the guideline institution phase of our intervention, time reductions were inconsistent and not sustained. This was likely due to competing clinical priorities among providers caring for a high volume of ill children. While in the U.S., fever and neutropenia is easy to prioritise within the paediatric emergency centre, future quality improvement measures in this setting may have a greater benefit on critical presentations such as shock or respiratory failure. Alternative strategies geared towards general efficiency improvement and teamwork, rather than focusing on one patient group may be a higher yield approach for improving care in this paediatric emergency centre.
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http://dx.doi.org/10.1016/j.afjem.2020.10.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7721625PMC
March 2021

Pediatric research priorities in healthcare-associated infections and antimicrobial stewardship.

Infect Control Hosp Epidemiol 2021 05 26;42(5):519-522. Epub 2020 Nov 26.

Division of Infectious Diseases and Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.

Objective: To develop a pediatric research agenda focused on pediatric healthcare-associated infections and antimicrobial stewardship topics that will yield the highest impact on child health.

Participants: The study included 26 geographically diverse adult and pediatric infectious diseases clinicians with expertise in healthcare-associated infection prevention and/or antimicrobial stewardship (topic identification and ranking of priorities), as well as members of the Division of Healthcare Quality and Promotion at the Centers for Disease Control and Prevention (topic identification).

Methods: Using a modified Delphi approach, expert recommendations were generated through an iterative process for identifying pediatric research priorities in healthcare associated infection prevention and antimicrobial stewardship. The multistep, 7-month process included a literature review, interactive teleconferences, web-based surveys, and 2 in-person meetings.

Results: A final list of 12 high-priority research topics were generated in the 2 domains. High-priority healthcare-associated infection topics included judicious testing for Clostridioides difficile infection, chlorhexidine (CHG) bathing, measuring and preventing hospital-onset bloodstream infection rates, surgical site infection prevention, surveillance and prevention of multidrug resistant gram-negative rod infections. Antimicrobial stewardship topics included β-lactam allergy de-labeling, judicious use of perioperative antibiotics, intravenous to oral conversion of antimicrobial therapy, developing a patient-level "harm index" for antibiotic exposure, and benchmarking and or peer comparison of antibiotic use for common inpatient conditions.

Conclusions: We identified 6 healthcare-associated infection topics and 6 antimicrobial stewardship topics as potentially high-impact targets for pediatric research.
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http://dx.doi.org/10.1017/ice.2020.1267DOI Listing
May 2021

A Pediatric Infectious Diseases Perspective of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) and Novel Coronavirus Disease 2019 (COVID-19) in Children.

J Pediatric Infect Dis Soc 2020 Nov;9(5):596-608

Division of Pediatric Infectious Diseases and Tropical Medicine, Department of Pediatrics, University of Maryland School of Medicine, Baltimore, Maryland, USA.

Understanding the role that children play in the clinical burden and propagation of severe acute respiratory syndrome coronavirus 2, responsible for coronavirus disease 2019 (COVID-19) infections, is emerging. While the severe manifestations and acute clinical burden of COVID-19 have largely spared children compared with adults, understanding the epidemiology, clinical presentation, diagnostics, management, and prevention opportunities and the social and behavioral impacts on child health is vital. Foremost is clarifying the contribution of asymptomatic and mild infections to transmission within the household and community and the clinical and epidemiologic significance of uncommon severe post-infectious complications. Here, we summarize the current knowledge, identify resources, and outline research opportunities. Pediatric infectious diseases clinicians have a unique opportunity to advocate for the inclusion of children in epidemiological, clinical, treatment, and prevention studies to optimize their care as well as to represent children in the development of guidance and policy during pandemic response.
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http://dx.doi.org/10.1093/jpids/piaa099DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7499621PMC
November 2020

Burden of Illness in Households With Severe Acute Respiratory Syndrome Coronavirus 2-Infected Children.

J Pediatric Infect Dis Soc 2020 Nov;9(5):613-616

Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA.

We investigated of illness among household members of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)-infected children receiving medical care (n = 32). We identified 144 household contacts (HCs): 58 children and 86 adults. Forty-six percent of HCs developed symptoms consistent with coronavirus disease. Child-to-adult transmission was suspected in 7 cases.
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http://dx.doi.org/10.1093/jpids/piaa097DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7454727PMC
November 2020

The impact of opening dedicated clinics on disease transmission during an influenza pandemic.

PLoS One 2020 6;15(8):e0236455. Epub 2020 Aug 6.

Department of Industrial and Systems Engineering, North Carolina State University, Raleigh, North Carolina, United States of America.

Dedicated clinics can be established in an influenza pandemic to isolate people and potentially reduce opportunities for influenza transmission. However, their operation requires resources and their existence may attract the worried-well. In this study, we quantify the impact of opening dedicated influenza clinics during a pandemic based on an agent-based simulation model across a time-varying social network of households, workplaces, schools, community locations, and health facilities in the state of Georgia. We calculate performance measures, including peak prevalence and total attack rate, while accounting for clinic operations, including timing and location. We find that opening clinics can reduce disease spread and hospitalizations even when visited by the worried-well, open for limited weeks, or open in limited locations, and especially when the clinics are in operation during times of highest prevalence. Specifically, peak prevalence, total attack rate, and hospitalization reduced 0.07-0.32%, 0.40-1.51%, 0.02-0.09%, respectively, by operating clinics for the pandemic duration.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0236455PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7410326PMC
October 2020

Design Strategies for Biocontainment Units to Reduce Risk During Doffing of High-level Personal Protective Equipment.

Clin Infect Dis 2019 09;69(Suppl 3):S241-S247

SimTigrate Design Lab, Georgia State University, and College of Design.

Background: Few data exist to guide the physical design of biocontainment units, particularly the doffing area. This can impact the contamination risk of healthcare workers (HCWs) during doffing of personal protective equipment (PPE).

Methods: In phase I of our study, we analyzed simulations of a standard patient care task with 56 trained HCWs focusing on doffing of high-level PPE. In phase II, using a rapid cycle improvement approach, we tested different balance aids and redesigned doffing area layouts with 38 students. In phase III, we tested 1 redesigned layout with an additional 10 trained HCWs. We assessed the effectiveness of design changes on improving the HCW performance (measured by occurrence and number of risky behaviors) and reducing the physical and cognitive load by comparing the results from phase I and phase III.

Results: The physical load was highest when participants were removing their shoe covers without any balance aid; the use of a chair required the lowest physical effort, followed by horizontal and vertical grab bars. In the revised design (phase III), the overall performance of participants improved. There was a significant decrease in the number of HCW risky behaviors (P = .004); 5 risky behaviors were eliminated and 2 others increased. There was a significant decrease in physical load when removing disposable shoe covers (P = .04), and participants reported a similar workload in the redesigned doffing layout (P = .43).

Conclusions: Through optimizing the design and layout of the doffing space, we reduced risky behaviors of HCWs during doffing of high-level PPE.
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http://dx.doi.org/10.1093/cid/ciz617DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743504PMC
September 2019

Variability in the Duration and Thoroughness of Hand Hygiene.

Clin Infect Dis 2019 09;69(Suppl 3):S221-S223

Division of Infectious Diseases, Department of Medicine, Emory University School of Medicine, Atlanta.

We observed 354 hand hygiene instances across 41 healthcare workers doffing personal protective equipment at 4 hospital-based biocontainment units. We measured the duration and thoroughness of each hand hygiene instance. Both parameters varied substantially, with systematic differences between hospitals and differences between healthcare workers accounting for much of the variance.
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http://dx.doi.org/10.1093/cid/ciz612DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743505PMC
September 2019

Common Behaviors and Faults When Doffing Personal Protective Equipment for Patients With Serious Communicable Diseases.

Clin Infect Dis 2019 09;69(Suppl 3):S214-S220

Division of Infectious Diseases, Atlanta Department of Medicine.

Background: The safe removal of personal protective equipment (PPE) can limit transmission of serious communicable diseases, but this process poses challenges to healthcare workers (HCWs).

Methods: We observed 41 HCWs across 4 Ebola treatment centers in Georgia doffing PPE for simulated patients with serious communicable diseases. Using human factors methodologies, we obtained the details, sequences, and durations of doffing steps; identified the ways each step can fail (failure modes [FMs]); quantified the riskiness of FMs; and characterized the workload of doffing steps.

Results: Eight doffing steps were common to all hospitals-removal of boot covers, gloves (outer and inner pairs), the outermost garment, the powered air purifying respirator (PAPR) hood, and the PAPR helmet assembly; repeated hand hygiene (eg, with hand sanitizer); and a final handwashing with soap and water. Across hospitals, we identified 256 FMs during the common doffing steps, 61 of which comprised 19 common FMs. Most of these common FMs were above average in their riskiness at each hospital. At all hospitals, hand hygiene, removal of the outermost garment, and removal of boot covers were above average in their overall riskiness. Measurements of workload revealed that doffing steps were often mentally demanding, and this facet of workload correlated most strongly with the effortfulness of a doffing step.

Conclusions: We systematically identified common points of concern in protocols for doffing high-level PPE. Addressing FMs related to hand hygiene and the removal of the outermost garment, boot covers, and PAPR hood could improve HCW safety when doffing high-level PPE.We identified ways that doffing protocols for high-level personal protective equipment may fail to protect healthcare workers. Hand hygiene, removing the outermost garment, boot covers, and respirator hood harbored the greatest risk and failed in similar ways across different hospitals.
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http://dx.doi.org/10.1093/cid/ciz614DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6743503PMC
September 2019

Can We Further Increase Protection Against Rotavirus by Reducing 2 Barriers to Immunization, Inpatient Hospitalization and Older Age?

J Pediatric Infect Dis Soc 2021 Mar;10(2):68-70

Department of Pediatrics, University of Rochester School of Medicine and Dentistry, New York.

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http://dx.doi.org/10.1093/jpids/piz046DOI Listing
March 2021

Effect of Concomitant Antibiotic and Vaccine Administration on Serologic Responses to Rotavirus Vaccine.

J Pediatric Infect Dis Soc 2020 Sep;9(4):479-482

Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tennessee.

Data from 1174 infants enrolled in a previous rotavirus vaccine study were analyzed to determine the effect of antibiotic exposure (from 14 days before to 7 days after vaccination) on rotavirus serum immunoglobulin A (IgA) responses. Serum IgA responses 1 month after the completion of vaccination were similar among antibiotic-exposed and nonexposed infants.
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http://dx.doi.org/10.1093/jpids/piz044DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7495907PMC
September 2020

Prospective Cohort Study of Next-Generation Sequencing as a Diagnostic Modality for Unexplained Encephalitis in Children.

J Pediatric Infect Dis Soc 2020 Jul;9(3):326-333

Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia.

Background: Encephalitis is an inflammatory condition of the brain associated with long-term neurologic sequelae and even death in children. Although viruses are often implicated, an etiology is not identified in the majority of cases. Metagenomics-based next-generation sequencing (mNGS) is a high-throughput sequencing technique that can enhance the detection of novel or low-frequency pathogens.

Methods: Hospitalized immunocompetent children aged 6 months to 18 years with encephalitis of unidentified etiology were eligible for enrollment. Demographic, historical, and clinical information was obtained, and residual blood and cerebrospinal fluid (CSF) samples were subjected to mNGS. Pathogens were identified by querying the sequence data against the NCBI GenBank database.

Results: Twenty children were enrolled prospectively between 2013 and 2017. mNGS of CSF identified 7 nonhuman nucleic acid sequences of significant frequency in 6 patients, including that of Mycoplasma bovis, parvovirus B19, Neisseria meningitidis, and Balamuthia mandrillaris. mNGS also detected Cladophialophora species, tobacco mosaic virus, and human bocavirus, which were presumed to be contaminants or nonpathogenic organisms. One patient was found to have positive serology results for California encephalitis virus, but mNGS did not detect it. Patients for whom mNGS identified a diagnosis had a significantly higher CSF white blood cell count, a higher CSF protein concentration, and a lower CSF glucose level than patients for whom mNGS did not identify a diagnosis.

Conclusion: We describe here the results of a prospective cohort analysis to evaluate mNGS as a diagnostic tool for children with unexplained encephalitis. Although mNGS detected multiple nonpathogenic organisms, it also identified multiple pathogens successfully and was most useful in patients with a CSF abnormality.
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http://dx.doi.org/10.1093/jpids/piz032DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7457329PMC
July 2020

Group B ().

Microbiol Spectr 2019 03;7(2)

Division of Pediatric Infectious Diseases, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA 30322.

Invasive disease due to group B infection () results in a wide spectrum of clinical disease. In North America, serotypes Ia, Ib, II, III, and V are most frequently associated with invasive disease. Group B remains a continuing source of morbidity and mortality in high-risk populations, including pregnant women, neonates, and the elderly; an increasing incidence of invasive disease has been observed in nonpregnant adults. Group B remains the most common culture-confirmed neonatal bacterial infection in the United States and is a significant source of neonatal morbidity globally. Intrapartum antibiotic prophylaxis has reduced the incidence of early-onset neonatal disease without a notable impact on the incidence of late-onset neonatal disease. Penicillin G remains the mainstay of therapy, although reduced penicillin susceptibility has been observed in select isolates. Increased frequency of resistance to non-beta-lactam antibiotics, including clindamycin, erythromycin, and fluoroquinolones, has been observed, with some isolates demonstrating resistance to vancomycin. The development and implementation of strategies to identify hosts, treat judiciously with antimicrobials with the narrowest spectra, and prevent invasive disease, with vaccines, are essential to reduce the burden of group B disease.
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http://dx.doi.org/10.1128/microbiolspec.GPP3-0007-2018DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6432937PMC
March 2019

Perspectives on the Management of Children in a Biocontainment Unit: Report of the NETEC Pediatric Workgroup.

Health Secur 2019 Jan/Feb;17(1):11-17

H. Dele Davies, MD, is Professor of Pediatric Infectious Diseases and Public Health, Department of Pediatrics, University of Nebraska Medical Center, Omaha NE.

During the outbreak of Ebola virus disease that struck West Africa during 2014-2016, a small handful of expatriate patients were evacuated to specialized high-level containment care units, or biocontainment units, in the United States and Western Europe. Given the lower mortality rate (18% versus 40% for those treated in Africa) among these patients, it is likely that high-level containment care will be used in the future with increasing frequency. It is also likely that children infected with Ebola and other highly hazardous communicable diseases will someday require such care. The National Ebola Training and Education Center convened a pediatric workgroup to consider the unique and problematic issues posed by these potential child patients. We report here the results of those discussions.
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http://dx.doi.org/10.1089/hs.2018.0074DOI Listing
June 2019

Comparison of a Smartphone Otoscope and Conventional Otoscope in the Diagnosis and Management of Acute Otitis Media.

Clin Pediatr (Phila) 2019 Mar 21;58(3):302-306. Epub 2018 Nov 21.

Emory University, Atlanta, GA, USA.

Acute otitis media (AOM) is a leading cause of health encounters and antimicrobial prescriptions in children worldwide. We assessed (1) the rates of antimicrobial prescribing by pediatric emergency department clinicians using a smartphone otoscope device as compared with a conventional otoscope and (2) clinician acceptability of the smartphone device. We conducted a randomized control study in children's hospital emergency departments over 6 months. More than 1500 encounters were analyzed. The odds of prescribing antibiotics after being given a diagnosis of AOM by clinicians assigned to the smartphone group was 11% higher than the conventional group (18.8% vs 18.0%, odds ratio = 1.106, = .600). Eight (73%) of the 11 physicians in the smartphone group preferred the smartphone device over the conventional otoscope. Use of a smartphone otoscope for detection of AOM in a pediatric emergency department setting did not lead to an increased likelihood of AOM diagnosis.
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http://dx.doi.org/10.1177/0009922818812480DOI Listing
March 2019

Impact of Pharmacy-Initiated Interventions on Influenza Vaccination Rates in Pediatric Solid Organ Transplant Recipients.

J Pediatric Infect Dis Soc 2019 Dec;8(6):525-530

Department of Pharmacy, Children's Healthcare of Atlanta, Georgia.

Background: In solid organ transplant (SOT) recipients, influenza infection can lead to subsequent graft dysfunction and death. Vaccination is the most effective approach to preventing influenza infection; however, vaccination rates are low, and interventions to optimize vaccine coverage are needed. The purpose of this study was to evaluate if pharmacy-initiated screening and recommendations for influenza immunization improve the rate of vaccination in pediatric SOT recipients.

Methods: We performed a retrospective pre-post chart review of all kidney, liver, and heart transplant recipients followed by Children's Healthcare of Atlanta/Emory University transplant services between September 1, 2011, and February 16, 2017. Influenza vaccination coverage and influenza rates before (2011-2013) and after (2014-2016) the implementation of pharmacy-driven vaccination in SOT recipients were assessed.

Results: A total of 822 patients were included; 101 (13%) of these patients were diagnosed with influenza, and 40 (5%) were hospitalized secondarily during the study period. Vaccination coverage increased over time (144 [36%] patients vaccinated in 2011 vs 430 [74%] in 2016; P < .001). Influenza diagnosis rates decreased between the 2 eras (P = .006). The median time in which 50% of the population was vaccinated decreased over time from 163 days in 2012 to 94 days in 2016 (P < .001).

Conclusion: Within the constraints of the pre-post study design, we observed a significant increase in influenza vaccination rates after implementation of a transplant pharmacy-initiated screening and vaccination program. The number of patients diagnosed with influenza and the time to vaccination decreased after our pharmacy intervention. All efforts should be made to increase compliance with influenza vaccination; pharmacy-initiated interventions can improve protection against influenza infection in pediatric SOT recipients.
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http://dx.doi.org/10.1093/jpids/piy095DOI Listing
December 2019

Does probiotic consumption reduce antibiotic utilization for common acute infections? A systematic review and meta-analysis.

Eur J Public Health 2019 06;29(3):494-499

Georgetown University, Washington, DC, USA.

Background: Overall reduction of antibiotic use is a widely adopted public health goal. Given evidence that consuming probiotics reduce the incidence, duration and/or severity of certain types of common acute infections, we hypothesized that probiotics are associated with reduced antibiotic use. This systematic review of randomized controlled trials (RCTs) assessed the impact of probiotic supplementation (any strain, dose or duration), compared to placebo, on antibiotic utilization for common, acute infections in otherwise healthy people of all ages.

Methods: We searched 13 electronic databases including MEDLINE, Embase and CENTRAL from inception to 17th January 2017. Backward and forward citation searches were also conducted. Two reviewers independently selected studies for inclusion and extracted study data. We assessed risk of bias for individual studies using criteria adapted from the Centre for Reviews and Dissemination, and the quality of evidence for each outcome was assessed using the GRADE system. Studies that evaluated similar outcomes were pooled statistically in meta-analyses using a random-effects model.

Results: We screened 1533 citations, and of these, 17 RCTs met our predefined inclusion criteria. All 17 were conducted in infants and/or children with a primary aim of preventing acute respiratory tract infections, acute lower digestive tract infections or acute otitis media. Included studies used 13 probiotic formulations, all comprising single or combination Lactobacillus and Bifidobacterium delivered in a range of food or supplement products. Mean duration of probiotic supplementation ranged from 4 days to 9 months. Trial quality was variable. Meta-analysis demonstrated that infants and children who received probiotics to prevent acute illnesses had a lower risk of being prescribed antibiotics, relative to those who received placebo (Pooled Relative Risk = 0.71, 95% CI: 0.54-0.94). When restricted to five studies with a low risk of bias, the pooled relative risk was 0.46 (95% CI: 0.23-0.97). Significant statistical heterogeneity was present in effect size estimates, which appeared to be due to one trial which could partly be considered as an outlier.

Conclusions: Probiotics, provided to reduce the risk for common acute infections, may be associated with reduced antibiotic use in infants and children. Additional well-designed studies are needed to substantiate these findings in children and explore similar findings in other population groups.
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http://dx.doi.org/10.1093/eurpub/cky185DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6532828PMC
June 2019

Discrepancies Between US Food and Drug Administration Vaccine Licensure Indications and Advisory Committee on Immunization Practices Recommendations: Provider Knowledge and Attitudes.

Clin Ther 2018 08 11;40(8):1308-1319.e16. Epub 2018 Aug 11.

Division of Pediatric Infectious Disease, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Georgia.

Purpose: In the United States, the Center for Biologics Evaluation and Research at the US Food and Drug Administration (FDA) is responsible for licensure of vaccines. The Advisory Committee on Immunization Practices (ACIP) is a federal advisory committee that provides guidance to the Centers for Disease Control and Prevention (CDC) on use of vaccines. Discrepancies between FDA licensure indications and ACIP/CDC vaccine recommendations exist, challenging health care providers. The objectives of this study were: (1) to categorize differences between FDA vaccine licensure indications and ACIP/CDC vaccine recommendations for vaccines; and (2) to assess knowledge, attitudes, and practices of pediatricians, family physicians, and obstetrician-gynecologists regarding their understanding of differences.

Methods: Information was extracted from FDAvaccine package inserts, and corresponding information was collected for ACIP/CDC vaccine recommendations (2000-2014) for vaccines in the childhood and adult immunization schedules. Surveys regarding knowledge of discrepancies were distributed electronically to members of the Georgia chapters of the American Academy of Pediatrics (GA-AAP) and the American Academy of Family Physicians (GA-AAFP), and the national American College of Obstetricians and Gynecologists (ACOG) in 2014.

Findings: Differences were identified in 20 instances: differences in age group indications were identified in 6, in dosing administration schedules in 4, and in immunocompromised hosts and pregnant women in 10. We received 145 (8.5%) responses from GA-AAP, 237 (9.5%) from GA-AAFP, and 869 (1.5%) from national ACOG members. A total of 105 (72%) GA-AAP respondents reported that they follow AAP recommendations and 168 (71%) GA-AAFP respondents follow ACIP recommendations. GA-AAP and GA-AAFP respondents generally were not aware of data the FDA considers for vaccine licensure or data that pharmaceutical company representatives are permitted to discuss. Respondents remain current with vaccine recommendations through review of materials from professional organizations, the CDC, and package inserts; Continuing Medical Education; and information from pharmaceutical representatives. A total of 780 (90%) ACOG respondents had no concerns regarding routinely recommended reduced diphtheria toxoid and acellular pertussis vaccines (n = 730 [84%]) and influenza during pregnancy vaccines (n = 852 [98%]) to pregnant patients. However, these findings must be interpreted within the context of a low overall ACOG survey response rate.

Implications: Education regarding existence of and reasons for discrepancies between FDA licensure of and ACIP/CDC recommendations for vaccines and reasons for these differences could optimize immunization delivery.
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http://dx.doi.org/10.1016/j.clinthera.2018.07.004DOI Listing
August 2018

Randomized trial comparing the safety and antibody responses to live attenuated versus inactivated influenza vaccine when administered to breastfeeding women.

Vaccine 2018 07 28;36(31):4663-4671. Epub 2018 Jun 28.

Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.

Background: Live attenuated influenza vaccine (LAIV) and inactivated influenza vaccine (IIV) are both licensed for administration to nursing mothers. Little is known about the potential for transmission of LAIV viruses from the mother to the infant and the comparative breast milk antibody responses to LAIV and IIV.

Methods: We performed a randomized, double-blind study comparing the immunogenicity of LAIV to IIV when administered to nursing mothers. The safety of LAIV to IIV in women and their infants was also compared. Women received LAIV + intramuscular placebo, or IIV + intranasal placebo on Day 0. Breast milk and nasal swabs (from women and infants) were collected on Days 0, 2, and 8 for detection of LAIV. Breast milk and serum antibody responses were measured at Days 0 and 28. The primary hypothesis was that LAIV would provide superior induction of breast milk IgA responses to influenza as compared to IIV when administered to nursing mothers.

Results: Breast milk IgG, breast milk IgA (H1N1 only), serum hemagglutination inhibition (HAI), and serum IgG responses were significantly higher following administration of IIV compared to LAIV. Receipt of either LAIV or IIV was safe in women and their infants. One (1%) LAIV recipient transmitted vaccine virus to her infant who remained well. No influenza virus was detected in breast milk.

Conclusions: Breast milk and serum antibody responses were higher for IIV compared to LAIV. LAIV and IIV were safe for nursing women but there was one (1%) possible transmission of LAIV to an infant. This study suggests that IIV may be the preferred vaccine for nursing mothers.
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http://dx.doi.org/10.1016/j.vaccine.2018.06.036DOI Listing
July 2018

Visitor restriction policies and practices in children's hospitals in North America: results of an Emerging Infections Network Survey.

Infect Control Hosp Epidemiol 2018 08 21;39(8):968-971. Epub 2018 Jun 21.

6Division of Pediatric Infectious Diseases,Department of Pediatrics,Emory University School of Medicine,Atlanta,Georgia.

Objective: To delineate the timing of, indications for, and assessment of visitor restriction policies and practices (VRPP) in pediatric facilities.

Design: An electronic survey to characterize VRPP in pediatric healthcare facilities.

Methods: The Infectious Diseases Society of America Emerging Infections Network surveyed 334 pediatric infectious disease consultants via an electronic link. Descriptive analyses were performed.

Results: A total of 170 eligible respondents completed a survey between 12 July and August 15, 2016, for a 51% response rate. Of the 104 respondents (61%) familiar with their VRPP, 92 (88%) had VRPP in all inpatient units. The respondents reported age-based VRPP (74%) symptom-based VRPP (97%), and outbreak-specific VRPP (75%). Symptom-based VRPP were reported to be seasonal by 24% of respondents and to be implemented year-round according to 70% of respondents. According to the respondents, communication of VRPP to families occurred at admission (87%) and through signage in care areas (64%), while communication of VRPP to staff occurred by email (77%), by meetings (55%), and by signage in staff-only areas (49%). Respondents reported that enforcement of VRPP was the responsibility of nursing (80%), registration clerks (58%), unit clerks (53%), the infection prevention team (31%), or clinicians 16 (16%). They also reported that the effectiveness of VRPP was assessed through active surveillance of hospital acquired respiratory infections (62%), through active surveillance of healthcare worker exposures (28%) and through patient/family satisfaction assessments (29%).

Conclusion: Visitor restriction policies and practices vary in scope, implementation, enforcement, and physician awareness in pediatric facilities. A prospective multisite evaluation of outcomes would facilitate the adoption of uniform guidance.
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http://dx.doi.org/10.1017/ice.2018.128DOI Listing
August 2018

Routine Supplementation of Lactobacillus rhamnosus GG and Risk of Necrotizing Enterocolitis in Very Low Birth Weight Infants.

J Pediatr 2018 04;195:73-79.e2

Department of Pediatrics, Emory University School of Medicine, Atlanta, GA; Children's Healthcare of Atlanta, Atlanta, GA. Electronic address:

Objective: To evaluate if routine supplementation of Lactobacillus rhamnosus GG ATCC 53103 (LGG) is associated with a decreased risk of necrotizing enterocolitis in very low birth weight (VLBW) infants.

Study Design: Retrospective observational cohort study of VLBW (<1500 g) infants at a single center from 2008 to 2016. LGG supplementation with Culturelle at a dose of 2.5 to 5 × 10 CFU/day began in 2014. We used multivariable logistic regression to evaluate the association between LGG supplementation and necrotizing enterocolitis (modified Bell stage IIA or greater), after adjusting for potential confounders. We also compared changes in necrotizing enterocolitis incidence before and after implementation of LGG using a statistical process control chart.

Results: We evaluated 640 VLBW infants with a median gestational age of 28.7 weeks (IQR 26.3-30.6); 78 (12%) developed necrotizing enterocolitis. The median age at first dose of LGG was 6 days (IQR 3-10), and duration of supplementation was 32 days (IQR 18-45). The incidence of necrotizing enterocolitis in the epoch before LGG implementation was 10.2% compared with 16.8% after implementation. In multivariable analysis, LGG supplementation was associated with a higher risk of necrotizing enterocolitis (aOR 2.10, 95 % CI 1.25-3.54, P = .005). We found no special cause variation in necrotizing enterocolitis after implementation of LGG supplementation. There were no episodes of Lactobacillus sepsis during 5558 infant days of LGG supplementation.

Conclusions: In this study, routine LGG supplementation was not associated with a decreased risk of necrotizing enterocolitis. Our findings do not support the use of the most common probiotic preparation currently supplemented to VLBW infants in the US.
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http://dx.doi.org/10.1016/j.jpeds.2017.11.055DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869135PMC
April 2018

2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea.

Clin Infect Dis 2017 Nov;65(12):1963-1973

Division of Infectious Diseases, Department of Pediatrics, Emory University, Atlanta, Georgia.

These guidelines are intended for use by healthcare professionals who care for children and adults with suspected or confirmed infectious diarrhea. They are not intended to replace physician judgement regarding specific patients or clinical or public health situations. This document does not provide detailed recommendations on infection prevention and control aspects related to infectious diarrhea.
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http://dx.doi.org/10.1093/cid/cix959DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5848254PMC
November 2017

2017 Infectious Diseases Society of America Clinical Practice Guidelines for the Diagnosis and Management of Infectious Diarrhea.

Clin Infect Dis 2017 Nov;65(12):e45-e80

Division of Infectious Diseases, Department of Pediatrics, Emory University, Atlanta, Georgia.

These guidelines are intended for use by healthcare professionals who care for children and adults with suspected or confirmed infectious diarrhea. They are not intended to replace physician judgement regarding specific patients or clinical or public health situations. This document does not provide detailed recommendations on infection prevention and control aspects related to infectious diarrhea.
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http://dx.doi.org/10.1093/cid/cix669DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5850553PMC
November 2017
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