Abstract Background Immunization prior to transplantation is important due to post-transplant immunosuppression. According to a national study, 15% of pediatric solid organ transplant recipients were hospitalized within 5 years post-transplant for a vaccine preventable illness or RSV. At our large academic pediatric hospital approximately 53% of heart and liver transplant recipients in 2016 -2018 were up to date with tetanus and pneumococcal vaccinations. This QI project was designed to improve our pre-transplant vaccination rates to minimize post-transplant infections. Methods An interdisciplinary team was convened including pharmacists, nurses, nurse practitioners, and physicians from cardiology, hepatology, and infectious diseases. After evaluating our current processes and key drivers, we selected interventions to implement via the PDSA model. Our first intervention was to have team members gain access to our statewide vaccine database (ICARE). Our second cycle was to link ICARE to our electronic medical record system (EPIC) for automatic immunization record integration. Process Map Key Driver Diagram Results Our outcome measure was up to date tetanus and pneumococcal vaccines per the CDC recommendations by age at transplant, as documented in the medical record. We saw an improvement in immunization rates to 100% during the third quarter of 2020 with an overall rate of over 80% for late 2019 - mid 2020. With the understanding that our average wait time for a heart and liver transplant was 2.4 and 3.8 months, respectively, the initiation of our QI project and obtaining access to ICARE by our team members was likely related to the improved vaccination rates. Unfortunately, after the team stopped meeting during the pandemic our immunization completion rates have decreased in 2021, despite implementing institutional access to ICARE. Control Chart Conclusion It is possible to obtain optimal immunization rates for pneumococcal and tetanus vaccines in pediatric heart and liver transplant recipients. Our future interventions include improving vaccinations after catch-up recommendations have been made and sustaining our interventions. Additionally, we look to expand our analysis to include outcomes related to vaccine-preventable diseases after transplantation. Disclosures Jacquie Toia, DNP, RN, APN, QarTek (Board Member) Ravi Jhaveri, MD, AstraZeneca (Consultant)Dynavax (Consultant)Elsevier (Other Financial or Material Support, Editorial Stipend as Co-editor in Chief, Clinical Therapeutics)Seqirus (Consultant)
Advancements in arterial stenting technology have challenged prior notions favoring medical management for intracranial atherosclerotic disease (ICAD). Where previous conclusions were drawn from bare metal stent (BMS) technology, recent studies suggest drug-eluting stents (DES) are favorable due to their anti-proliferative effect, which reduces vascular remodeling.
After pediatric heart transplant, commitment to lifelong immunosuppression is crucial to maintaining graft health. However, a review of the current literature surrounding adherence to immunosuppression in pediatric heart transplant patients is lacking. This systematic review aims to summarize the current landscape of adherence to immunosuppression in pediatric heart transplant patients. We conducted searches in PubMed MEDLINE, Embase, CENTRAL register of Controlled Trials (Wiley), and Scopus, from inception to March 2020. Studies were eligible if they outlined an aspect of adherence to immunosuppression and the measurement of adherence was performed with an objective or otherwise validated measure of adherence (e.g., drug levels, adherence questionnaires). The titles/abstracts of 880 articles were reviewed. After initial screening, 106 articles underwent full text review. As such, 14 articles were included in the final review. Baseline adherence estimates varied greatly, with most values between 40% and 70%. Nonadherence to immunosuppression is associated with worse outcomes (rejection, hospitalization, mortality), impaired quality of life, and mental health concerns in pediatric heart transplant patients. As nonadherence to immunosuppression is common and associated with worse outcomes, there is a need for further development and evaluation of interventions in this space.
This study aims to systematically review the management and outcomes of pediatric patients who develop intracranial pseudoaneurysm (IPA) following head trauma or iatrogenic injury.
Background Intracranial atherosclerotic disease (ICAD) is a major cause of stroke with a high rate of re-occlusion following mechanical thrombectomy (MT). Among the available rescue options, glycoprotein IIb/IIIa inhibitors (GPI) have shown promise as a potential therapeutic strategy. This systematic review and meta-analysis examine studies exploring the use of glycoprotein inhibitors as a first-line treatment for refractory occlusion or high-grade stenosis following EVT in the setting of ICAD. Methods A systematic review and meta-analysis were performed. Studies using GPI as the first-line rescue treatment (GPI-rt) after failed thrombectomy or in the setting with high-grade stenosis (>50%) were included. The primary outcome of interest was good clinical outcomes (defined as a modified Rankin Scale (mRS) score of 0–2 at 90 days). Secondary outcomes of interest were successful recanalization (TICI 2b-3), symptomatic intracranial hemorrhage (sICH), and mortality by 90 days. Results Our study processed 2111 articles, which yielded eight relevant studies for review, four single and four double arm. These studies comprised 763 patients, divided into GPI-rt (535 patients) and non-GPI-rt (228 patients) cohorts. The GPI-rt group had higher rates of mRS ≤ 2 at 90 days (58.5% vs 38.9%, p = 0.002) and lower mortality rates (7.8% vs 17.5%, p = 0.04) compared to the non-GPI-rt cohort. mTICI 2b-3 rates and rates of sICH were not significantly different between the cohorts. Conclusions First line GPI-rt demonstrates significant clinical benefit and significantly lower mortality without a rise in rates of sICH. GPI are a potential first line rescue treatment of ICAD.
Abstract Background Valganciclovir is approved for cytomegalovirus prophylaxis in pediatrics using the Pescovitz algorithm. There are reports of valganciclovir overdoses in children with low body surface area and overestimated creatinine clearance utilizing this algorithm. This study compared the incidence of neutropenia and cytomegalovirus infection between the Pescovitz and weight‐based dosing algorithms. Methods A single‐center retrospective chart review from January 2010 to September 2018 was performed on pediatric heart, liver, and kidney transplant recipients, who received valganciclovir. Data were collected from the initiation of valganciclovir prophylaxis to 30 days after discontinuation. The primary objective was the incidence of neutropenia in patients receiving valganciclovir dosed by the Pescovitz versus weight‐based dosing algorithms. Results This study included 187 pediatric transplant recipients who received valganciclovir dosed via the Pescovitz (62 recipients) or weight‐based dosing algorithms (125 recipients). The incidence of neutropenia was higher in the Pescovitz (69.4%) compared to the weight‐based dosing group (53.6%; p = .04) including moderate and severe neutropenia. Cytomegalovirus viremia was not significantly different between the two groups and occurred in 4.8% of the Pescovitz group compared to 2.4% of the weight‐based group ( p = .4). Conclusions The incidence of neutropenia was greater in recipients receiving valganciclovir dosed via the Pescovitz algorithm compared to the weight‐based dosing. There were no significant differences in regard to cytomegalovirus viremia or disease between the two groups.
Chronic Foley catheter use significantly increases the risk of scrotal abscesses, particularly in patients with comorbidities that impair immune function, such as diabetes and chronic kidney disease (CKD). We report a case of a 56-year-old male with type II diabetes, CKD, and a chronic indwelling Foley catheter who presented with progressive scrotal swelling and pain. Cultures identified Escherichia coli and Serratia marcescens from both urine and abscess fluid, confirming a possible urinary tract infection (UTI) as the source of scrotal abscess. The patient was found to have an abscess approximately 5 cm in size with significant drainage of abscess fluid overlying necrotic tissue of the right hemiscrotum. The management involved surgical debridement and excision of all necrotic scrotal tissue down to viable tissue, along with abscess washout to reduce the risk of further infections, and culture-directed antibiotic therapy. Outpatient and inpatient physicians, as well as advanced care providers, should prioritize proactive measures that include regular catheter care protocols to reduce the likelihood of complications arising in this vulnerable population.
Previous studies suggest a positive relationship between higher hospital endovascular thrombectomy (EVT) volume and improved outcomes. We investigated this association using the National Inpatient Sample (NIS) database from 2016 to 2020. A cross-sectional analysis of the NIS examined the relationship between hospital EVT volume and outcomes. Data on clinical and demographic variables were collected. Outcomes included favorable functional outcome (discharge home without assistance), inpatient mortality, and intracerebral hemorrhage (ICH). Hospitals in the top quintile of annual EVT volume were classified as high-volume centers. We conducted univariate, multivariate, nearest neighbor matched analysis, and an exploratory analysis to identify annual EVT volume cutoffs. Among 114,640 patients with EVT, 24,415 (21.3%) were treated at high-volume centers. High-volume centers had higher rates of favorable functional outcomes in univariate (odds ratio (OR) 1.20, p < 0.001), multivariate (adjusted OR (aOR) 1.19, p = 0.003), and matched analysis (OR 1.14, p = 0.028). Before matching, inpatient mortality was lower in high-volume centers (OR 0.83, p < 0.001), but this difference was not significant in univariate and matched analyses. No differences in ICH were observed. Functional benefit was noted at ≥ 50 EVTs annually, with centers performing ≥ 175 EVTs showing significantly higher benefits (aOR 1.42, p = 0.002). Increased hospital EVT volume is associated with modestly improved functional outcomes in patients with acute ischemic stroke. Functional improvements are evident at ≥ 50 EVTs annually and increase with higher case volumes, without associated increases in inpatient mortality or ICH.
Abstract Background The management of bloodstream infections (BSIs) may be improved with rapid diagnostic identification. The updated Biofire FilmArray blood culture identification (BCID) 2 panel is able to detect extended-spectrum beta-lactamase and additional carbapenemase encoding genes amongst other resistance markers, allowing for earlier antimicrobial stewardship interventions. The purpose of this study was to evaluate the time to optimal antimicrobial therapy. Methods This was a single-center retrospective chart review of patients before and after the implementation of the updated BCID panel (BCID1 vs. BCID2, respectively). Adult patients were eligible for inclusion if they had a positive blood culture with an accompanying BCID panel result. Patients were excluded if they received concomitant treatment for an unrelated infection or had monomicrobial BSI with Staphylococcus species. The primary endpoint was time to initiation of optimal antimicrobial therapy from index blood culture, defined as pathogen and resistance gene directed therapy per hospital treatment algorithm. Secondary endpoints included time to active antimicrobial therapy, defined as empiric therapy shown to be active against index isolate(s) with an antimicrobial susceptibility report, and 30-day mortality. Results Overall, 143 patients were included in the BCID1 group and 175 patients in the BCID2 group. Time to optimal antimicrobial therapy was shorter in the BCID2 group compared to the BCID1 group (17.1 hours vs. 29.3 hours; p < 0.05). Time to active therapy was shorter in the BCID2 group compared to the BCID1 group (3.1 hours vs. 5.9 hours; p=0.03). Thirty-day mortality rate was lower in the BCID2 group compared to the BCID1 group (9.7% vs. 20.9%; p < 0.05). Conclusion Time to optimal and active antimicrobial therapy were significantly shorter after the implementation of the BCID2 panel. Furthermore, 30-day mortality was lower, indicating that optimized therapy per local hospital treatment algorithms may improve outcomes. Disclosures All Authors: No reported disclosures
