P-425. Implementation of Urinalysis with Reflex to Urine Culture at a Pediatric Health System: A Diagnostic Stewardship Intervention

Open Forum Infectious Diseases · 2026-01-01

Abstract Background Asymptomatic bacteriuria usually does not require treatment and is a common reason for inappropriate antibiotic use. Urine reflex testing is a widely utilized diagnostic stewardship tool that reduces unnecessary urine cultures while maintaining ease of use for providers. There are few reports of the impact of urine reflex testing in a pediatric healthcare system.Figure 1:Breakdown of urine tests done after implementation of reflex testingLE - leukocyte esterase, WBC - white blood cells, hpf - high power fieldFigure 2:Change in urine culture rates after implementation of reflex testing.A) inpatient urine culture rate - the number of urine cultures collected on admitted patients per 100 patient-days. B) Emergency department urine culture rate - the umber of urine cultures collected on patients in the ED per 100 ED-encounters. Methods Before implementing reflex testing, our healthcare system had a combined urinalysis and urine culture order that was widely used in the emergency department. In May 2024, we replaced the combination order with a “Urinalysis with Reflex to Urine Culture (suspected UTI)” order, which was made available to all providers. For this order, urine culture was only performed if reflex criteria were met. Our reflex criteria were at least one of: nitrites positive, leukocyte esterase small/medium/large, or urine WBC ≥ 10 per hpf. Patients under 24 months old were excluded from the reflex pathway and always had cultures done if this order was used. Providers could also select from a short list of conditions for which urine culture would be done regardless of urinalysis results. Urine culture utilization was compared between the pre-intervention period (January 2021 to May 2024) and post-intervention (May 2024 to February 2025) using interrupted time series analysis. Results From May 23, 2024, to February 28, 2025, 22,716 urine reflex tests were ordered, of which 10,391 led to urine cultures and 12,325 (54.3%) did not reflex to culture (Figure 1). Patients who had urine cultures done were younger in the post-intervention period compared to the pre-intervention period (mean 4.1 years vs 6.2 years, P< 0.0001) and were less likely to have been tested in the emergency department (59.8% vs 66.6%, P< 0.001). Interrupted time series analysis demonstrated an immediate 44% decrease in urine culture incidence on inpatient units (95% CI 0.40-0.47, Figure 2a) and 43% decrease in urine culture incidence in the emergency department (95% CI 0.40–0.46, Figure 2b). This amounted to ∼1100 urine cultures avoided per month. Conclusion Implementation of reflex urine culture testing in a pediatric healthcare system led to a large decrease in urine culture rate. Disclosures Zachary M. Most, MD, MSc, VisualDx: Honoraria Laura Filkins, PhD, Avsana Labs: Advisor/Consultant|Biofire Diagnostics/Biomerieux: Grant/Research Support

Potential for misclassification of community-acquired respiratory virus infections as healthcare-associated respiratory virus infections at a pediatric healthcare system

Infection Control and Hospital Epidemiology · 2026-04-10

During a period of universal admission respiratory virus testing, many events (5%-14%) that might have been classified as healthcare-associated respiratory viral infections (HARVI) during routine operations were found to be community-acquired. These findings emphasize unique challenges for HARVI surveillance and the impact that testing strategies have on reported rates.

Multiyear environmental surveillance in a pediatric teaching hospital: association between airborne mold spores and invasive mold infections

Infection Control and Hospital Epidemiology · 2025-09-10

Abstract Background: The utility of routine environmental sampling to monitor the airborne fungal load (AFL) in healthcare settings is uncertain. Methods: AFL was measured by monthly cultures at a tertiary-care pediatric hospital from November 2018 through October 2023 on eleven units caring for patients at risk for invasive mold infection (IMI). Surveillance for healthcare-associated IMI was conducted for all patients in the healthcare system using locally developed definitions for possible, probable, and definite hospital-onset infections. Poisson regression was used to analyze the association between AFL and monthly IMI rates. Results: 78 cases of IMI were identified during the period of AFL monitoring. Of these, 51 infections were classified as healthcare-associated probable or proven IMI and were tested for association with AFL measurements. There was not a significant facility-wide association between the average monthly AFL and the overall IMI rate. On units where hematology/oncology patients were treated, however, an increase in average monthly local AFL for opportunistic fungal pathogens of 1 CFU/m 3 was associated with a 1.48-fold increase in the IMI rate for these patients (95% CI 1.00–2.19, P = .05). The AFL for Aspergillus species on these units showed a particularly strong association with the hematology/oncology IMI rate (15.9-fold elevation for an increase of 1 CFU/m 3 [95% CI 2.8–90.7, P = .002]). Neither hematology/oncology nor facility-wide IMI rates showed comparable associations with changes of the AFL in outdoor air. Conclusions: Regular monitoring of AFL on targeted hospital units may identify periods when hematology/oncology patients are at increased risk for IMI.

Discontinuation of Contact Precautions for Methicillin-resistant <i>Staphylococcus aureus</i> in a Pediatric Healthcare System

Journal of the Pediatric Infectious Diseases Society · 2024-01-02 · 3 citations

BACKGROUND: Many hospitals caring for adult patients have discontinued the requirement for contact precautions (CP) for patients with methicillin-resistant Staphylococcus aureus (MRSA) infection or colonization without reported negative effects. It is not clear whether this experience can be extrapolated to pediatric facilities. METHODS: CP for MRSA were discontinued in all locations except the neonatal intensive care unit at a 3-hospital pediatric healthcare system in September 2019. All hospitalized patients underwent surveillance for LabID healthcare facility-onset MRSA infections. Analysis was done using interrupted time series (ITS) from September 2017 through August 2023 and aggregate before-and-after rate ratios. RESULTS: There were 234 incident healthcare facility-onset MRSA infections during 766 020 patient days of surveillance. After discontinuation of CP for MRSA there was no change in the ITS slope (0.06, 95% CI: -0.35 to 0.47, P = .78) or intercept (0.21, 95% CI: -0.36 to 0.78, P = .47) of the LabID healthcare facility-onset MRSA infection incidence density rate. Additionally, there was no change in the aggregate incidence density rate of these MRSA LabID events (aggregate rate ratio = 0.98, 95% CI: 0.74 to 1.28). MRSA nasal colonization among patients being screened before cardiac surgery did not change (aggregate rate ratio = 0.94, 95% CI: 0.60 to 1.48). The prevalence rate of contact isolation days decreased by 14.0%. CONCLUSIONS: Discontinuation of CP for pediatric patients with MRSA was not associated with increased MRSA infection over 4 years. Our experience supports considering discontinuation of CP for MRSA in similar pediatric healthcare settings in the context of good adherence to horizontal infection prevention measures.

Respiratory virus infections in symptomatic and asymptomatic children upon hospital admission: new insights

Antimicrobial Stewardship & Healthcare Epidemiology · 2024-01-01 · 6 citations

Objective: Describe and compare the prevalence of symptomatic and asymptomatic or recently resolved respiratory infections in hospitalized children. Design: Cross-sectional study. Setting: Three hospital primary-to-quaternary care pediatric healthcare system. Patients: People less than 22 years old who underwent admission screening for respiratory viruses using a multitarget polymerase chain reaction (PCR) panel from August 2020 through April 2022. Methods: The symptom status of each patient was recorded by the ordering provider. The prevalence of each virus was described comparing symptomatic and asymptomatic patients. Results for each virus were stratified by age group and trends were examined over time. Results: Of the 32,812 eligible PCR panels collected, 12,965 (39.5%), 18,651 (56.8%), and 1,196 (3.6%) were obtained from patients who were symptomatic, asymptomatic, or had missing or unknown symptom status, respectively. Symptomatic patients were much more likely to test positive for a respiratory virus (67.3% vs 27.0%). The most common viruses detected in asymptomatic patients were rhinovirus/enterovirus (18.0%), SARS-CoV-2 (3.6%), and parainfluenza viruses (2.3%). The odds ratio of testing positive when symptomatic was significantly greater than unity for all viruses but varied by virus and age group. The proportion of positive tests for each virus was dynamic and changed with intermittent epidemics, or viral "waves." Conclusions: More than one-quarter of children without respiratory symptoms admitted to a pediatric healthcare system had PCR-detectable respiratory viruses. Children with symptoms of a respiratory infection are nevertheless much more likely to have a respiratory virus detected by PCR.

Healthcare-associated respiratory viral infections after discontinuing universal masking

Infection Control and Hospital Epidemiology · 2023-09-25 · 12 citations

In November 2022, our pediatric hospital replaced the requirement for universal masking of all healthcare personnel and visitors in all clinical buildings with a requirement for masking only during patient encounters. Following this change, we observed an immediate, substantial, and sustained increase in healthcare-associated respiratory viral infections.

Retrospective Observational Assessment of the Impact of Cefepime Prophylaxis in Neutropenic Pediatric Patients With Acute Myelogenous Leukemia

Journal of the Pediatric Infectious Diseases Society · 2023-08-01 · 2 citations

BACKGROUND: The potential for cefepime prophylaxis to reduce bloodstream infections (BSIs) in pediatric patients with acute myelogenous leukemia (AML) has been incompletely characterized. METHODS: A retrospective quasi-experimental study of patients under 21 years of age admitted with AML from 2010 through 2018 at two affiliated pediatric tertiary-care hospitals before and after the adoption of routine cefepime prophylaxis for afebrile AML patients during profound neutropenia. RESULTS: The rate of BSIs per 1000 neutropenia days was significantly lower in the prophylaxis group than the baseline group (2.6 vs 15.5, incidence rate ratio [IRR] 0.17, 95% CI 0.09-0.32). Interrupted time-series analysis showed that a sharp reduction in BSIs coincided with the implementation of prophylaxis. Bacteremia with viridans group streptococci was frequent in the baseline group but not observed after adopting prophylaxis. Despite the increased use of cefepime, the rate of cefepime-nonsusceptible BSIs per 1000 neutropenia days decreased (1.6 vs 4.1, IRR 0.40, 95% CI 0.16-0.99). The median number of febrile neutropenia episodes per patient also decreased in the prophylaxis group, as did the proportion of patients admitted to the intensive care unit (ICU) (22/51 (43.1%) vs 26/38 (68.4%); risk difference -25.3%, 95% CI -44.4 to -2.8). A trend was observed toward an increased proportion of patients with Clostridioides difficile infection in the prophylaxis group (10/51 (19.6%) vs 3/38 (7.9%); risk difference 11.7%, 95% CI -3.4 to 29.0). CONCLUSIONS: Cefepime prophylaxis was associated with a significant reduction in BSIs, febrile neutropenia, and ICU admission among pediatric AML patients.

Respiratory Virus infections in symptomatic and asymptomatic children: Results of one year of hospital admission screening

Antimicrobial Stewardship & Healthcare Epidemiology · 2022-05-16

Background: Respiratory viral infections are very common among children. Transmission-based precautions are frequently used with patients who test positive for a respiratory virus in pediatric hospitals to prevent transmission of infections, regardless of whether the patient has symptoms of a respiratory infection or not (asymptomatic). However, few data are available on the prevalence of respiratory viral infections in symptomatic and asymptomatic children who are admitted to a pediatric hospital. The study was conducted in 3 hospitals that combine for a 601-bed pediatric healthcare system in northern Texas. Methods: From July 7, 2020, to the present, all patients admitted to the hospital had a nasopharyngeal swab collected and tested with a multiplex PCR panel including SARS-CoV-2 and 8 other common respiratory viruses. Over a 1-year period from October 1, 2020, to September 30, 2021, the prevalences of infection with each of the 9 respiratory viruses were calculated and stratified by respiratory infection symptom status (determined by the ordering provider in an electronic order set) and age group. Results: During this 1-year period, 28,421 PCR panels were collected on patients admitted to the hospital. The median age was 5 years (IQR, 1–12 years), and 15,105 patients were male (53.2%). Overall, 12,792 panels were positive for at least 1 virus (45.0%). Among 26,688 panels on individuals with known symptom status, 26.3% of asymptomatic patients and 69.4% of symptomatic patients tested positive for at least 1 virus. The most common virus was rhinovirus or enterovirus (17.7% asymptomatic positive and 40.2% symptomatic positive) (Fig. 1). Asymptomatic rhinovirus or enterovirus prevalence varied by age group and was greatest in children aged 1–4 years (31.7%) and those aged 5–9 years (23.1%). It was lowest in adolescents aged 15–21 years (7.1%) (Fig. 2). Over time, the prevalence of asymptomatic infections fluctuated with local outbreaks. For SARS-CoV-2, in the resolution phase of an outbreak the prevalence of asymptomatic infections tended to overlap or surpass symptomatic infections. Conclusions: Asymptomatic respiratory viral infections, and in particular rhinovirus or enterovirus infections, were common among pediatric patients admitted to the hospital during the COVID-19 pandemic and were most common among children aged 1–9 years. However, symptomatic patients were still more likely to test positive for a respiratory virus compared to asymptomatic patients. Prolonged shedding of SARS-CoV-2 may explain why asymptomatic prevalence surpasses symptomatic prevalence in the resolution phase after outbreaks. Funding: None Disclosures: None

Contrasting definitions and incidence of healthcare-associated respiratory viral infections in a pediatric hospital

Infection Control and Hospital Epidemiology · 2022-03-23 · 8 citations

OBJECTIVE: To determine the difference in the incidence of healthcare-associated respiratory viral infection (HARVI) in a pediatric hospital depending on the definition used. DESIGN: Descriptive historical cohort study. SETTING AND PARTICIPANTS: Patients aged 0-21 years old who were admitted between July 2013 and June 2018 to a 490-bed primary to quaternary-care pediatric hospital serving northern Texas. METHODS: HARVI was defined using microbiologic confirmation, development of new symptoms while hospitalized, and exposure time greater than the minimum incubation period for each specific virus. Events that occurred following the maximum incubation period for that virus were classified as definite, otherwise they were classified as possible. This definition was compared to definitions using alternate timing of onset and symptomatology requirements. Data pertaining to demographics, diagnoses, and illness severity were collected. RESULTS: In total, 498 HARVIs (320 definite and 178 possible) were identified, with an incidence rate of 0.98 per 1,000 patient days (0.63 and 0.35, respectively). Rhinovirus or enterovirus and respiratory syncytial virus were the most identified viruses (58% and 10%, respectively). The median time from admission until HARVI was 10.5 days (interquartile range [IQR], 5-30 days). When alternate definitions were employed, the incidence of HARVI ranged from 0.96 to 2.00 per 1,000 admitted patient days. CONCLUSIONS: HARVI remain a common nosocomial infection in pediatric hospitals and the measured incidence is dependent on the definition used. Because of the endemic and pandemic potential of respiratory viruses, standardized definitions are needed to facilitate intra- and interhospital comparisons.

#87: Association Between Healthcare-Associated Respiratory Viral Infections and Length of Stay at a Pediatric Hospital

Journal of the Pediatric Infectious Diseases Society · 2021-03-01

Abstract Background Healthcare-associated infections (HAI) are major preventable causes of morbidity and mortality. While there are fewer overall HAI in children, there is a greater potential impact in disability-adjusted life years. Healthcare-associated respiratory viral infections (HARVI) are not frequently tracked within institutions, yet the risk for such infections in pediatric hospitals is very high. Recent data demonstrate large inter-hospital variability of HARVI incidence that may depend on various factors including the number of immunocompromised patients in the hospital and the presence of shared rooms. We hypothesize that the burden of healthcare-associated respiratory viral infections and their impact on the length of stay (LOS) is substantial at a large urban pediatric hospital. Methods A cohort of all children with any HARVI admitted to a large urban pediatric hospital between July 2017 and June 2018 were included after obtaining IRB approval. We defined a HARVI as a respiratory infection with an onset of symptoms while the patient was hospitalized meeting three criteria: A positive microbiologic test for one of 8 viruses, presence of symptoms of a respiratory infection, and onset of symptoms after admission beyond the minimum incubation period for each virus. Infections with symptom onset after admission beyond the maximum incubation period were considered definite hospital onset whereas others were considered possible hospital onset. The electronic medical record provided data on demographics, underlying medical conditions, hospital length of stay prior to infection and hospital unit of infection, and consequences and outcome of HARVI. The at-risk population for calculation of the incidence of HARVI was all admitted patient-days at the hospital over this time period. Results Between July 2017 and June 2018 the incidence of HARVI (definite or possible hospital onset) was 1.2 infections per 1,000 admitted patient-days (60% due to rhinovirus/enterovirus, 12% due to respiratory syncytial virus, and 9% due to influenza). Overall, 48% of patients were under 2 years of age, 18% were between 2 and 5 years of age, and 34% were over 5 years of age. Twenty-one percent were immunocompromised and 35% had underlying lung disease. The median length of stay prior to symptom onset was 11 days (IQR 5–36 days) and the median total length of stay was 30 days (IQR 15–82.5 days). Eight individuals had more than one HARVI over this time period. Nineteen percent were transferred to the intensive care unit and 7% died during their hospital admission Conclusion HARVI occurs frequently in a pediatric hospital and often in patients with underlying comorbidities. The risk for HARVI increases substantially with increased length of stay. Such data support the need for tracking HARVI in high-risk institutions.