Sustainability of Handshake Stewardship: Extending a Hand Is Effective Years Later.

Background: Children's Hospital Colorado created a unique method of antimicrobial stewardship, called handshake stewardship, that effectively decreased hospital anti-infective use and costs in its pilot year (2013). Handshake stewardship is distinguished by: (1) the lack of prior authorization; (2) a review of all prescribed anti-infectives; (3) a shared review by the physician and the pharmacist; and (4) a daily, rounding-based, in-person approach to supporting providers. We sought to reevaluate the outcomes of the program after 5 years of experience, totaling 8 years of data.

Hospital-wide Description of Clinical Indications for Pediatric Anti-infective Use.

Purpose: This study is the first description of hospital-wide anti-infective use according to clinical indication for a pediatric hospital. Children's Hospital Colorado (CHCO) is uniquely poised to examine its anti-infective use after the implementation of provider-selected order indications (PSOIs), which are distinct from Diagnosis Related Group classifications in that they are used for clinical treatment as opposed to final diagnosis codes for billing and thus are more granular.

Methods: This study used our institution's mandatory PSOIs to describe overall clinical indications for anti-infective use.

Safety, tolerability, and efficacy of fluoxetine as an antiviral for acute flaccid myelitis.

Objective: To determine the safety, tolerability, and efficacy of fluoxetine for proven or presumptive enterovirus (EV) D68-associated acute flaccid myelitis (AFM).

Methods: A multicenter cohort study of US patients with AFM in 2015-2016 compared serious adverse events (SAEs), adverse effects, and outcomes between fluoxetine-treated patients and untreated controls. Fluoxetine was administered at the discretion of treating providers with data gathered retrospectively.

Intervention and Acceptance Rates Support Handshake-Stewardship Strategy.

We instituted a new antimicrobial stewardship approach that involves review of all antimicrobial agents and communication of interventions in person by a pharmacist-physician team termed handshake stewardship. The acceptance rate in this study was 86%, intervention rates were higher with a physician, and interventions on antibiotics not reviewed by other strategies were made frequently.

Experience with Continuous Infusion Vancomycin Dosing in a Large Pediatric Hospital.

Background: There is a paucity of data on dosing of continuous infusion of vancomycin (CIV) in pediatric patients, despite it being an attractive treatment option for limiting escalating doses of intermittent infusion of vancomycin. The purpose of this study was to determine the total daily dose of CIV required to attain therapeutic serum vancomycin concentrations (SVCs) in pediatric patients according to age (≥31 days to <2 years, 2 to <8 years, and 8 to <18 years).

Methods: We retrospectively evaluated patients who were transitioned from intermittent infusion of vancomycin to CIV between January 2013 and December 2016.

Effect of provider-selected order indications on appropriateness of antimicrobial orders in a pediatric hospital.

Purpose: The effect of mandatory provider-selected order indications (PSOIs) on appropriateness of antimicrobial ordering in a tertiary pediatric hospital was evaluated.

Methods: Mandatory PSOIs for 14 antimicrobials were implemented in September 2013. Data on initial and final orders in the first 24 hours after ordering were collected from the electronic medical record.

Oral Fluoroquinolone Administration and Interacting Substances: The Pediatric Diet Dilemma.

Concomitant administration of enteral fluoroquinolones (FQs) with divalent or trivalent cation-containing compounds results in a reduction in FQ bioavailability. A review of enteral FQ administration with regards to the timing of divalent or trivalent cation-containing compounds in pediatric patients revealed a high number of inappropriately administered FQs. Suggestions for reducing the number of inappropriately timed FQ administrations are presented here.

Use of Intravenous Posaconazole in Hematopoietic Stem Cell Transplant Patients.

Background: Posaconazole is a broad-spectrum antifungal used for prophylaxis and treatment of invasive fungal infections. There is no published data to inform prescribers on dosing of the intravenous (IV) formulation in the pediatric population. We describe our experience including dosing, serum concentrations, and tolerability.

Anti-infective Acquisition Costs for a Stewardship Program: Getting to the Bottom Line.

Background: Though antimicrobial stewardship programs (ASPs) are in place for patient safety, financial justification is often required. In 2016, the Infectious Diseases Society of America (IDSA) recommended that anti-infective costs be measured by patient-level administration data normalized for patient census. Few publications use this methodology.

A Handshake From Antimicrobial Stewardship Opens Doors for Infectious Disease Consultations.

Implementation of a unique in-person pediatric antimicrobial stewardship program was associated with a significant increase in infectious disease consultations at a quaternary care children's hospital. This study demonstrates that antimicrobial stewardship programs support, and do not compete with, infectious disease programs.

Clinical Impact and Provider Acceptability of Real-Time Antimicrobial Stewardship Decision Support for Rapid Diagnostics in Children With Positive Blood Culture Results.

Background: Rapid diagnostic technologies for infectious diseases have the potential to improve clinical outcomes, but guideline-recommended antimicrobial stewardship (AS) strategies are not currently optimized for rapid intervention. We evaluated the clinical impact and provider acceptability of implementing real-time AS decision support for children with positive blood culture results according to the FilmArray blood culture identification panel (BCID [BioFire Diagnostics]) at Children's Hospital Colorado.

Methods: A pre-post quasi-experimental design was used to compare the outcomes of 100 postintervention children with positive blood culture results matched with 200 preintervention control children.

Handshake Stewardship: A Highly Effective Rounding-based Antimicrobial Optimization Service.

Background: Implementation of an antimicrobial stewardship program is recommended as one solution to combat increasing antimicrobial resistance. Most antimicrobial stewardship programs use preauthorization or restrictive strategies recommended in national guidelines. We describe a unique, rounding-based strategy, handshake stewardship.

Pediatric appendicitis and need for antibiotics at time of discharge: Does route of administration matter?

Introduction: Following complicated appendicitis, there are limited data available to guide the surgeon regarding antibiotic selection, specifically in regards to route of administration. We hypothesized that among children with appendicitis who are discharged home with antibiotic therapy, the post-discharge readmission and complication rates do not differ between those children who receive IV antibiotics and those who receive PO antibiotics.

Methods: We performed a retrospective review of all children discharged home on antibiotics following appendectomy at a single institution between 11/10-10/14.

Once-Daily Ceftriaxone Plus Metronidazole Versus Ertapenem and/or Cefoxitin for Pediatric Appendicitis.

Background: Appendicitis is a common surgical emergency in pediatric patients, and broad-spectrum antibiotic therapy is warranted in their care. A simplified once-daily regimen of ceftriaxone and metronidazole (CTX plus MTZ) is cost effective in perforated patients. The goal of this evaluation is to compare a historic regimen of cefoxitin (CFX) in nonperforated cases and ertapenem (ERT) in perforated and abscessed cases with CTX plus MTZ for all cases in terms of efficacy and cost.

Investigation of a cluster of Clostridium difficile infections in a pediatric oncology setting.

Background: We investigated an increase in Clostridium difficile infection (CDI) among pediatric oncology patients.

Methods: CDI cases were defined as first C difficile positive stool tests between December 1, 2010, and September 6, 2012, in pediatric oncology patients receiving inpatient or outpatient care at a single hospital. A case-control study was performed to identify CDI risk factors, infection prevention and antimicrobial prescribing practices were assessed, and environmental sampling was conducted.

Supra-therapeutic tacrolimus concentrations associated with concomitant nicardipine in pediatric liver transplant recipients.

Tacrolimus is prescribed to prevent allograft rejection in pediatric liver transplant recipients; however, its metabolism through the cytochrome P-450 enzyme system presents a multitude of challenges in regard to drug interactions. Here, we describe four children (ages 1.4-8.