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Biomedical subjects

Susan E Coffin

Publications and source records attributed to Susan E Coffin.

At least 19 recordsLinked to original sources
PubMed2006

Administrative data fail to accurately identify cases of healthcare-associated infection.

OBJECTIVE: Some policy makers have embraced public reporting of healthcare-associated infections (HAIs) as a strategy for improving patient safety and reducing healthcare costs. We compared the accuracy of 2 methods of identifying cases of HAI: review of administrative data and targeted active surveillance. DESIGN, SETTING, AND PARTICIPANTS: A cross-sectional prospective study was performed during a 9-month period in 2004 at the Children's Hospital of Philadelphia, a 418-bed academic pediatric hospital. "True HAI" cases were defined as those that met the definitions of the National Nosocomial Infections Surveillance System and that were detected by a trained infection control professional on review of the medical record. We examined the sensitivity and the positive and negative predictive values of identifying HAI cases by review of administrative data and by targeted active surveillance. RESULTS: We found similar sensitivities for identification of HAI cases by review of administrative data (61%) and by targeted active surveillance (76%). However, the positive predictive value of identifying HAI cases by review of administrative data was poor (20%), whereas that of targeted active surveillance was 100%. CONCLUSIONS: The positive predictive value of identifying HAI cases by targeted active surveillance is very high. Additional investigation is needed to define the optimal detection method for institutions that provide HAI data for comparative analysis.

Cross Infection↗
PubMed2006

Cerebrospinal fluid mononuclear cell predominance is not related to symptom duration in children with enteroviral meningitis.

We used a binomial regression model to determine the relationship between the percent of cerebrospinal fluid (CSF) mononuclear white blood cells and symptom duration in children with proven enteroviral meningitis. The odds of a CSF white blood cell being mononuclear increased by 15.7% (95% confidence interval: -3.8% to 38.0%; P = .11) for each day of symptoms. Fifty percent of patients with symptoms of 1 day or less had predominance of mononuclear cells among CSF white blood cells. These findings suggest that factors other than symptom duration influence the composition and evolution of the CSF white blood cell response to enteroviral infection.

Adolescent↗
PubMed2006

Neuroborreliosis with progression from pseudotumor cerebri to aseptic meningitis.

We report a patient with an initial diagnosis of Lyme-associated pseudotumor cerebri who developed cerebrospinal fluid pleocytosis consistent with Lyme meningitis. The case illustrates the importance of considering neuroborreliosis in the differential diagnosis of pseudotumor cerebri and describes the evolution of cerebrospinal fluid findings in this condition.

Antibodies, Bacterial↗
PubMed2006

Clinical and molecular epidemiology of community-acquired methicillin-resistant Staphylococcus aureus infections among children with risk factors for health care-associated infection: 2001-2003.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) has recently emerged as a common cause of infection in children in many parts of the world. The epidemiology of community-acquired MRSA (CA-MRSA) among healthy children has been recently described. However, little is known about CA-MRSA in children with underlying medical conditions. OBJECTIVE: To compare the clinical and molecular epidemiology of CA-MRSA in children with and without risk factors for health care-associated infections (RF-HAI). METHODS: We conducted a 3-year retrospective cohort study of children with CA-MRSA infection. RF-HAI, including hospitalization within the past year, indwelling medical devices or chronic medical condition, were identified by chart review. Genetic relatedness of CA-MRSA strains was assessed by pulsed field gel electrophoresis. Polymerase chain reaction was used to detect Panton-Valentine leukocidin and determine staphylococcal chromosomal cassette carrying the mecA methicillin-resistant gene (SCCmec) type. RESULTS: We identified 446 episodes of community-acquired S. aureus infections, of which 134 (30%) were caused by MRSA. During the 3-year study period, the proportion of S. aureus infections caused by MRSA rose from 15% (12 of 80) to 40% (93 of 235) (P < 0.001) with the increase noted predominately in children with skin and soft tissue infections. RF-HAI were identified in 56 (42%) patients with CA-MRSA. Among subjects with CA-MRSA, children with RF-HAI were more likely to have had an invasive infection than healthy children (32% versus 5%; P < 0.001). CA-MRSA isolates from children with RF-HAI were similar to those without RF-HAI; all laboratory-retained CA-MRSA isolates harbored the SCCmec type IV cassette, and almost all isolates were susceptible to trimethoprim-sulfamethoxazole and clindamycin. However, pulsed field gel electrophoresis revealed greater molecular diversity among CA-MRSA isolates recovered from children with RF-HAI compared with those from otherwise healthy children (P = 0.001). Additionally CA-MRSA isolates from children with RF-HAI were less likely to contain sequences for Panton-Valentine leukocidin (P < 0.001) and more likely to be resistant to 3 or more classes of antibiotics (P = 0.033). CONCLUSION: CA-MRSA strains recovered from children with RF-HAI were phenotypically similar to those recovered from healthy children The absence of SCCmec type II or III MRSA among children with RF-HAI suggests that CA-MRSA strains might have become endemic within pediatric health care facilities.

Child↗
PubMed2006

Impact of acute rotavirus gastroenteritis on pediatric outpatient practices in the United States.

OBJECTIVES: The objectives of this study were to determine the presenting symptoms, healthcare utilization, and lost time from work and day care associated with acute rotavirus gastroenteritis. METHODS: During the winter to spring seasons of 2002-2003 or 2003-2004, children <36 months of age presenting with acute gastroenteritis to urban and suburban pediatric outpatient practices affiliated with 5 academic centers across the United States were enrolled in similarly designed studies. The case definition required >or=3 watery or looser-than-normal stools and/or forceful vomiting within a 24-hour period beginning <or=72 hours before presentation. Stool samples were tested for rotavirus antigen by standard commercial assays. Symptom frequencies for laboratory-confirmed rotavirus and nonrotavirus gastroenteritis were compared by Fisher's exact test; the number of healthcare contacts and lost days from work or day care were compared with the median 2-sample test. RESULTS: Stool specimens were obtained from 284 of 303 (94%) participants; 115 (40%) of tested specimens were positive for rotavirus (range, 31-50% across the 5 centers). Compared with participants with nonrotavirus gastroenteritis, children with rotavirus gastroenteritis were more likely to have 1) vomiting (83% versus 66%; P = 0.003), 2) combined diarrhea and vomiting (75% versus 50%; P < 0.001), and 3) fever (60% versus 43%; P = 0.010). More time from work was lost by parents/guardians of children with rotavirus than nonrotavirus gastroenteritis (median 2 versus 0 day; P = 0.007). More day care was missed by children with rotavirus than nonrotavirus gastroenteritis (median 3 versus 1 day; P = 0.002). CONCLUSIONS: In this multicenter study, rotavirus consistently caused a sizable proportion of cases of acute gastroenteritis seen in pediatric outpatient practices in the United States during the winter and spring. Rotavirus gastroenteritis was more frequently associated with vomiting, combined diarrhea and vomiting, fever and lost time from work and day care than nonrotavirus gastroenteritis.

Acute Disease↗
PubMed2006

Direct medical cost of influenza-related hospitalizations in children.

OBJECTIVE: Our goal was to determine the cost of influenza-related hospitalization in children with community-acquired laboratory-confirmed influenza and to identify predictors of high hospitalization costs. PATIENTS AND METHODS: This was a retrospective cohort study of patients 21 years and younger hospitalized at a children's hospital with community-acquired laboratory-confirmed influenza during 4 consecutive influenza seasons (2000-2004). The main outcome measure was the direct medical cost of influenza-related hospitalizations, including the cost of diagnostics, therapeutics, room, and physician services. RESULTS: Electronic billing data were retrievable for 727 (98%) of 745 patients hospitalized for community-acquired laboratory-confirmed influenza during the study period. A total of 478 (66%) children were in a high-risk group for whom the Advisory Committee on Immunization Practices recommended influenza vaccine (patients with Advisory Committee on Immunization Practices-designated chronic medical conditions or aged 6-23 months). The mean total cost of hospitalization for influenza-related illness was 13,159 dollars (39,792 dollars for patients admitted to an ICU; 7030 dollars for patients cared for exclusively on the wards). High-risk patients had higher mean total costs (15,269 dollars) than low-risk patients (9107 dollars). Cardiac, metabolic, and neurologic/neuromuscular diseases and age of 18 to 21 years were independently associated with the highest hospitalization costs (>15th percentile). CONCLUSIONS: The cost of influenza-related hospitalizations in children may be considerably higher than previously estimated. The presence of certain Advisory Committee on Immunization Practices-designated chronic medical conditions is associated with higher influenza-related hospitalization costs. Successfully immunizing patients with these conditions has the potential for significant cost savings.

Adolescent↗
PubMed2005

Neurological and neuromuscular disease as a risk factor for respiratory failure in children hospitalized with influenza infection.

CONTEXT: The Advisory Committee on Immunization Practices (ACIP) recommends annual influenza vaccination for children with certain chronic medical conditions to prevent serious complications of influenza infection. Little is known about the relative contribution of each of these chronic medical conditions to the development of serious influenza-associated complications. OBJECTIVE: To identify chronic medical conditions that are associated with respiratory failure in children hospitalized with community-acquired laboratory-confirmed influenza. DESIGN, SETTING, AND PATIENTS: A retrospective cohort study of patients aged 21 years or younger hospitalized at The Children's Hospital of Philadelphia with community-acquired laboratory-confirmed influenza during 4 consecutive influenza seasons (June 2000 through May 2004). We examined 9 ACIP-designated high-risk chronic medical conditions and 3 additional chronic medical conditions (neurological and neuromuscular disease [NNMD], gastroesophageal reflux disease [GERD], and history of prematurity) that in recent studies have been associated with influenza hospitalization and severe influenza-related complications. MAIN OUTCOME MEASURES: Rate and odds ratio (OR) of respiratory failure, defined as need for mechanical ventilation. RESULTS: Of 745 children hospitalized with community-acquired laboratory-confirmed influenza, 322 (43%) had 1 or more ACIP-designated high-risk chronic medical conditions. Neurological and neuromuscular disease, GERD, and history of prematurity were present in 12%, 14%, and 3%, of children, respectively. Thirty-two children (4.3%) developed respiratory failure. In multivariate logistic regression analyses, conditions associated with respiratory failure included NNMD (OR, 6.0; 95% confidence interval [CI], 2.7-13.5), chronic pulmonary disease other than asthma (OR, 4.8; 95% CI, 1.5-15.1), and cardiac disease (OR, 4.0; 95% CI, 1.6-10.2). The predicted probabilities of respiratory failure derived from the multivariate model were 12% (95% CI, 7%-20%), 9% (95% CI, 3%-23%), and 8% (95% CI, 4%-18%) for children with NNMD, chronic pulmonary disease, and cardiac disease, respectively. CONCLUSIONS: These results support the ACIP's recent decision to add NNMD to the list of conditions for which annual influenza vaccine is recommended in children. Neurologists and primary care pediatricians should be alerted to the increased risk of respiratory failure and the importance of influenza vaccination in children with NNMD.

Adolescent↗
PubMed2005

Infection control, hospital epidemiology, and patient safety.

Health care-acquired are a major risk for hospitalized children. Similar to adult patients, children are vulnerable to infections related to medical devices. Children also are at significant risk of nosocomial transmission of common pediatric viral illness, such as respiratory syncytial virus and varicella. In addition, pediatric patients have unique or incompletely developed immune system.

Child↗
PubMed2005

Bronchiolitis: in-patient focus.

Bronchiolitis is among the most common and serious lower respiratory tract syndromes that affects young children. In developed countries, the case fatality rate among previously healthy children remains low; in contrast, infants with underlying medical conditions, such as immunodeficiency or chronic lung disease, are at risk of prolonged illness and death. Bronchiolitis is associated with significant morbidity among healthy young children. During the winter season, bronchiolitis is the most common cause of hospitalization among infants. Each year in the United States, approximately 2 per 100,000 infants die as a result of complications associated with bronchiolitis.

Bronchiolitis↗
PubMed2005

Postoperative mediastinitis in children: epidemiology, microbiology and risk factors for Gram-negative pathogens.

BACKGROUND: Mediastinitis, although an infrequent complication of median sternotomy, represents a significant source of morbidity and mortality. OBJECTIVE: To determine the incidence and describe the epidemiology and microbiology of mediastinitis in children after cardiac surgery and to identify risk factors for the development of Gram-negative mediastinitis. STUDY DESIGN: This was a retrospective case-control study nested within the cohort of children, birth to 18 years of age, undergoing median sternotomy between January 1, 1995 and December 31, 2003. RESULTS: Forty-three cases of mediastinitis were identified. The incidence of mediastinitis was 1.4%. Median patient age at time of inciting sternotomy was 32 days (interquartile range, 5 days-9 months). Twenty-three (54%) cases occurred in girls. Median time to onset of infection after surgery was 11 days (range, 4-34 days). Overall Gram-positive organisms were present in 29 (67%) cases, and Gram-negative organisms were present in 13 (30%) cases. The organisms most commonly isolated from mediastinal culture were Staphylococcus aureus (46%), coagulase-negative staphylococci (17%) and Pseudomonas aeruginosa (17%). The rate of concurrent bacteremia was 53% (95% confidence interval, 38-69%). In multivariable analysis, delayed sternal closure was an independent risk factor for the development of Gram-negative mediastinitis (odds ratio, 9.3; 95% confidence interval, 1.5-56.8; P = 0.016). CONCLUSIONS: Although Gram-positive organisms were the most common cause of infection, Gram-negative organisms accounted for one-third of all isolates. More than one-half of patients with mediastinitis had concurrent bacteremia. Delayed sternal closure was an independent risk factor for Gram-negative mediastinitis.

Bacteremia↗
PubMed2005

Early differentiation of Lyme from enteroviral meningitis.

BACKGROUND: Differentiating Lyme meningitis from enteroviral meningitis remains difficult because both occur mostly in the summer and early fall. This distinction is clinically important because pathogen-specific diagnostic test results are not available immediately and only patients with Lyme meningitis require parenteral antibiotic therapy. OBJECTIVES: The objective of this study was to identify clinical and laboratory features that might help clinicians distinguish patients with Lyme meningitis from those with enteroviral meningitis. METHODS: This cross-sectional study compared patients diagnosed with Lyme or enteroviral meningitis evaluated at a large children's hospital between January 1, 1999 and September 20, 2002. RESULTS: Twenty-four patients with Lyme meningitis and 151 patients with enteroviral meningitis had median ages of 10.5 and 5.5 years, respectively (P < 0.0001). There was an equal proportion of boys with Lyme (63%) and enteroviral meningitis (62%; P = 1.0). The duration of symptoms before evaluation was longer for patients with Lyme meningitis (12 days) than with enteroviral meningitis (1 day; P < 0.0001). Cranial neuropathy was a presenting feature in 71% of children with Lyme meningitis. Cranial neuropathy, erythema migrans rash or papilledema occurred in 88% of patients with Lyme meningitis; no patients with enteroviral meningitis exhibited any of these findings (P < 0.0001). Lyme meningitis was unlikely when cerebrospinal fluid neutrophils exceeded 10% (negative predictive value, 99%). CONCLUSIONS: We identified several clinical and laboratory features that may permit early differentiation of Lyme from enteroviral meningitis. These results may assist clinicians with decisions regarding additional testing and empiric antibiotic therapy.

Adolescent↗
PubMed2005

Risk factors for mortality in children with candidemia.

We performed a retrospective cohort study of hospitalized children with positive blood cultures for Candida species. Independent risk factors for mortality by multivariable analysis were location in the pediatric intensive care unit at the time of infection (hazard ratio, 6.3; 95% confidence interval, 1.6-24.3) and the presence of an arterial catheter (hazard ratio, 2.4; 95% confidence interval, 1.1-5.8). Our findings help identify a group of pediatric patients that should be targeted for future interventions to prevent and treat candidemia.

Antifungal Agents↗
PubMed2005

Induction of mucosal B-cell memory by intranasal immunization of mice with respiratory syncytial virus.

The capacity of live or inactivated respiratory syncytial virus (RSV) to induce B-cell memory in respiratory-associated lymphoid tissues of mice was examined. Eight weeks after primary inoculation with either live or inactivated RSV, adult BALB/c mice were challenged with 4x10(5) PFU of RSV. Protection from viral shedding and mucosal production of RSV-specific antibodies were examined at various time points after challenge. We found that primary immunization with live, but not inactivated, RSV induced complete and durable protection upon challenge within the upper and lower respiratory tract. Also, primary immunization with live, but not inactivated, RSV enhanced the production of mucosal RSV-specific immunoglobulin A (IgA) upon challenge. Secondary mucosal IgA responses were characterized by (i) the early production of mucosal IgA by B cells that reside in organized nasal-associated lymphoid tissues, cervical lymph nodes, and bronchial lymph nodes, and (ii) the subsequent production of RSV-specific IgA by mucosal effector tissues, such as the tracheal lamina propria and lung. These findings suggest that primary infection of mice with live RSV might induce mucosal IgA-committed memory B cells. A greater understanding of the characteristics of RSA-specific mucosal memory B cells may facilitate the development of an RSV vaccine.

Administration, Intranasal↗
PubMed2005

Risk factors for and outcomes of bloodstream infection caused by extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species in children.

OBJECTIVE: The increasing prevalence of infections caused by extended-spectrum beta-lactamase-producing Escherichia coli and Klebsiella species (ESBL-EK) has become a growing concern in the hospitalized patient population. Previous studies on risk factors for infection with ESBL-EK have mainly focused on adult populations, and these findings may not be relevant among the pediatric population that experiences a unique set of health care exposures and underlying conditions. The objective of this study was to define the risk factors and outcomes associated with ESBL-EK bloodstream infections in children. METHODS: We conducted a nested case-control study using data from the Children's Hospital of Philadelphia from May 1, 1999, to September 30, 2003. Eligible patients were identified from the hospital database of microbiology laboratory records. All patients with ESBL-EK bloodstream infections were compared to a random sample of patients with non-ESBL-EK bloodstream infections. Risk factors analyzed included prior antimicrobial use, comorbid conditions, and demographic characteristics. Pulsed-field gel electrophoresis was performed to determine genetic relatedness of the ESBL-EK isolates. RESULTS: Thirty-five cases and 105 control subjects were included in the study. The median age among the cases was 2 years (interquartile range: 0-11), compared with 1 year (interquartile range: 0-8) among control subjects. Patients with ESBL-EK infections were 5.8 times (95% confidence interval: 1.9-17.7) more likely to have had exposure to an extended-spectrum cephalosporin in the 30 days before infection than those with non-ESBL-EK infections. Other independent predictors of ESBL-EK infection were being female, infection with a Klebsiella species, and steroid use in the 30 days before infection. All ESBL-EK isolates were susceptible to carbapenem antibiotics. Pulsed-field gel electrophoresis analysis revealed that the ESBL-EK isolates were polyclonal. Although a substantially higher proportion of children with ESBL-EK died (in-hospital mortality: 36% vs 13%), this difference was not statistically significant. CONCLUSIONS: Receipt of extended-spectrum cephalosporins in the 30 days before infection by an Escherichia coli or Klebsiella species is significantly associated with having an ESBL-EK infection in hospitalized children. Curtailed use of cephalosporins among high-risk groups may reduce the occurrence of ESBL-EK infections. Future studies on identifying high-risk children and investigating the impact of curtailed third-generation cephalosporin use to limit additional emergence of ESBL-EK infections should be undertaken.

Analysis of Variance↗
PubMed2005

Addisonian pigmentation of the oral mucosa.

Cutaneous pigmentation is a hallmark of Addison disease. When present, the hyperpigmentation generally localizes to sun-exposed surfaces. This case highlights a less well-recognized cutaneous feature that is pathognomonic for the disease: oral mucous membrane hyperpigmentation. We describe this unique type of discoloration in detail and contrast it with other forms of oral pigmentation.

Addison Disease↗
PubMed2004

Regional differences in the early mucosal immune response induced by primary inoculation of mice with respiratory syncytial virus.

Respiratory syncytial virus (RSV) is the most important cause of respiratory tract infection in infants. Little is known about the characteristics of critical immunologic inductive sites within respiratory-associated lymphoid tissues (RALT) upon RSV infection. We examined the kinetics and characteristics of early mucosal RSV-specific immune responses after primary inoculation of mice. We found that the initial production of virus-specific antibodies was restricted to the organized lymphoid tissues of RALT, such as nasal-associated lymphoid tissue (NALT), cervical and bronchial lymph nodes (CLN and BLN). In addition, virus-specific IgM was produced by B cells resident in CLN and BLN, but not NALT, of mice. Finally, we observed regional differences in the pattern of RSV-specific antibodies produced by RALT; B cells within NALT and CLN produced equivalent quantities of virus-specific IgG2a and IgG2b. However, an IgG2a response predominated in BLN. Together these data demonstrate regional differences in the early mucosal immune response to RSV. Further understanding of these differences may assist the development of RSV vaccines.

Animals↗