Jonna Lorenz is a freelance journalist with more than 20 years of experience. Her background is in business and health care news, including reporting, editing and research for newspapers and websites.

Jonna Lorenz

Incorporating a clinical decision support (CDS) strategy was associated with significantly higher odds of hospitalized children receiving the influenza vaccine, a recent study found.

The quality improvement study, published in 

, examined 17740 hospitalizations at 3 hospitals in a tertiary pediatric health system. The patients, who were hospitalized during 3 influenza seasons between 2018 and 2020, were divided among intervention groups and concurrent controls and historical controls.

“Clinical decision support (CDS) in the electronic health record (EHR) that integrates with clinicians' workflow can significantly improve use of evidence-based practices such as providing influenza vaccine to eligible hospitalized children,” Evan Orenstein, MD, pediatric hospitalist and chief medical information officer, Children's Healthcare of Atlanta, Emory University, told 

. “Many QI are limited to pre/post designs (i.e. what was the vaccination rate before and after the intervention). These approaches are susceptible to inappropriate conclusions from secular trends -- for example we know the vaccination rate naturally falls the later we get in the flu season. Step-wise implementations that provide both historical and concurrent controls are practical and improve the scientific rigor of QI interventions.”

The study examined a CDS intervention that included placing a default influenza vaccine order into admission order sets for eligible patients, a nursing script to offer the vaccine using a presumptive strategy, and education for clinicians including links to references.

“Small changes in CDS design can have a large impact on behavior,” Orenstein said. “For example, adding links to references justifying influenza vaccine for immunocompromised children or for those on steroids changed how physicians behaved during usability testing. Similarly, providing nursing flexibility by placing the influenza vaccine order in admission order sets instead of at the time of discharge made it easier to get the vaccine in despite a busy hospitalization. Finally, we were surprised that the vaccination rate among our concurrent controls (hospitalizations during the same season where we intervened but who were not exposed to our CDS intervention) was significantly higher than our historical controls (hospitalization in the prior flu season). We suspect this may have been due to the fact that physicians were seeing influenza vaccine orders in their workflow more often for the intervention group and were therefore reminded about the vaccine more often.”

Among the study participants, the average age was 8 years, 52% were boys, 50% were Black, 43% were White, and 64% had public insurance. The study authors noted that hospitalized children are at higher risk for morbidity and mortality related to influenza, but vaccine coverage is lower than the national average for this group.

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, the study found. An influenza vaccine was ordered for 4199 out of 5449 (77%) hospitalizations in the intervention group and administered during 1676 (31%) hospitalizations. In the concurrent control group, an influenza vaccine was ordered during 1488 (27%) of hospitalizations and administered during 1051 (19%). In the historical control group, an influenza vaccine was ordered during 1024 (15%) hospitalizations and administered during 912 (14%).

The odds of receiving the vaccine were highest early in the influenza season, declining by 3.7% with each additional week into the season. Age also was evaluated, with adolescents ages 13 to 17 being 28% less likely to receive the vaccines than children ages 6 to 23 months.

Further research is underway to improve influenza vaccination rates among children.

“While we saw significant improvements in flu vaccination rates, even among our intervention group only 31% of eligible hospitalizations had a flu vaccine administered,” Orenstein said. “We are undergoing a thorough analysis of the reasons why flu vaccines get ordered but not administered and developed additional CDS interventions for the 2020-2021 influenza season. We will be evaluating the effectiveness of those in concert with the interventions described here.”

“We are hoping to expand the use of this CDS beyond a single institution to determine if this pattern is effective in other health systems,” he added. “We are evaluating similar strategies in different care settings—i.e. the emergency department and ambulatory specialty clinics.”

The importance of vaccination is heightened amid the COVID-19 pandemic. Investigators are studying the possible 

Efforts to improve vaccination rates and influenza vaccines are ongoing.

The National Institutes of Health recently began a 

Phase 1 human trial of a universal influenza vaccine

, FluMos-v1, which is designed to stimulate antibodies against multiple influenza virus strains.

Articles

A clinical decision support (CDS) strategy including a default influenza vaccine order for eligible patients, a nursing script using a presumptive strategy, and education for clinicians, was associated with significant improvement in vaccination rates among hospitalized children, a new study showed.

A Clinical Decision Support Strategy Boosted Influenza Vaccination Rates Among Hospitalized Children

Initiation of preexposure prophylaxis was high among young women at risk for HIV in Africa, but adherence declined over time and with longer time between visits, a recent study found.

The study, published in a research letter in 

, included data on 451 sexually active women ages 16 to 25 in South Africa and Zimbabwe between October 2016 and October 2018. Those enrolled in the program were HIV negative and had multiple risks for HIV such as uncertainty about their partners’ HIV status and other sexual partners, low rates of condom use, and a high prevalence of bacterial sexually transmitted infections.

“Uptake of HIV preexposure prophylaxis (PrEP) was high among a cohort of young South African and Zimbabwean women at risk for HIV, which is encouraging in terms of interest in this novel biomedical HIV prevention method,” Connie Celum, MD, MPH, a professor of global health, medicine and epidemiology and director of the International Clinical Research Center at the University of Washington, told 

. “PrEP adherence was moderately high initially but declined with time and as visits were spaced out to quarterly.”

Participants were randomized into two groups: one offering standard adherence support—including counseling, 2-way SMS, and adherence clubs—and an enhanced adherence support group, which included drug level feedback. Those in the enhanced adherence support arm received feedback based on intracellular tenofovir-diphosphate (TFV-DP) levels in dried blood spots (DBS) to try to encourage adherence to treatment.

Celum said the study yielded some surprising results.

“First, STI prevalence was very high (over 1/3 of women having a treatable STI primarily chlamydia and gonorrhea), indicating that more attention needs to be paid to STIs in this population,” she said. “Second, HIV incidence was low (1%) in this population where we would have predicted a several-fold higher HIV incidence; this may indicate that young women benefitted from the package of services that they received. Third, retrospective drug level feedback did not increase adherence compared to a standard package of adherence interventions (two-way SMS, counseling and peer support/adherence clubs) without drug level feedback. Additional research is needed on use of real-time point of care PrEP adherence assays.”

Of the 451 study participants, 39% had curable STIs, 95% started PrEP and 55% had uninterrupted PrEP refills through 12 months. Detectable tenofovir-diphosphate levels were present in 84% at month 3, 57% at month 6, and 31% at month 12. High adherence (TFV-DP ≥700 fmol/punch) was found in 21% of the enhanced arm and 22% of the standard arm at 6 months.

Four women (1%) acquired HIV during the study.

“These data indicate that young African women are motivated to use PrEP but adherence and persistence with daily pill-taking are challenging,” Celum said. “We need to do more to simplify PrEP programs and give women options for long-acting PrEP methods, including the dapivirine vaginal ring and injectable cabotegravir which have shown efficacy.”

The study authors said reasons drug level feedback weren’t associated with increased adherence could have included lag times between when the sample was taken and when counseling was provided. Women also may have doubted reported drug levels or been discouraged from using PrEP if they perceived they were failing the treatment if their levels weren’t what they thought they should be. Also, other measures, such as 2-way SMS and peer support adherence clubs also may have improved adherence enough that benefits of drug level feedback weren’t noticeable.

“It is important to identify what proportion of young African women can adhere to PrEP with simple support such as two-way SMS or WhatsApp support groups, who needs more intensive adherence support, and what adherence support works better for those who need more support,” Celum said. “In addition, it is important to evaluate PrEP delivery and choice of PrEP options as they become available. Lastly, additional long-acting methods could be important for women who want HIV prevention but are not able to take a daily pill. Two novel PrEP agents—a monthly PrEP pill, islatravir, and an every six month SQ injection of an HIV capsid inhibitor, lenacapravir—are currently in efficacy trials.”

Studies have showed that PrEP is effective in maintaining low HIV infection rates, and efforts are ongoing to boost adherence to the treatment.

 in men who have sex with men in Australia found that HIV infection rates remained low among men, with 1.09 infections per 1,000 people in the first year, 2.10 infections per 1,000 people in the second year and 2.18 infections per 1,000 people in the third year.

 showed greater adherence associated with event-driven PrEP regimens than daily regimens of the treatment.

A recent study of sexually active young women in Africa found that initiation of HIV preexposure prophylaxis (PrEP) was high at 95% and one-fifth showed high adherence at 6 months.

PrEP Initiation is High Among Women in Africa, But Adherence Is Challenging

Remdesivir was not associated with improved survival in a large study of U.S. veterans, but length of hospitalization was longer.

, included 2344 U.S. veterans hospitalized with COVID-19 at 123 hospitals from May 1 to October 8, 2020. Associations between remdesivir treatment, survival, and length of hospital stay were examined.

“The takeaway message was that remdesivir treatment was not associated with greater survival, but was associated with a longer length of hospital stay,” Michael Ohl, MD, MSPH, associate professor of internal medicine-infectious disease at the University of Iowa Carver College of Medicine told 

. “The median length of stay was 3 days longer for people who received remdesivir compared to those who did not.”

The study included 1172 patients who received remdesivir and 11 matched controls. The groups were similar in age, with an average of about 67 years old, 93.9% were men, 47.7% received dexamethasone and about one-fifth were admitted to intensive care units.

All-cause mortality within 30 days was 12.2% among the remdesivir group compared with 10.6% among the control group. Results were similar regardless of use of the corticosteroid dexamethasone. Median time to hospital discharge was 6 days among the remdesivir group compared with 3 days for the control group.

“We were surprised to find the longer length of stay for people who received remdesivir,” Ohl said. “The Adaptive COVID-19 Treatment Trial 1, a randomized clinical trial comparing remdesivir to placebo, had previously found that remdesivir treatment shorted time to clinical recovery. We therefore expected that people would be able to go home from the hospital sooner after receiving remdesivir. In our study of remdesivir use in ‘real world care settings,' examination of the timing of remdesivir treatment and hospital discharge suggested that clinicians were keeping some patients in the hospital simply to complete 5 or 10-day remdesivir courses, even though the patients may otherwise have been ready to leave the hospital sooner. This likely contributed to longer hospital stays. The implication is that routine use of remdesivir may have led to an unintended consequence of increased use of hospital beds during the COVID-19 pandemic, without improving outcomes.”

The study authors noted that mixed results of studies of remdesivir for COVID-19 have complicated recommendations for use of the intravenous antiviral treatment, which was originally developed to treat Ebola.

“It is reasonable to follow the NIH and Infectious Disease Society of America guidelines for remdesivir use, but clinicians should avoid admitting people or keeping people in hospital solely to receive remdesivir if they do not meet other criteria for hospitalization,” Ohl said.

Limitations of the study included the possibility of residual differences in illness severity, the study included only 49.5% of patients receiving remdesivir who were able to be matched with controls, and limited data prevented the identification of specific subgroups who may have seen more benefit from remdesivir treatment.

Remdesivir was the first drug to receive 

 for the treatment of COVID-19 in the United States, when the FDA authorized its use in October after granting 

 former President Donald Trump received for COVID-19.

“Treatments for COVID-19 are evolving rapidly,” Ohl said. “We are examining more recent data to determine if remdesivir treatment is still associated with longer length of stay, or if clinicians have modified behavior to send people home earlier when appropriate. We are also working to get the message out to clinicians that they should not keep people in hospital simply to give remdeisvir.”

Use of remdesivir for COVID-19 was associated with longer hospital stays but was not associated with improved mortality, a recent study of 2344 patients at 123 VA hospitals found.

Remdesivir Did Not Improve Mortality at Hospitals, Prolonged Stays

The prevalence of serious bacterial infections among febrile infants who visited an emergency department in Canada doubled during the pandemic, while ED visits fell by two-thirds, a new study found.

The retrospective cross-sectional study, detailed in a research letter published in 

, included data from young infants up to age 3 months evaluated for fever between March 2018 and March 2021 at Montreal Children’s Hospital of the McGill University Health Centre. Primary outcomes were the proportions of serious bacterial infections (SBIs) and invasive bacterial infections (IBI).

“The spike in serious bacterial infections that we observed during the pandemic is concerning,” said corresponding author Brett Burstein, MD, CM, PhD, MPH, a pediatric emergency medicine physician and a junior investigator in the Child Health and Human Development Program at the Research Institute of the McGill University Health Center. “With fewer viruses circulating because of public health measures, fever is now more often a sign of a serious bacterial infection.”

Between March 2020 and March 2021, 324 infants were evaluated for fever, down dramatically from 951 between March 2018 and March 2019 and 973 between March 2019 and March 2020.

Before the pandemic, 63.3% of infants received multiplex virus testing. During the pandemic, SARS-CoV-2 testing replaced the 13-virus panel, and 96% of infants were tested for SARS-CoV-2.

“About 2% of all full-term babies are evaluated for fever in the first few months of life, and there exists significant ongoing variation in their management,” Burstein said. “These babies often have few other symptoms and doctors want to avoid unnecessary invasive tests, antibiotics and hospitalization.”

While the number of febrile infants who came to the emergency department decreased dramatically (66.3%) during the pandemic, the proportion of those with serious bacterial infections doubled from 10% before the pandemic to 20.4% during the pandemic. Serious bacterial infections include urinary tract infections, bacteremia and bacterial meningitis.

The proportion with life-threatening invasive bacterial infections tripled from 1.1% before the pandemic to 3.4% during the pandemic.

Among the infants who came to the emergency department during the pandemic, 20 tested positive for SARS-CoV-2. The study also found that the proportion of concomitant SBIs among those infected with SARS-CoV-2 (5%) was similar to that of other respiratory viruses before the pandemic.

“It is critical that physicians exercise caution and investigate appropriately, and that parents seek care for infants with fever, during the pandemic even more than before,” Burstein said.

Limitations of the study include a shortage of reagents leading to infrequent testing for respiratory viruses other than SARS-CoV-2 during the pandemic and that data was limited to a single hospital.

Diagnosing serious bacterial infections in young infants can be difficult and risky, and work is ongoing to improve diagnosis and treatment.

Investigators from the Pediatric Emergency Care Applied Research Network (PECARN) sought to avoid spinal taps and unnecessary antibiotic treatments with a 

 to rule out serious bacterial infection by evaluating levels of bacteria in the urine, as well as procalcitonin in serum, and neutrophils.

 found that taking 2 blood cultures before administering antibiotics for children admitted to the hospital with suspected sepsis or serious bacterial infection increased pathogen isolation and improved anti-microbial decision-making.

 year found that children prescribed at least 1 course of antibiotics before age 2 were more likely to develop asthma, allergic rhinitis, overweight, and ADHD.

An emergency department in Canada saw a steep drop in emergency department visits and a spike in the proportion of serious bacterial infections among newborns and young infants during the first year of the pandemic, a new study found.