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Mahindroo S, Mohan S, Dance S, O'Mara A, Elabd A, Tabaie S. Neighborhood Deprivation and Treatment Challenges in Pediatric Musculoskeletal Infections: A Socioeconomic Analysis. Cureus 2024; 16:e61998. [PMID: 38855499 PMCID: PMC11162602 DOI: 10.7759/cureus.61998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/09/2024] [Indexed: 06/11/2024] Open
Abstract
Introduction Musculoskeletal (MSK) infections are prevalent in the pediatric population, with previous research highlighting the significant impact of socioeconomic status (SES) on treatment outcomes. However, the specific link in pediatric cohorts remains poorly understood. The Area Deprivation Index (ADI), a measure of neighborhood-level disadvantage, serves as a crucial marker for SES. This study aims to investigate how ADI influences disease characteristics, treatment delays, and outcomes in pediatric patients with MSK infections. Methods A single-center retrospective cohort analysis was conducted using patient charts from a large urban pediatric hospital over six years from 2017 to 2022. Patients aged 0-18 years with diagnoses of osteomyelitis, septic arthritis, cellulitis, or pyomyositis were identified using the International Classification of Diseases - 10th Revision (ICD-10) codes. Data collection included demographics, disease characteristics, treatment delay intervals, and complications. Patient zip codes were obtained and entered into the Neighborhood Atlas® mapping website to determine their ADI. Patients were then stratified into four groups based on ADI scores: 1-10, 11-20, 21-40, and 41-100. Statistical analysis included the use of the Mann-Whitney U test for continuous data and the Chi-square/Fisher's exact test for binary and categorical data comparisons among the ADI groups. Results A total of 121 patients were included. Categorization based on ADI revealed 25 (20.7%) patients in the 1-10 ADI percentile group, 36 (29.8%) in the 11-20 group, 38 (31.4%) in the 21-40 group, and 22 (18.2%) in the 41-100 group. There were no significant differences between ADI and patient demographics, disease characteristics, presentation delay interval, treatment received, and complications. Conclusion The study demonstrates that there was no significant difference between ADI groups regarding demographics, disease characteristics, presentation delay interval, treatment received, and complications in pediatric populations. Despite the lack of evidence for differences in MSK infections attributable to ADI, this does not negate the potential existence of such a relationship.
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Affiliation(s)
- Sonal Mahindroo
- Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Shruthi Mohan
- Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Sarah Dance
- Orthopaedic Surgery, Children's National Hospital, Washington DC, USA
| | - Alana O'Mara
- Orthopaedic Surgery, George Washington University School of Medicine and Health Sciences, Washington DC, USA
| | - Ahmed Elabd
- Orthopaedic Surgery, Children's National Hospital, Washington DC, USA
| | - Sean Tabaie
- Orthopaedic Surgery, Children's National Hospital, Washington DC, USA
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Mercadante S, Ficari A, Romani L, De Luca M, Tripiciano C, Chiurchiù S, Calo Carducci FI, Cursi L, Di Giuseppe M, Krzysztofiak A, Bernardi S, Lancella L. The Thousand Faces of Invasive Group A Streptococcal Infections: Update on Epidemiology, Symptoms, and Therapy. CHILDREN (BASEL, SWITZERLAND) 2024; 11:383. [PMID: 38671600 PMCID: PMC11048970 DOI: 10.3390/children11040383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/15/2024] [Accepted: 03/20/2024] [Indexed: 04/28/2024]
Abstract
Invasive infections caused by Streptococcus pyogfenes (iGAS), commonly known as Group A Streptococcus, represent a significant public health concern due to their potential for rapid progression and life-threatening complications. Epidemiologically, invasive GAS infections exhibit a diverse global distribution, affecting individuals of all ages with varying predisposing factors. The pathogenesis of invasive GAS involves an array of virulence factors that contribute to tissue invasion, immune evasion, and systemic dissemination. In pediatrics, in the last few years, an increase in iGAS infections has been reported worldwide becoming a challenging disease to diagnose and treat promptly. This review highlights the current knowledge on pathogenesis, clinical presentations, and therapeutic approaches for iGAS in children.
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Affiliation(s)
- Stefania Mercadante
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Andrea Ficari
- Residency School of Pediatrics, University of Rome Tor Vergata, 00133 Rome, Italy;
| | - Lorenza Romani
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Maia De Luca
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Costanza Tripiciano
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Sara Chiurchiù
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Francesca Ippolita Calo Carducci
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Laura Cursi
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Martina Di Giuseppe
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Andrzej Krzysztofiak
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Stefania Bernardi
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
| | - Laura Lancella
- Infectious Disease Unit, Bambino Gesù Children’s Hospital, IRCCS, 00165 Rome, Italy; (S.M.); (L.R.); (C.T.); (S.C.); (S.B.); (L.L.)
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Restrepo R, Park HJ, Karakas SP, Cervantes LF, Rodriguez-Ruiz FG, Zahrah AM, Inarejos-Clemente EJ, Laufer M, Shreiber VM. Bacterial osteomyelitis in pediatric patients: a comprehensive review. Skeletal Radiol 2024:10.1007/s00256-024-04639-x. [PMID: 38504031 DOI: 10.1007/s00256-024-04639-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 02/24/2024] [Accepted: 02/27/2024] [Indexed: 03/21/2024]
Abstract
Bacterial osteomyelitis, an inflammatory response in the bone caused by microorganisms, typically affects the metaphysis in the skeletally immature. Bacterial osteomyelitis possesses a significant diagnostic challenge in pediatric patients due to its nonspecific clinical presentation. Because the metaphysis is the primary focus of infection in skeletally immature patients, understanding the normal physiologic, maturation process of bones throughout childhood allows to understand the pathophysiology of osteomyelitis. Timely and accurate diagnosis is crucial to initiate appropriate treatment, and prevent long-term sequelae and efforts must be made to isolate the causative organism. The potential causative organism changes according to the age of the patient and underlying medical conditions. Staphylococcus Aureus is the most common isolated bacteria in pediatric pyogenic osteomyelitis whereas Kingella Kingae is the most common causative agent in children aged 6 months to 4 years. Imaging plays a pivotal role in the diagnosis, characterization, evaluation of complications, and follow up of bacterial osteomyelitis. Imaging also plays a pivotal role in the evaluation of potential neoplastic and non-neoplastic mimickers of osteomyelitis. In children, MRI is currently the gold standard imaging modality when suspecting bacterial osteomyelitis, whereas surgical intervention may be required in order to isolate the microorganism, treat complications, and exclude mimickers.
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Affiliation(s)
- Ricardo Restrepo
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA.
| | - Halley J Park
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | - S Pinar Karakas
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | - Luisa F Cervantes
- Radiology Department, Nicklaus Children's Hospital, 3100 SW 62nd Ave, Miami, FL, 33155, USA
| | | | - Anna Maria Zahrah
- Krieger School of Arts and Sciences, Johns Hopkins University, Baltimore, MD, USA
| | | | - Marcelo Laufer
- Infectious Disease Department, Nicklaus Children's Hospital, Miami, USA
| | - Verena M Shreiber
- Orthopedic, Sports Medicine, and Spine Institute, Nicklaus Children's Hospital, Miami, USA
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4
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Wood JB, Russell K, Davis TE, Park SY, Smollin MJ, Schneider JG. Plasma Microbial Cell-Free DNA Sequencing for Pathogen Detection and Quantification in Children With Musculoskeletal Infections. J Pediatric Infect Dis Soc 2024; 13:211-219. [PMID: 38330338 DOI: 10.1093/jpids/piae012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Accepted: 02/07/2024] [Indexed: 02/10/2024]
Abstract
BACKGROUND Nearly half of all pediatric musculoskeletal infections (MSKIs) are culture negative. Plasma microbial cell-free DNA (mcfDNA) sequencing is noninvasive and not prone to the barriers of culture. We evaluated the performance of plasma mcfDNA sequencing in identifying a pathogen, and examined the duration of pathogen detection in children with MSKIs. METHODS We conducted a prospective study of children, aged 6 months to 18 years, hospitalized from July 2019 to May 2022 with MSKIs, in whom we obtained serial plasma mcfDNA sequencing samples and compared the results with cultures. RESULTS A pathogen was recovered by culture in 23 of 34 (68%) participants, and by initial mcfDNA sequencing in 25 of 31 (81%) participants. Multiple pathogens were detected in the majority (56%) of positive initial samples. Complete concordance with culture (all organisms accounted for by both methods) was 32%, partial concordance (at least one of the same organism(s) identified by both methods) was 36%, and discordance was 32%. mcfDNA sequencing was more likely to show concordance (complete or partial) if obtained prior to a surgical procedure (82%), compared with after (20%), (RR 4.12 [95% CI 1.25, 22.93], p = .02). There was no difference in concordance based on timing of antibiotics (presample antibiotics 60% vs no antibiotics 75%, RR 0.8 [95% CI 0.40, 1.46], p = .65]). mcfDNA sequencing was positive in 67% of culture-negative infections and detected a pathogen for a longer interval than blood culture (median 2 days [IQR 1, 6 days] vs 1 day [1, 1 day], p < .01). CONCLUSIONS Plasma mcfDNA sequencing may be useful in culture-negative pediatric MSKIs if the sample is obtained prior to surgery. However, results must be interpreted in the appropriate clinical context as multiple pathogens are frequently detected supporting the need for diagnostic stewardship.
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Affiliation(s)
- James B Wood
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kelsey Russell
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tom E Davis
- Department of Pathology and Laboratory Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | | | | | - Jack G Schneider
- Ryan White Center for Pediatric Infectious Diseases and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Liu Y, Zhao K, Liu Y, Sun YH, Li MX, Yu M, Zhu LQ, Wang XD. Bone and joint infection complicated with sepsis in neonates and infants under three months of age. J Pediatr (Rio J) 2024; 100:156-162. [PMID: 37837994 PMCID: PMC10943287 DOI: 10.1016/j.jped.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 09/06/2023] [Accepted: 09/06/2023] [Indexed: 10/16/2023] Open
Abstract
OBJECTIVE Studies focusing on bone and joint infections (BJIs) in young infants are rare. Some cases of BJI are accompanied by sepsis. This study aimed to identify the clinical and bacteriological features of sepsis in neonates and young infants with BJIs. METHODS Neonates and infants younger than 3 months diagnosed with BJI in the present institution from 2014 to 2021 were retrospectively reviewed. Patient characteristics, clinical data, and outcomes were documented and compared between those with and without sepsis. RESULTS Twenty-five patients with a mean age of 34.8 days were included. Nine BJI cases had concomitant sepsis (group A), and 16 had BJI without sepsis (group B). Within group A, staphylococcus aureus was the major pathogenic germ (5 cases, of which 4 were of the methicillin-resistant staphylococcus aureus (MRSA) type). There was no statistical difference in male-to-female ratio, age, history of hospitalization, anemia, birth asphyxia, peripheral leukocyte counts, C-reactive protein on admission, and sequelae between groups. Univariate analyses indicated a significant difference in the incidence of septic arthritis (SA) combined with osteomyelitis (OM) (88.9% vs 37.5%), congenital deformities (44.4% vs 0%), and mean duration of symptoms (2.83 days vs 9.21 days) in comparisons between groups A and B. CONCLUSION Staphylococcus aureus is the main pathogenic bacteria in BJI cases complicated with sepsis in neonates and young infants. Among infants younger than 3 months diagnosed with BJI, those with concurrent SA and OM, MRSA infection, or congenital deformities are more likely to develop sepsis.
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Affiliation(s)
- Yao Liu
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Kai Zhao
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Ya Liu
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Yu-Han Sun
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Meng-Xia Li
- Children's Hospital of Soochow University, Pediatrics Research Institute, Suzhou, Jiangsu Province, China
| | - Min Yu
- Children's Hospital of Soochow University, Department of Neonatology, Suzhou, Jiangsu Province, China
| | - Lun-Qing Zhu
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China
| | - Xiao-Dong Wang
- Children's Hospital of Soochow University, Department of Orthopaedics, Suzhou, Jiangsu Province, China.
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Woods CR, Bradley JS, Chatterjee A, Kronman MP, Arnold SR, Robinson J, Copley LA, Arrieta AC, Fowler SL, Harrison C, Eppes SC, Creech CB, Stadler LP, Shah SS, Mazur LJ, Carrillo-Marquez MA, Allen CH, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics. J Pediatric Infect Dis Soc 2024; 13:1-59. [PMID: 37941444 DOI: 10.1093/jpids/piad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee Health Sciences Center College of Medicine Chattanooga, Chattanooga, Tennessee
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, School of Medicine, and Rady Children's Hospital, San Diego, California
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonio C Arrieta
- Division of Infectious Diseases, Children's Hospital of Orange County and University of California, Irvine, California
| | - Sandra L Fowler
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of Montreal Research Center, Montreal, Quebec, Canada
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Kao CM, Fritz SA. Infection prevention-how can we prevent transmission of community-onset methicillin-resistant Staphylococcus aureus? Clin Microbiol Infect 2024:S1198-743X(24)00010-7. [PMID: 38218373 DOI: 10.1016/j.cmi.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/11/2023] [Accepted: 01/06/2024] [Indexed: 01/15/2024]
Abstract
BACKGROUND Staphylococcus aureus is a versatile organism, capable of existing as a commensal organism while also possessing pathogenic potential. The emergence of clinically and genetically distinct strains of methicillin-resistant S. aureus (MRSA), termed community-onset MRSA (CO-MRSA), resulted in an epidemic of invasive and skin and soft tissue infections (SSTI) in otherwise healthy individuals without traditional risk factors. Colonization with S. aureus is a risk factor for developing infection and also a source of transmission to close contacts. Outbreaks of S. aureus SSTI have been described in crowded settings and within households. Thus, preventive strategies are essential to interrupt recurrent infections. OBJECTIVES The objective of this narrative review is to provide a comprehensive, evidence-based approach to prevent transmission of CO-MRSA. We highlight key clinical trials that emphasize the importance of household and environmental S. aureus colonization in propagating household transmission. Finally, we highlight research priorities to prevent S. aureus infection. SOURCES We cite primary literature from peer-reviewed publications as sources for this review. CONTENT Our recommended approach to the management of individuals presenting with skin abscesses includes optimal treatment of the initial infection and hygiene education. Decolonization measures should be recommended for individuals with recurrent SSTIs or whose household members have SSTIs. Targeted decolonization with topical antimicrobials should be prescribed to all affected individuals within the household. IMPLICATIONS S. aureus infections result in substantial mortality and morbidity because of the high incidence of recurrent skin infections. Although current decolonization strategies are beneficial, interventions are often costly to families and effectiveness wanes over time. Results from a recently completed trial evaluating integrated periodic decolonization and household environmental hygiene will further add to our understanding of what constitutes a sustainable decolonization approach. In addition, novel preventive strategies are being developed such as S. aureus vaccines, lytic agents, probiotics, microbiota transplants, and phage therapy.
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Affiliation(s)
- Carol M Kao
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA
| | - Stephanie A Fritz
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Washington University School of Medicine, St. Louis, MO, USA.
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Galar F, Ulmer C, Gibbons S, McCormick S, Landrum M. Recurrent Infections After Percutaneous Pinning of a Proximal Radius and Ulna Fracture. J Am Acad Orthop Surg Glob Res Rev 2023; 7:01979360-202310000-00004. [PMID: 37801633 PMCID: PMC10561805 DOI: 10.5435/jaaosglobal-d-23-00081] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/08/2023]
Abstract
Elbow fractures in the pediatric population are an exceedingly common injury, comprising 5% to 10% of all pediatric fractures, with supracondylar fractures being the most common of the subset. Radial neck fractures are less frequent, comprising only 1% of all pediatric fractures. We provide a case report of a 7-year-old girl with a left radial neck and proximal ulna fracture. A 7-year-old girl presented to the emergency department after falling off a rock wall the day before. Imaging showed a left proximal ulna and proximal radial neck fracture. The patient underwent percutaneous reduction and fixation, complicated by subsequent infection requiring surgical débridement. The patient then developed a recurrent infection 1 year later, requiring repeat irrigation and débridement. The patient has since made a full recovery, returned to activities of daily living, and regained a full range of motion. Radial neck fractures have a low incidence and have been frequently associated with poor outcomes. The main mechanism by which these fractures occur is due to falling on an outstretched arm. Percutaneous pinning is often recommended after unsuccessful attempts at closed reduction because open reduction is often complicated by postoperative stiffness. As with any procedure that involves breaking the skin, there is a risk of infection. However, there is unclear evidence regarding ideal perioperative management to prevent postoperative infection.
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Affiliation(s)
- Federico Galar
- From the Department of Orthopedic Surgery, UT Health San Antonio, San Antonio, TX (Mr. Galar, Dr. Ulmer, Dr. Gibbons, Dr. McCormick, and Dr. Landrum); Orthopaedic Surgery, University of Arkansas Medical Sciences, Little Rock, AR (Dr. Landrum)
| | - Clinton Ulmer
- From the Department of Orthopedic Surgery, UT Health San Antonio, San Antonio, TX (Mr. Galar, Dr. Ulmer, Dr. Gibbons, Dr. McCormick, and Dr. Landrum); Orthopaedic Surgery, University of Arkansas Medical Sciences, Little Rock, AR (Dr. Landrum)
| | - Steven Gibbons
- From the Department of Orthopedic Surgery, UT Health San Antonio, San Antonio, TX (Mr. Galar, Dr. Ulmer, Dr. Gibbons, Dr. McCormick, and Dr. Landrum); Orthopaedic Surgery, University of Arkansas Medical Sciences, Little Rock, AR (Dr. Landrum)
| | - Sekinat McCormick
- From the Department of Orthopedic Surgery, UT Health San Antonio, San Antonio, TX (Mr. Galar, Dr. Ulmer, Dr. Gibbons, Dr. McCormick, and Dr. Landrum); Orthopaedic Surgery, University of Arkansas Medical Sciences, Little Rock, AR (Dr. Landrum)
| | - Matthew Landrum
- From the Department of Orthopedic Surgery, UT Health San Antonio, San Antonio, TX (Mr. Galar, Dr. Ulmer, Dr. Gibbons, Dr. McCormick, and Dr. Landrum); Orthopaedic Surgery, University of Arkansas Medical Sciences, Little Rock, AR (Dr. Landrum)
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Saturio S, Rey A, Samarra A, Collado MC, Suárez M, Mantecón L, Solís G, Gueimonde M, Arboleya S. Old Folks, Bad Boon: Antimicrobial Resistance in the Infant Gut Microbiome. Microorganisms 2023; 11:1907. [PMID: 37630467 PMCID: PMC10458625 DOI: 10.3390/microorganisms11081907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Revised: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 08/27/2023] Open
Abstract
The development of the intestinal microbiome in the neonate starts, mainly, at birth, when the infant receives its founding microbial inoculum from the mother. This microbiome contains genes conferring resistance to antibiotics since these are found in some of the microorganisms present in the intestine. Similarly to microbiota composition, the possession of antibiotic resistance genes is affected by different perinatal factors. Moreover, antibiotics are the most used drugs in early life, and the use of antibiotics in pediatrics covers a wide variety of possibilities and treatment options. The disruption in the early microbiota caused by antibiotics may be of great relevance, not just because it may limit colonization by beneficial microorganisms and increase that of potential pathogens, but also because it may increase the levels of antibiotic resistance genes. The increase in antibiotic-resistant microorganisms is one of the major public health threats that humanity has to face and, therefore, understanding the factors that determine the development of the resistome in early life is of relevance. Recent advancements in sequencing technologies have enabled the study of the microbiota and the resistome at unprecedent levels. These aspects are discussed in this review as well as some potential interventions aimed at reducing the possession of resistance genes.
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Affiliation(s)
- Silvia Saturio
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
| | - Alejandra Rey
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
| | - Anna Samarra
- Institute of Agrochemistry and Food Technology (IATA-CSIC), 46980 Paterna, Spain; (A.S.); (M.C.C.)
| | - Maria Carmen Collado
- Institute of Agrochemistry and Food Technology (IATA-CSIC), 46980 Paterna, Spain; (A.S.); (M.C.C.)
| | - Marta Suárez
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
- Pediatrics Service, Central University Hospital of Asturias (HUCA-SESPA), 33011 Oviedo, Spain
| | - Laura Mantecón
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
- Pediatrics Service, Central University Hospital of Asturias (HUCA-SESPA), 33011 Oviedo, Spain
| | - Gonzalo Solís
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
- Pediatrics Service, Central University Hospital of Asturias (HUCA-SESPA), 33011 Oviedo, Spain
| | - Miguel Gueimonde
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
| | - Silvia Arboleya
- Instituto de Productos Lácteos de Asturias (IPLA-CSIC), 33300 Villaviciosa, Spain; (S.S.); (A.R.)
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), 33011 Oviedo, Spain; (M.S.); (L.M.); (G.S.)
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Lynch JP, Zhanel GG. Escalation of antimicrobial resistance among MRSA part 2: focus on infections and treatment. Expert Rev Anti Infect Ther 2023; 21:115-126. [PMID: 36469648 DOI: 10.1080/14787210.2023.2154654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION MRSA is associated with causing a variety of infections including skin and skin structure infections, catheter and device-related (e.g. central venous catheter, prosthetic heart valve) infections, infectious endocarditis, blood stream infections, bone, and joint infections (e.g. osteomyelitis, prosthetic joint, surgical site), central nervous system infections (e.g. meningitis, brain/spinal cord abscess, ventriculitis, hydrocephalus), respiratory tract infections (e.g. hospital-acquired pneumonia, ventilator-associated pneumonia), urinary tract infections, and gastrointestinal infections. The emergence and spread of multidrug resistant (MDR) MRSA clones has limited therapeutic options. Older agents such as vancomycin, linezolid and daptomycin and a variety of newer MRSA antimicrobials and combination therapy are available to treat serious MRSA infections. AREAS COVERED The authors discuss infections caused by MRSA as well as common older and newer antimicrobials and combination therapy for MRSA infections. A literature search of MRSA was performed via PubMed (up to September 2022), using the keywords: antimicrobial resistance; β-lactams; multidrug resistance, Staphylococcus aureus, vancomycin; glycolipopeptides. EXPERT OPINION Innovation, discovery, and development of new and novel classes of antimicrobial agents are critical to expand effective therapeutic options. The authors encourage the judicious use of antimicrobials in accordance with antimicrobial stewardship programs along with infection-control measures to minimize the spread of MRSA.
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Affiliation(s)
- Joseph P Lynch
- Division of Pulmonary, Critical Care Medicine, Allergy, and Clinical Immunology, Department of Internal Medicine, the David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - George G Zhanel
- Department of Medical Microbiology/Infectious Diseases, Max Rady College of Medicine, University of Manitoba, Professor-Department of Medical Microbiology and Infectious Diseases, Winnipeg, Manitoba, Canada
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11
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Wood JB, Hawryluk B, Lynch D, Claxton G, Russell K, Bennett WE, Wiehe SE, Carroll AE. Identifying Patient-Centered Outcomes for Caregivers and Children With Musculoskeletal Infections. Open Forum Infect Dis 2022; 10:ofac671. [PMID: 36655190 PMCID: PMC9835755 DOI: 10.1093/ofid/ofac671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 12/09/2022] [Indexed: 12/14/2022] Open
Abstract
Background Musculoskeletal infections (MSKI), including osteomyelitis and septic arthritis, are among the most common invasive infections in children and have the potential to cause significant morbidity. Guidelines have been developed to optimize care based on clinician-developed endpoints. Patient-centered outcomes have not been defined for children with MSKI. This study identified outcomes most important to caregivers and patients with MSKI. Methods This was a single-center prospective qualitative study of children 6 months to 18 years of age hospitalized with MSKI from November 2019 to September 2021. Using design-research methods, patients and caregivers participated in interviews and/or completed journals to describe their experiences during acute infection and recovery from MSKI. Results A total of 51 patient/caregivers were approached to participate in the study, 35 of whom declined to participate, resulting in 8 interviews conducted and 14 journals collected from 16 patient/caregivers. From these, a journey map was created highlighting points of stress during the onset of symptoms, through hospitalization, and returning home with new challenges. In addition, patient-centered outcomes were identified. For caregivers, these included managing mental health, managing responsibilities, and receiving support. Both caregivers and patients shared the importance of understanding of treatment plans and responsibilities. For patients, improving mental and physical health was important. Conclusions Management of children with MSKI is complex and requires a multidisciplinary team approach. Validation of the outcomes identified and development of a measurement tool are needed. Addressing the patient-centered outcomes we identified in this study can greatly improve the holistic care of children with MSKI.
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Affiliation(s)
- James B Wood
- Correspondence: James B. Wood, MD, MSCI, Center for Pediatric and Adolescent Comparative Effectiveness Research, 410 W. 10th Street, HITS Building 2000A, Indianapolis, IN 46202 (). Aaron E. Carroll, Center for Pediatric and Adolescent Comparative Effectiveness Research, 410 W. 10th Street, HITS Building 2000A, Indianapolis, IN 46202 ()
| | - Bridget Hawryluk
- Indiana Clinical and Translational Sciences Institute's Patient Engagement Core, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dustin Lynch
- Indiana Clinical and Translational Sciences Institute's Patient Engagement Core, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Gina Claxton
- Indiana Clinical and Translational Sciences Institute's Patient Engagement Core, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Kelsey Russell
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - William E Bennett
- Center for Pediatric and Adolescent Comparative Effectiveness Research, Indiana University School of Medicine, Indianapolis, Indiana, USA,Indiana Clinical and Translational Sciences Institute's Patient Engagement Core, Indiana University School of Medicine, Indianapolis, Indiana, USA,Division of Pediatric Gastroenterology, Hepatology and Nutrition, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Sarah E Wiehe
- Indiana Clinical and Translational Sciences Institute's Patient Engagement Core, Indiana University School of Medicine, Indianapolis, Indiana, USA,Children's Health Services Research, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Aaron E Carroll
- Correspondence: James B. Wood, MD, MSCI, Center for Pediatric and Adolescent Comparative Effectiveness Research, 410 W. 10th Street, HITS Building 2000A, Indianapolis, IN 46202 (). Aaron E. Carroll, Center for Pediatric and Adolescent Comparative Effectiveness Research, 410 W. 10th Street, HITS Building 2000A, Indianapolis, IN 46202 ()
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12
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Povilaitis SC, Chakraborty A, Kirkpatrick LM, Downey RD, Hauger SB, Eberlin LS. Identifying Clinically Relevant Bacteria Directly from Culture and Clinical Samples with a Handheld Mass Spectrometry Probe. Clin Chem 2022; 68:1459-1470. [DOI: 10.1093/clinchem/hvac147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 07/11/2022] [Indexed: 11/13/2022]
Abstract
Abstract
Background
Rapid identification of bacteria is critical to prevent antimicrobial resistance and ensure positive patient outcomes. We have developed the MasSpec Pen, a handheld mass spectrometry-based device that enables rapid analysis of biological samples. Here, we evaluated the MasSpec Pen for identification of bacteria from culture and clinical samples.
Methods
A total of 247 molecular profiles were obtained from 43 well-characterized strains of 8 bacteria species that are clinically relevant to osteoarticular infections, including Staphylococcus aureus, Group A and B Streptococcus, and Kingella kingae, using the MasSpec Pen coupled to a high-resolution mass spectrometer. The molecular profiles were used to generate statistical classifiers based on metabolites that were predictive of Gram stain category, genus, and species. Then, we directly analyzed samples from 4 patients, including surgical specimens and clinical isolates, and used the classifiers to predict the etiologic agent.
Results
High accuracies were achieved for all levels of classification with a mean accuracy of 93.3% considering training and validation sets. Several biomolecules were detected at varied abundances between classes, many of which were selected as predictive features in the classifiers including glycerophospholipids and quorum-sensing molecules. The classifiers also enabled correct identification of Gram stain type and genus of the etiologic agent from 3 surgical specimens and all classification levels for clinical specimen isolates.
Conclusions
The MasSpec Pen enables identification of several bacteria at different taxonomic levels in seconds from cultured samples and has potential for culture-independent identification of bacteria directly from clinical samples based on the detection of metabolic species.
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Affiliation(s)
- Sydney C Povilaitis
- Department of Chemistry, The University of Texas at Austin , Austin, TX 78712 , USA
| | - Ashish Chakraborty
- Department of Chemistry, The University of Texas at Austin , Austin, TX 78712 , USA
| | - Lindsey M Kirkpatrick
- Department of Pediatrics, Division of Pediatric Infectious Diseases, J.W. Riley Hospital for Children, Indiana University School of Medicine , Indianapolis, IN 46202 , USA
| | - Rachel D Downey
- Department of Pediatric Infectious Diseases, Dell Children's Medical Group , Austin, TX 78723 , USA
| | - Sarmistha B Hauger
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin , Austin, TX 78712 , USA
| | - Livia S Eberlin
- Department of Surgery, Baylor College of Medicine , Houston, TX 77030 , USA
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13
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Sanchez MJ, Patel K, Lindsay EA, Tareen NG, Jo C, Copley LA, Sue PK. Early Transition to Oral Antimicrobial Therapy Among Children With Staphylococcus aureus Bacteremia and Acute Hematogenous Osteomyelitis. Pediatr Infect Dis J 2022; 41:690-695. [PMID: 35703303 DOI: 10.1097/inf.0000000000003594] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Staphylococcus aureus bacteremia (SAB) is a frequent complication of acute hematogenous osteomyelitis (AHO) in children, but data on the optimal duration of parenteral antibiotics prior to transition to oral antibiotics remains sparse. We examined clinical outcomes associated with early transition to oral antimicrobial therapy among children admitted to our institution with AHO and SAB, and evaluated the utility of a severity of illness score (SIS) to guide treatment decisions in this setting. METHODS Children with AHO and SAB admitted to our institution between January 1, 2009, and December 31, 2018, were retrospectively reviewed and stratified according to a previously validated SIS into mild (0-3), moderate (4-7) and severe (8-10) cohorts. Groups were assessed for differences in treatment (eg, parenteral and oral antibiotic durations, surgeries) and clinical response (eg, bacteremia duration, acute kidney injury, length of stay and treatment failure). RESULTS Among 246 children identified with AHO and SAB, median parenteral antibiotic duration differed significantly between mild (n = 80), moderate (n = 98) and severe (n = 68) cohorts (3.6 vs. 6.5 vs. 14.3 days; P ≤ 0.001). SIS cohorts also differed with regard to number of surgeries (0.4 vs. 1.0 vs. 2.1; P ≤ 0.001), duration of bacteremia (1.0 vs. 2.0 vs. 4.0 days; P ≤ 0.001), acute kidney injury (0.0% vs. 3.0% vs. 20.5%; P ≤ 0.001), hospital length of stay (4.8 vs. 7.4 vs. 16.4 days; P ≤ 0.001) and total duration of antibiotics (34.5 vs. 44.7 vs. 60.7 days; P ≤ 0.001). Early transition to oral antimicrobial therapy among mild or moderate SIS cohorts was not associated with treatment failure despite SAB. CONCLUSIONS SAB is associated with a wide range of illness among children with AHO, and classification of severity may be useful for guiding treatment decisions. Early transition to oral antimicrobial therapy appears safe in children with mild or moderate AHO despite the presence of SAB.
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Affiliation(s)
- Maria J Sanchez
- From the Department of Pediatrics, Children's Health System of Texas
| | - Karisma Patel
- Department of Pharmacy, University of Texas Southwestern Medical Center, Children's Health System of Texas, Dallas, Texas
| | - Eduardo A Lindsay
- Department of Family Medicine, Mayagüez Medical Center, Mayagüez, Puerto Rico
| | - Naureen G Tareen
- From the Department of Pediatrics, Children's Health System of Texas
| | - Chanhee Jo
- Research Department, Texas Scottish Rite Hospital for Children
| | - Lawson A Copley
- Department of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern Medical Center, Children's Health System of Texas, Texas Scottish Rite Hospital for Children, Dallas, Texas
| | - Paul K Sue
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Texas Southwestern Medical Center, Dallas
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Zhang T, Yu S, Lv X, Gan Y, Luo Y, Li T. Paediatric Osteomyelitis and Septic Arthritis Pathogen Distribution and Antimicrobial Resistance in a Single Centre: A 15-Year Retrospective Analysis. J Trop Pediatr 2022; 68:6589881. [PMID: 35595253 DOI: 10.1093/tropej/fmac038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
BACKGROUND The epidemiological characteristics of the common pathogens underlying acute haematogenous osteoarticular infection (AHOI) and their resistance to drugs have temporal and regional differences. AIMS To determine the antimicrobial treatment most effective for culture-negative AHOI patients and those without bacterial cultures. METHODS Retrospective analysis of clinical data of children with AHOI who were culture positive from January 2007 to December 2021. And the distribution of the main pathogens and the drug resistance Staphylococcus aureus were analysed in different time periods, age groups and infection types. RESULTS A total of 188 cases met the inclusion criteria, including 97 cases of acute haematogenous osteomyelitis (AHO), 75 cases of septic arthritis (SA) and 16 cases of AHO concomitant with SA. The commonest causative pathogen in local children was S. aureus of Gram-positive cocci, followed by Streptococcus, and occasionally Gram-negative bacilli. The distribution of S. aureus had no significant correlation with age or infection type. Staphylococcus aureus accounted for 81.82%, 90.91% and 96.15% of all pathogens, and methicillin-resistant S. aureus (MRSA) accounted for 24.22%, 53.33% and 76.00% of S. aureus in 2007-11, 2012-16 and 2017-21, respectively. The frequency of MRSA infection showed an increasing trend over time. CONCLUSION Staphylococcus aureus is still the main pathogen of AHOI in local children. The proportion of MRSA in S. aureus has also increased over time to 76% in the last 5 years, and the increased proportion of MRSA can affect the choice of initial empirical medication.
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Affiliation(s)
- Tianjiu Zhang
- Department of Orthopaedics, the Affiliated Hospital of Guizhou Medical University, Guiyang 550000, China
| | - Song Yu
- Department of Orthopaedics, the Affiliated Hospital of Guizhou Medical University, Guiyang 550000, China
| | - Xin Lv
- Department of Pediatric Orthopaedics, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
| | - Yongqiao Gan
- Department of Pediatric Orthopaedics, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
| | - Yu Luo
- Department of Pediatric Orthopaedics, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
| | - Tangjiang Li
- Department of Pediatric Orthopaedics, Affiliated Hospital of Zunyi Medical University, Zunyi 563000, China
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Kalu IC, Kao CM, Fritz SA. Management and Prevention of Staphylococcus aureus Infections in Children. Infect Dis Clin North Am 2022; 36:73-100. [PMID: 35168715 PMCID: PMC9901217 DOI: 10.1016/j.idc.2021.11.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Staphylococcus aureus is a common skin commensal with the potential to cause severe infections resulting in significant morbidity and mortality. Up to 30% of individuals are colonized with S aureus, though infection typically does not occur without skin barrier disruption. Infection management includes promptly addressing the source of infection, including sites of metastatic infection, and initiation of effective antibiotics, which should be selected based on local antibiotic susceptibility patterns. Given that S aureus colonization is a risk factor for infection, preventive strategies are aimed at optimizing hygiene measures and decolonization regimens for outpatients and critically ill children with prolonged hospitalizations.
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Affiliation(s)
| | | | - Stephanie A. Fritz
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Washington University School of Medicine, St. Louis, Missouri, USA
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16
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Yagupsky P. Traditional culture methods consistently overlook Kingella kingae osteoarticular infections. J Pediatr 2021; 236:331-332. [PMID: 33989655 DOI: 10.1016/j.jpeds.2021.05.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 05/06/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Pablo Yagupsky
- Clinical Microbiology Laboratory, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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17
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Truelove JJ, House SA. Reducing PICC Placement in Pediatric Osteomyelitis: A Diamond in the Deimplementation Rough? Hosp Pediatr 2021; 11:e111-e114. [PMID: 34187790 DOI: 10.1542/hpeds.2021-006029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Jessica J Truelove
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire .,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
| | - Samantha A House
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,Geisel School of Medicine, Dartmouth College, Hanover, New Hampshire
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