Early Central Venous Catheter Replacement After Candida in Pediatric Intestinal Failure Patients

Background

Deferred central venous catheter (CVC) replacement places children with intestinal failure (IF) at risk of complications. We hypothesized that early CVC replacement after uncomplicated candidemia is safe and beneficial.

Methods

We performed a retrospective review of children with IF. Patients were divided into early (<7 days after their first negative culture), and late (≥7 days after their first negative culture) CVC replacement following uncomplicated candidemia. We calculated the median time to CVC removal, clearance of infection, CVC replacement or exchange, and duration of the initial hospitalization. The proportion of patients readmitted within 30 days was also calculated, taking note of the number of candida reinfections.

Results

Early replacement occurred in 18 encounters and late replacement in 21 encounters. The median time in both groups to CVC removal was 3 days (P = 0.949), and clearance of infection was 4 days (P = 0.466). The median time to CVC replacement or exchange in the early group was 4 days, compared to 10 days in the late group (P < 0.001). The median duration of the hospitalization in the early group was 12 days compared to 21 days in the late group (P = 0.011). In total 39% of patients from the early group were readmitted within 30 days compared to 57% from the late group (P = 0.359). None of the patients were reinfected with candida within 30 days.

Conclusion

Early CVC replacement after uncomplicated candidemia in children with IF decreases hospital stay without increased risk of readmission or reinfection.

NFKB2 haploinsufficiency identified via screening for IFN-α2 autoantibodies in children and adolescents hospitalized with SARS-CoV-2-related complications

BACKGROUND

Autoantibodies against type I IFNs occur in approximately 10% of adults with life-threatening coronavirus disease 2019 (COVID-19). The frequency of anti-IFN autoantibodies in children with severe sequelae of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is unknown.

OBJECTIVE

We quantified anti-type I IFN autoantibodies in a multicenter cohort of children with severe COVID-19, multisystem inflammatory syndrome in children (MIS-C), and mild SARS-CoV-2 infections.

METHODS

Circulating anti-IFN-α2 antibodies were measured by a radioligand binding assay. Whole-exome sequencing, RNA sequencing, and functional studies of peripheral blood mononuclear cells were used to study any patients with levels of anti-IFN-α2 autoantibodies exceeding the assay's positive control.

RESULTS

Among 168 patients with severe COVID-19, 199 with MIS-C, and 45 with mild SARS-CoV-2 infections, only 1 had high levels of anti-IFN-α2 antibodies. Anti-IFN-α2 autoantibodies were not detected in patients treated with intravenous immunoglobulin before sample collection. Whole-exome sequencing identified a missense variant in the ankyrin domain of NFKB2, encoding the p100 subunit of nuclear factor kappa-light-chain enhancer of activated B cells, aka NF-κB, essential for noncanonical NF-κB signaling. The patient's peripheral blood mononuclear cells exhibited impaired cleavage of p100 characteristic of NFKB2 haploinsufficiency, an inborn error of immunity with a high prevalence of autoimmunity.

CONCLUSIONS

High levels of anti-IFN-α2 autoantibodies in children and adolescents with MIS-C, severe COVID-19, and mild SARS-CoV-2 infections are rare but can occur in patients with inborn errors of immunity.

1166. Reverse Syphilis Screening and Adherence to The Congenital Syphilis Guidelines: Institutional Experience

Background

This study is analysis the consequences of the reverse syphilis screening on the management of newborns exposed to maternal syphilis, and pediatric physicians’ adherence to the existing guidelines.

Methods

We conducted a 5-year retrospective review of the maternal population and their newborns diagnosed with syphilis. Women with positive results (TT+/NTT+) and discordant (TT+/NTT-/TT+) and their newborns were included in the analysis.

Results

Per American Academy of Pediatrics (AAP), the 202 newborns were divided in two groups: proved or highly probable and possible congenital syphilis (Group A, n=102) and less likely and unlikely congenital syphilis (Group B, n=100). Except for the RPR, none of the other laboratory tests showed higher odds for predicting congenital syphilis. The RPR titers above 1:16 were only identified among newborns belonging to the Group A (5%); 32 patients (31%) in the Group A and 19 (9%) in the Group B had an RPR titer equal to or below 1:8. An RPR titer equal to or above 1:4 was almost three times more likely to be identified in patients from Group A (OR 2.91; CI 1.51- 5.59, p< 0.05). The newborns with non-reactive RPRs represented 64% of the patients in the Group A and 47% of them were born to mother with non-reactive RPR also (mothers with discordant results). Among the Group B, 82% of the neonates had a non-reactive RPR and 54% were delivered to mother with non-reactive RPRs. Babies in Group B had additional work-up performed 69% (n=37) of the time; 15% of these babies were treated with intramuscular penicillin which does not follow established AAP guidelines.

Statistical analysis of the laboratory tests used for the congenital syphilis work-up

Result table comparing the two groups of newborns

Conclusion

The reverse syphilis screening and non-adherence to the guidelines led to additional screening to half of the newborns in both groups. This study highlights the need for a comprehensive maternal history at the time of delivery that is effectively communicated between the providers. This might lead to greater congruence with the established AAP guidelines.

Disclosures

All Authors: No reported disclosures

Describing universal Strongyloides serologic screening among pediatric intestinal and liver transplant recipients

BACKGROUND

Strongyloides spp hyperinfections are a worldwide phenomenon that proves fatal for solid organ transplant recipients. Screening protocols to guide prophylaxis management vary institution to institution from universal to epidemiology driven. Our institution initiated a universal screening protocol regardless of travel history and exposure to ensure no cases were missed.

METHODS

In this study, we describe the outcomes of three Strongyloides sero-positive children whom underwent intestinal or liver transplantation and the experience of universal screening at a tertiary care county hospital in South Florida.

RESULTS

Among the 66 intestine and liver pediatric transplant recipients who were screened for Strongyloides antibodies, only three were identified to be sero-positive via the screening mechanism. Two of three had significant epidemiology risk factors. None of the patients reviewed were found to have developed hyperinfection. However, reflecting on the experience represented by our series of pediatric patients, the risk of any complication related to Strongyloides status appears low. Even among this South Florida population whom come from or travel to endemic regions are in contact with sero-positive individuals, very few illustrate sero-positivity.

CONCLUSION

While institutions continue to analyze the cost-benefit of universal testing vs. universal prophylaxis vs. targeted screening, the decision must encompass the patient population, rolling cumulative incidence, and morbidity and mortality related to this disease.

Care of Pediatric Solid Organ Transplant Recipients: An Overview for Primary Care Providers

As the number of living pediatric solid organ transplant (SOT) recipients continues to grow, there is an increased likelihood that primary care providers (PCPs) will encounter pediatric SOT recipients in their practices. In addition, as end-stage organ failure is replaced with chronic medical conditions in transplant recipients, there is a need for a comprehensive approach to their management. PCPs can significantly enhance the care of immunosuppressed hosts by advising parents of safety considerations and avoiding adverse drug interactions. Together with subspecialty providers, PCPs are responsible for ensuring that appropriate vaccinations are given and can play an important role in the diagnosis of infections. Through early recognition of rejection and posttransplant complications, PCPs can minimize morbidity. Growth and development can be optimized through frequent assessments and timely referrals. Adherence to immunosuppressive regimens can be greatly improved through reinforcement at every encounter, particularly among adolescents. PCPs can also improve long-term outcomes by easing the transition of pediatric SOT recipients to adult providers. Although guidelines exist for the primary care management of adult SOT recipients, comprehensive guidance is lacking for pediatric providers. In this evidence-based overview, we outline the main issues affecting pediatric SOT recipients and provide guidance for PCPs regarding their management from the first encounter after the transplant to the main challenges that arise in childhood and adolescence. Overall, PCPs can and should use their expertise and serve as an additional layer of support in conjunction with the transplant center for families that are caring for a pediatric SOT recipient.

Clinical Impact of BioFire Film Array in Pediatric Sepsis

Objective Rapid molecular tests are important components of antimicrobial stewardship programs (ASP) and for early and accurate diagnosis of sepsis etiology. Their utility in helping providers to de-escalate therapy remains a subject of debate, especially among patients with chronic conditions and indwelling devices.

Methods We have conducted a retrospective cohort study of medical records from August 1, 2016 to July 31, 2018, following the implementation at our institution of the BioFire FilmArray blood culture identification panel (BioFire Diagnostics, Salt Lake City, Utah, United States). We have assessed the clinical impact of the assay looking at antimicrobial optimization and time needed to make this change in different pediatric wards.

Results Two hundred and twenty-nine patients were included in our analysis. We identified a significant statistical difference between different pediatric wards regarding antimicrobial therapy optimization (p < 0.001) and between the type of therapeutic attitude related to BioFire result, escalation versus de-escalation, or no change (p < 0.03). The likelihood for an infectious disease consult requested upon BioFire result to lead to an antimicrobial regimen optimization was also statistically significant (p < 0.01). The positive BioFire results were associated with antimicrobial escalation in 81.4% of cases, with approximately 75% of changes made within 12 hours of the assay result.

Conclusion Our study suggests that BioFire Film Array does not help de-escalating the therapy in patients with chronic disorders. Physician education and level of confidence in the assay remains an essential obstacle in maximizing the test performance in clinical practice. In recent years, the market for more sensitive and comprehensive rapid molecular diagnostic tests has evolved rapidly, requiring effective ASP to optimize the management of infectious diseases.

GCV/VCVG prophylaxis against CMV DNAemia in pediatric renal transplant patients: A systematic review and meta-analysis

CMV disease continues to stand as a significant threat to the longevity of renal transplants in children. More pediatric recipients are CMV-negative with CMV-positive donor serologies resulting in a HR mismatch. The length of prophylaxis with GCV or VGCV required to optimally prevent recurrence of CMVDNAemia remains unknown. This study is a meta-analysis comparing GCV/VGCV prophylaxis regimens provided for <6 months, from 6 to <12 months, and ≥12 months after transplant in order to prevent CMVDNAemia. The search conducted involved PubMed, EMBASE, ISI Web of Science, and Cochrane Central Register from inception through December 2017. Search terms Kidney Transplantation, CMV, GCV, and VGCV provided 204 studies for abstract review. Studies excluded were those which did not itemize pediatric data separately, single case reports, and duplicate studies. Pooled analysis of five retrospective studies and one prospective study identified that there is no statistically significant difference in the incidence of CMV DNAemia when comparing <6 months of prophylaxis and >12 months of prophylaxis (23% and 15%, respectively, P = 0.23). Regardless of the length of prophylaxis, there was no statistical difference in the incidence of CMV DNAemia in the HR patients (6 to <12 months vs <6 months, P = 0.62; 6 to <12 months vs ≥12 months, P = 0.78; ≥12 months vs <6 months, P = 0.83). This study identifies no optimal length of prophylaxis for HR mismatch pediatric renal transplant patients as many develop CMV DNAemia.

Comparison in outcome with tailored antibiotic prophylaxis postoperatively in pediatric intestinal transplant population

BIs are ubiquitous among the pediatric intestinal transplant patient population. Personalizing postoperative prophylaxis antibiotic regimens may improve outcomes in this population. A retrospective analysis of all pediatric patients who underwent intestinal transplantation was evaluated to compare standardized and tailored regimens of antibiotics provided as prophylaxis postoperatively. Patients in the standard group have both shorter time to and higher rate of BIs, which was statistically significant (P < 0.001). Of the children who developed a BI, there was no statistical difference in average times to the development of a second BI (293 vs 119 days, P = 0.211). The tailored group had prolonged times until the development of a MDRO (52.6 vs 63.9 days, P = 0.677). Although not statistically significant, the tailored group had a propensity to present with gram-negative pathogens after transplant as compared to the standard regimen group, which presented with gram-positive pathogens (P = 0.103). Children with a history of an MDRO held a 7.3 (P < 0.01) times more likelihood of death within a year of transplant. A tailored prophylactic antibiotic regimen in the post-transplant period appears to prolong the time to the first BI. Although the data do not show differences in mortality, further study may prove the impact of a tailored antibiotic regimen on morbidity and mortality rates.