Clinical Management of a Pandrug-Resistant OXA-48 Klebsiella pneumoniae Infection in the Pediatric Intensive Care Unit

Background: Carbapenem-resistant Klebsiella pneumoniae (CRKP) is one of the serious forms of health care-associated infection. Pan-drug resistant (PDR) CRKP infections can cause severe infections. Mortality and treatment costs in the pediatric intensive care unit (PICU) are high. This study aims to share our experience regarding the treatment of oxacillinase (OXA)-48-positive PDR-CRKP infection in our 20-bed tertiary PICU with isolated rooms and 1 nurse for every 2-3 patients. Methods: Patient demographic characteristics, underlying diseases, previous infections, source of infection PDR-CRKP, treatment modalities, measures used, and outcomes were recorded. Findings: Eleven patients (eight men and three women) were found to have PDR OXA-48-positive CRKP. Because of the simultaneous detection of PDR-CRKP in three patients and the rapid spread of the disease, it was classified as a clinical outbreak, and strict infection control measures were taken. Combination therapy with double carbapenemase (meropenem and imipenem), amikacin, colistin, and tigecycline was used for treatment. The mean duration of treatment and isolation was 15.7 and 65.4 days, respectively. No treatment-related complication was observed, only one patient died, and the mortality rate was 9%. Conclusions: This severe clinical outbreak can be successfully treated with effective treatment with combined antibiotics and strict adherence to infection control measures. ClinicalTrial.gov ID: 28/01/2022 - 1/5.

Community-acquired S. aureus infection in childhood: a multi-center study

BACKGROUND

The prevalence of community-acquired methicillin-resistant S. aureus (CA-MRSA) has been increasing worldwide. We aimed to investigate the prevalence of MRSA in community-acquired S. aureus infections, the risk factors for CA-MRSA infection and the clinical features of CA-MRSA.

METHODS

A multi-center study with prospective and retrospective sections was conducted. Patients ≥ 3 months old and ≤18 years of age who were diagnosed with community-acquired S. aureus infections were included in this study and the patients` information were reviewed from the medical and microbiological database of the hospital. A standard question form about living conditions and exposure risk factors was administered to the parents of patients. The CA-MRSA infections were compared with the methicillin-susceptible S. aureus (CAMSSA) infections in terms of the queried risk factors and clinical variables.

RESULTS

We identified 334 pediatric patients with S. aureus infection, 58 (17.4%) had an infection with CAMRSA. The refugee rate was higher in the CA-MRSA group. There was no significant difference regarding the exposure risk. The treatment modalities and outcomes were similar.

CONCLUSIONS

The study was not able to show reliable clinical variables or epidemiological risk factors except for being a refugee for CA-MRSA infections. Empirical antibiotic treatment should therefore be determined according to the local CA-MRSA prevalence in patients presenting with a possible staphylococcus infection.

Clinical Features and Outcomes of Children Admitted to the PICU due to Rotavirus Infection

OBJECTIVES

In this study, we aimed to evaluate the clinical and laboratory features of the patients with rotavirus (RV) antigen positivity on or following admission to the pediatric intensive care unit (PICU).

METHODS

Patients admitted to the PICU due to community-acquired rotavirus (CA-RV) or hospital-acquired rotavirus (HA-RV)-induced gastroenteritis between January 1, 2013, and December 31, 2019 were evaluated.

RESULTS

Thirty-four patients with a mean age of 14.00 ± 19.17 months were enrolled. Fortyfour percent were girls. Twenty (58.8%) patients had a history of chronic diseases. Nine (26.5%) patients had CA-RV and 25 (73.5%) patients had HA-RV infection. RV antigens were simultaneously found in 44.1% (n = 14) of the other patients at the time of diagnosis. In the study sample, 5 patients had hyponatremia, 8 had hypernatremia, 6 had hypokalemia, 4 had hypoalbuminemia, 21 had leukocytosis, 2 had leukopenia and 3 had thrombocytopenia, and 17 had elevatedC-reactive protein (CRP) levels. Three patients had seizures, 1 patient had cardiac arrest, and 2 patients had secondary bacteremia. The mean (SD) PICU length of stay was 6 (6.02) with CA-RV gastroenteritis. All CA-RV patients survived, but 8 of the HA-RV patients succumbed to causes other than RV.

CONCLUSION

RV-related PICU admission is not rare, and occasional severe clinical consequences occur, especially in young children, with both CA-RV and HA-RV gastroenteritis. Appropriate timely intervention and meticulous follow-up improve survival.

The role of galactomannan test results in the diagnosis of pediatric invasive aspergillosis

BACKGROUND

Invasive aspergillosis (IA) is an important cause of morbidity and mortality in immunosuppressed children. Early detection of the infection can improve prognosis in this patient population.

OBJECTIVES

To investigate the utility of Aspergillus galactomannan antigen assay (GM-EIA) as a diagnostic tool for IA in at-risk paediatric patients.

PATIENTS/METHODS

For the study, 659 GM-EIA results from 59 patients diagnosed with IA and 3368 GM-EIA results from 351 subjects without evidence for IA (controls) were reviewed retrospectively. Three cut-off values (i.e. ≥0.5, ≥1, ≥1.5) were specified to determine GM-EIA positivity.

RESULTS

The median age was 6.3 years for boys and 14.5 years for girls. There was a significant difference between the girls and boys in terms of age (p < 0.01). For proven/probable/possible IA patients, sensitivity of 67.8% and specificity of 59.8% were detected when the ≥0.5 cut-off value was used for GM-EIA-positivity. The specificity increased to 80% at the cut-off of ≥1 and to 88% at the cut-off of ≥1.5. False positivity rates were 9.14, 3, and 1.45% at the ≥0.5, ≥1 and ≥1.5 cut-offs respectively. In the proven/probable IA group, sensitivity and negative predictive values were 86.9 and 97.2% at the ≥0.5 cut-off, 85.7 and 97.9%, at the ≥1 cut-off and 84.2 and 98.1% at ≥1.5 cut-off respectively. The positive likelihood ratio was 7.57 and the odds ratio was 42.67 at ≥1.5 cut-off.

CONCLUSION

The GM-EIA may be used for both screening and diagnostic purposes in paediatric patients using a cut-off value of ≥1.5 for GM-EIA positivity.

[Burden of Pneumococcal Meningitis and Bacteremia, Serotype Distribution and Antibiotic Resistance in Healthy Children After Conjugated Pneumococcal Vaccine Implementation: Single Center Experience]

In Turkey, the seven-valent pneumococcal conjugated vaccine (PCV7) was included in the childhood national immunization programme in April 2008 and was replaced by the 13-valent pneumococcal conjugated vaccine (PCV13) in April 2011. In this retrospective, single-center study, it was aimed to determine the serotype distribution and antimicrobial resistance in Streptococcus pneumoniae isolates of pediatric patients with invasive pneumococcal disease (IPD) after the introduction of PVC7 and PVC13. Fifty pediatric patients diagnosed with meningitis and sepsis/bacteremia between October 2009 and October 2019 were included in the study. The pediatric patient group consisted of previously healthy patients diagnosed with meningitis and sepsis/bacteremia with S.pneumoniae isolated in their blood or cerebrospinal fluids. Patients with pneumonia-associated bacteremia and empyema were not included in the study. Serotyping of the isolates was performed by Quellung reaction using specific antisera (Statens Serum Institute, Denmark) and antibiotic (penicillin and ceftriaxone) susceptibility was determined by antibiotic gradient method based on Clinical Laboratory Standards Institute (CLSI) criteria. Of the children, 29 (58%) were boys and 21 (42%) were girls. The median age of the patients was 19 months (1 month-18 year). When the children under the age of five were evaluated, it was found that 30 (79%) patients were diagnosed with occult bacteremia/sepsis and 8 (21%) with meningitis. The overall annual incidence rate of IPD among the healthy children aged <5 years decreased significantly from 9.35/100000 to 0.83/100000 (p< 0.001). Serotype identification was determined for 44 of 50 pneumococcal isolates . However, since six patients with underlying disease were not included in the evaluation, the remaining 38 isolates were found to be one of the serotypes included in PCV7 and PCV13 at a rate of 28.9% (n= 11) and 44.7% (n= 17), respectively. While the rate of PCV13 serotypes seen in the PCV7 period was 81.8%, this rate decreased to 29.6% within eight years after PCV13 administration. The rate of non-vaccine serotypes was determined as 54.5% in PCV7 period and 70.3% in PCV13 period. The rate of non-vaccine serotypes in patients under 5 years was 60% in the period of PCV7 and 75% in the period of PCV13. The proportion of non-vaccine serotypes has increased over time. However, this difference was not statistically significant (p> 0.05). The most common serotypes detected in isolates were 19F, 23F, 7F, 31 and 24B. According to the minimum inhibitory concentration values of the isolates recovered from patients with meningitis, penicillin and ceftriaxone resistance rates were found as 43.9% and 9.8%, respectively. In conclusion, our study showed that there was a 91.1% decrease in the incidence of IPD in healthy children aged under five years after the implementation of PCV7 and PCV13. It was determined that while the rate of serotypes in vaccine content decreased, there was an increase in non-vaccine serotypes. In addition no significant change was observed in antibiotic resistance rates over the years.

Impaired respiratory burst contributes to infections in PKCδ-deficient patients

Patients with autosomal recessive protein kinase C δ (PKCδ) deficiency suffer from childhood-onset autoimmunity, including systemic lupus erythematosus. They also suffer from recurrent infections that overlap with those seen in patients with chronic granulomatous disease (CGD), a disease caused by defects of the phagocyte NADPH oxidase and a lack of reactive oxygen species (ROS) production. We studied an international cohort of 17 PKCδ-deficient patients and found that their EBV-B cells and monocyte-derived phagocytes produced only small amounts of ROS and did not phosphorylate p40phox normally after PMA or opsonized Staphylococcus aureus stimulation. Moreover, the patients' circulating phagocytes displayed abnormally low levels of ROS production and markedly reduced neutrophil extracellular trap formation, altogether suggesting a role for PKCδ in activation of the NADPH oxidase complex. Our findings thus show that patients with PKCδ deficiency have impaired NADPH oxidase activity in various myeloid subsets, which may contribute to their CGD-like infectious phenotype.

Epidemiological, Clinical, and Laboratory Features of Children With COVID-19 in Turkey

Objectives: The aim of this study is to identify the epidemiological, clinical, and laboratory features of coronavirus disease 2019 (COVID-19) in children. Methods: A retrospective study was conducted by pediatric infectious disease specialists from 32 different hospitals from all over Turkey by case record forms. Pediatric cases who were diagnosed as COVID-19 between March 16, 2020, and June 15, 2020 were included. Case characteristics including age, sex, dates of disease onset and diagnosis, family, and contact information were recorded. Clinical data, including the duration and severity of symptoms, were also collected. Laboratory parameters like biochemical tests and complete blood count, chest X-ray, and chest computed tomography (CT) were determined. Results: There were 1,156 confirmed pediatric COVID-19 cases. In total, male cases constituted 50.3% (n = 582) and females constituted 49.7% (n = 574). The median age of the confirmed cases was 10.75 years (4.5-14.6). Of the total cases, 90 were younger than 1 year of age (7.8%), 108 were 1-3 years of age (9.3%), 148 were 3-6 years of age (12.8%), 298 were 6-12 years of age (25.8%), 233 were 12-15 years of age (20.2%), and 268 cases were older than 15 years of age (23.2%). The most common symptom of the patients at the first visit was fever (50.4%) (n = 583) for a median of 2 days (IQR: 1-3 days). Fever was median at 38.4°C (38.0-38.7°C). The second most common symptom was cough (n = 543, 46.9%). The other common symptoms were sore throat (n = 143, 12.4%), myalgia (n = 141, 12.2%), dyspnea (n = 118, 10.2%), diarrhea (n = 112, 9.7%), stomachache (n = 71, 6.1%), and nasal discharge (n = 63, 5.4%). When patients were classified according to disease severity, 263 (22.7%) patients were asymptomatic, 668 (57.7%) patients had mild disease, 209 (18.1%) had moderate disease, and 16 (1.5%) cases had severe disease. One hundred and forty-nine (12.9%) cases had underlying diseases among the total cases; 56% of the patients who had severe disease had an underlying condition (p < 0.01). The need for hospitalization did not differ between patients who had an underlying condition and those who do not have (p = 0.38), but the need for intensive care was higher in patients who had an underlying condition (p < 0.01). Forty-seven (31.5%) of the cases having underlying conditions had asthma or lung disease (38 of them had asthma). Conclusions: To the best of our knowledge, this is one of the largest pediatric data about confirmed COVID-19 cases. Children from all ages appear to be susceptible to COVID-19, and there is a significant difference in symptomatology and laboratory findings by means of age distribution.

A Case of Cutaneous Leishmaniasis Responding to Systemic Liposomal Amphotericin B Treatment

Leishmania is a vector-induced endemic tropical disease caused by protozoans. The most common cutaneous, mucosal and visceral forms are the cutaneous form. The main drugs in treatment are pentavalent antimony compounds, but their side effects create limitation of use. Local antimony compounds are used primarily in the treatment of cutaneous leishmaniasis. In some cases, alternative treatment modalities are required due to insufficient response to local treatment. Systemic amphotericin B treatment is one of the alternative treatments. In a patient who developed cutaneous Leishmania at 21 months and who did not respond with local meglumine antimoniate therapy, a total of 21 mg/kg dose of systemic amphotericin B was given intermittently and successful results were obtained.

A Case of Cutaneous Leishmaniasis Responding to Systemic Liposomal Amphotericin B Treatment

Leishmania is a vector-induced endemic tropical disease caused by protozoans. The most common cutaneous, mucosal and visceral forms are the cutaneous form. The main drugs in treatment are pentavalent antimony compounds, but their side effects create limitation of use. Local antimony compounds are used primarily in the treatment of cutaneous leishmaniasis. In some cases, alternative treatment modalities are required due to insufficient response to local treatment. Systemic amphotericin B treatment is one of the alternative treatments. In a patient who developed cutaneous leishmania at 21 months and who did not respond with local meglumine antimoniate therapy, a total of 21 mg / kg dose of systemic amphotericin B was given intermittently and successful results were obtained.

The incidence and clinical effects of Bordetella pertussis in children hospitalized with acute bronchiolitis

BACKGROUND

Pertussis is a disease leading to high morbidity and mortality in neonates and infants. Bronchiolitis is the most common cause of hospitalization especially in children < 2 year-old. Although the clinical findings are different in these two diseases, it is sometimes difficult to make this distinction in partially or fully vaccinated children. This study aimed to identify the incidence, clinical and laboratory effects of B. pertussis as a causative agent in hospitalized children with acute bronchiolitis.

METHODS

The study included patients diagnosed with acute bronchiolitis and admitted to the Division of Pediatric Infectious Diseases from January 2012 to December 2015, aged 24 months or younger, evaluated for viruses and bacteria with polymerase chain reaction in respiratory tract secretions.

RESULTS

The study included 380 patients hospitalized with acute bronchiolitis. Of these patients, 85.8% were identified to be positive for at least one respiratory pathogen. The most commonly identified pathogens were respiratory syncytial virus (RSV) A/B, rhinovirus, parainfluenza virus, adenovirus, bocavirus and metapneumovirus A/B. B. pertussis was only detected in 5 patients (1.5%). In the patients with B. pertussis identified, coinfection with another virus was observed including rhinovirus (n= 2), influenza A virus (n= 1), coronavirus OC43 (n= 1) and RSV A/B (n= 1). The presence of B. pertussis did not appear to cause any significant clinical or laboratory differences in patients.

CONCLUSIONS

B. pertussis is a rare pathogen in patients admitted to hospital for acute bronchiolitis. However, in patients who do not respond to standard bronchiolitis treatment, B. pertussis should be considered as a causative agent. Early identification of this pathogen is important in terms of quarantining the patient, administering appropriate antimicrobial treatment, and prophylactic treatment to household and other close contacts.

Nosocomial pneumonia caused by water-born Legionella pneumophila in a pediatric hematopoietic stem cell transplantation recipient for thalassemia major

BACKGROUND

Nosocomial pneumonia caused by Legionella pneumophila serogroup 2-14 occurred in a 7-year-old patient following allogeneic hematopoietic stem cell transplantation for thalassemia major.

CASE

The patient was diagnosed with nosocomial Legionella pneumophila by polymerase chain reaction (PCR) examination of the bronchoalveolar lavage and culturing Legionella pneumophila serogroup 2-14 from the patient`s room faucet water. Legionella pneumophila was eradicated from our hospital`s water distribution system by superheating and chemical eradication methods (hyper-chlorination and hydrogen peroxide). We did not detect any other case after this event.

CONCLUSION

Early recognition of contamination of the hospital water system with Legionella proves the importance of prevention in new cases.

A rare cause of secondary hemophagocytic lymphohistiocytosis: systemic loxoscelism

BACKGROUND

Loxoscelism is caused by the bite of a specific spider type called the Loxosceles genus. In Turkey, most cases are seen after L. rufescens bites. Clinical manifestation of the bites ranges from local cutaneous reaction to severe ulcerative necrosis. Systemic loxoscelism may also occur.

CASE

Herein, we report a previously healthy five-year-old male patient who developed a secondary hemophagocytic lymphohistiocytosis after a presumed brown spider bite. He was treated with dexamethasone. Within the following 14 days, hemophagocytic syndrome resolved. Local hyperbaric oxygen therapy was applied to the necrotic areas.

CONCLUSION

Secondary hemophagocytic lymphohistiocytosis may develop after systemic loxoscelism. In the presence of persistent fever, hepatosplenomegaly and laboratory findings this clinical entity should be kept in mind.

[Frequency of Influenza, Influenza Types and Influenza Vaccine Use in Hospitalized Children with Influenza-Like Symptoms]

Influenza is an important cause of respiratory illness in children and is still an important cause of morbidity and mortality in children. The influenza virus subtypes determine the prevalence of the epidemic and pandemic influenza, the hospitalization and mortality rates in children each year. Surveillance of the circulation of different influenza virus strains is important in ensuring a good strain con-cordance for the composition of the annual influenza vaccine. The Global Influenza Hospital Surveillance Network® (GIHSN) is an international institution in which tertiary hospitals from many countries participate and where epidemiological surveillance of influenza disease is conducted. Six centers from Turkey participated in the study organized by GIHSN during the influenza season 2016 2017. The aim of this study was to demonstrate the frequency of influenza, virus types, clinical characteristics and vaccination rates in children admitted to our hospital with influenza-like symptoms in the influenza season 2016-2017. Informed consents were obtained from patients. 217 pediatric patients were screened with in the 24th and 48th hours of the hospitalization. Then a nasal/nasopharyngeal swab were collected from 184 patients who met the inclusion criteria. Real-time reverse-transcription polymerase chain reaction (rRT-PCR) was used to obtain laboratory results. Influenza virus, influenza virus subtypes were studied by rRT-PCR. The 83.3% of the patients with positive influenza was under 5 years of age. The rate of influenza positivity was 16.3% (n= 30 patients). Influenza A (H3N2) was the predominant strain in children. The 70% of isolates were influenza A (H3N2) and the 30% were influenza B (Yamagata). There were no case of influenza A (H1N1) or influenza B (Victoria). In 30% of cases with influenza positivity, there was an underlying disease. The most prevalent of them were neuromuscular disease followed by cardiovascular disease and asthma. Tobacco exposure was 86.6% in influenza positive cases. The empirical oseltamivir prescription rate was 28.2%. The vaccination rate of the influenza vaccine was very low (1.6%). The out of 3 patients with influenza positivity were admitted to pediatric intensive care unit, and 2 of them required mechanical ventilation. None of these patients required extracorpereal membrane oxygenation and did not die. Our results highlight the importance of surveillance for influenza and in particular, influenza vaccination rates of groups with risk for morbidity and mortality, such as children, need to be increased.

Is antibiotic lock therapy effective for the implantable longterm catheter-related bloodstream infections in children?

Tural Kara T, Özdemir H, Erat T, Yahşi A, Aysev AD, Taçyıldız N, Ünal E, İleri T, İnce E, Haskoloğlu Ş, Çiftçi E, İnce E. Is antibiotic lock therapy effective for the implantable long-term catheter-related bloodstream infections in children? Turk J Pediatr 2019; 61: 895-904. Catheter-related bloodstream infections (CRBSIs) are an important problem in pediatric patients with central venous catheters. This study aimed to determine the incidence of CRBSIs, responsible pathogens and outcomes of antibiotic lock treatment (ALT) in pediatric patients. Between January 2010 and November 2015 all hospitalized pediatric hematology, oncology and immunology patients diagnosed with CRBSIs were retrospectively analyzed. Seventy-eight CRBSI episodes were detected in 60 pediatric patients. The incidence of CRBSIs was 4.20/1000 catheter days. The most frequently detected pathogen was methicillin-resistant coagulase-negative Staphylococcus. Pseudomonas aeruginosa, Klebsiella spp., and Escherichia coli were other commonly isolated microorganisms. ALT was administered in 42 patients. The success rate of ALT was 81% (34/42). Catheter was removed without ALT in 36 episodes. Common reasons for catheter removal were sepsis and causative microorganisms which had high probability of biofilm formation. CRBSIs are an important cause of morbidity and mortality in pediatric patients. ALT is safe and effective. It is possible to obtain satisfactory results when ALT is used with intravenous systemic antibiotics for CRBSIs, though in some cases catheter removal is necessary. ALT helps to prevent unnecessary catheter removal in pediatric patients.

Impact of the mandatory Hepatitis A immunization program: before and after the vaccine in Ankara, Central of Turkey

Kanık Yüksek S, Tezer H, Özkaya Parlakay A, Gülhan B, Kara A, Çiftçi E, Tapısız A, Çelik M, Özdemir H, Aykaç K, Demirdağ TB, Tural Kara T, Hayran G, İnce E. Impact of the mandatory Hepatitis A immunization program: before and after the vaccine in Ankara, Central of Turkey. Turk J Pediatr 2019; 61: 677-685. In Turkey Hepatitis A virus (HAV) infection is considered to be moderateendemic. Hepatitis A vaccine was included in the mandatory vaccination schedule of Turkey on November 2012. We aimed to evaluate the cases of HAV infection followed in Ankara, which is located in the center of Central Anatolia, retrospectively according to the date of the administration of the mandatory hepatitis A vaccine. A total of 272 children followed-up between January 2008 and December 2015 for HAV infection in five separate hospitals were enrolled to the study. There were 200 (68.2%) cases in the pre-vaccination group, 72 (31.74%) cases in the post-vaccination group, and 55.1% were male in total. The immunization status were as follow; 89.7% (n = 244) unvaccinated, 0.4% (n = 1) vaccinated and 9.9% (n = 27) with unknown immune status. There was a statistically significant difference between the groups in hospitalization rates, but no statistically significant differences in hospitalization indications, length of hospital stay, complication types and proportions, and normalization period of transaminases. The national hepatitis A immunization program in Turkey has had a significant impact when the targeted population is considered, with suggestive herd protection effects.

A case of fulminant pneumococcus meningoencephalitis progressing with white matter involvement despite two doses of conjugated pneumococcus vaccine

BACKGROUND

Streptococcus pneumonia is a cause of serious mortality and morbidity, especially among small children. However, currently, it causes lower rates of invasive infections due to successful vaccination programs Case. We report an exceptional case of a 6-month-old child with meningoencephalitis caused by Streptococcus pneumonia despite the administration of two doses of pneumococcal conjugate vaccine (PCV). Meningitis progressed rapidly and led to widespread damage in parenchymal brain tissue with the emergence of fulminant meningoencephalitis. Computed tomography (CT) and magnetic resonance imaging (MRI) revealed widespread brain lesions, suggesting extensive parenchymal injury.

CONCLUSION

Such diffuse white matter lesions among pediatric patients with Streptococcus pneumonia meningoencephalitis despite two doses of PCV have not been reported previously.

Comparison of the clinical and laboratory characteristics of pertussis or viral lower respiratory tract infections

INTRODUCTION

Whooping cough-like respiratory tract infections (WCLRTI) caused by factors other than the Bordetella pertussis are available. Clinical picture is difficult to differentiate between the B. pertussis and viral respiratory infections.

METHODOLOGY

Eighty-five patients with the diagnosis of WCLRTI were divided into 3 groups. Group 1 involved patients with pertussis shown by nasopharyngeal aspirate culture (NAC) and/or PCR. Group 2 consisted of patients who B. pertussis was not detected by NAC however, clinicians still evaluated them as potential patients of pertussis. Group 3 involved patients with the diagnosis of WCLRTI and those with VRTI detected by antigen detection/PCR.

RESULTS

Patients with pertussis had longer duration of the symptoms prior to admission. Paroxysmal cough, whooping, vomiting after coughing, cyanosis, apnea, seizures and abdominal hernias were more common in patients with pertussis. Fever, wheezing, tachypnea, retraction, fine crackles and rhonchi were more common in Group 3. Chest radiographs of patients in Group 3 revealed more bronchopneumonic infiltration, increased aeration, and atelectasis. CRP (C-reactive protein) and ESR (erythrocyte sedimentation rate) were significantly higher in Group 3. Of the patients 43.6% had no pertussis vaccination due to being < 2 months in age and 29.4% had 1 dose.

CONCLUSIONS

Pertussis should be thought in differential diagnosis of children with complaints of episodes of paroxysmal cough, cough accompanied by gasping, vomiting after coughing; with leukocytosis, lymphocytosis and a normal chest X-ray. The majority of children with pertussis infection are those who have not had the opportunity for vaccination.

Bloodstream infections in pediatric hematology/oncology patients: Six years’ experience of a single center in Turkey

Background/aim

Bloodstream infections are the major cause of morbidity, increased cost, prolonged hospitalization, and mortality in pediatric patients. Identifying the predominant microorganisms and antimicrobial susceptibilities in centers helps to select effective empirical antimicrobials which leads to positive clinical outcomes. We aimed to identify the causative microorganisms and their antimicrobial susceptibilities in patients with bloodstream infections.

Materials and methods

Data belonging to patients with hematological and/or oncological diseases admitted to our hospital with fever between January 2010 and November 2015 were analyzed.

Results

In total, 71 patients who had 111 bloodstream infection episodes were included. Responsible pathogens were detected as follows: 35.1% gram-positive microorganisms, 60.5% gram-negative bacteria, and 4.4% fungi. The most common causative gram-negative pathogen was Escherichia coli and the most commonly isolated gram-positive microorganism was coagulase-negative staphylococci.

Conclusion

Gram-negative microorganisms were predominant pathogens in bloodstream infections. Escherichia coli and coagulase-negative staphylococci were the most commonly isolated responsible pathogens. Beta-lactam/lactamase inhibitors were suitable for empirical treatment. However, in critical cases, colistin could have been used for empirical treatment until the culture results were available. Routine glycopeptide use was not required. By identifying the causative microorganisms and their antimicrobial resistance patterns, it will be possible to obtain positive clinical results.

Effects of respiratory viruses on febrile neutropenia attacks in children

Respiratory tract viruses have an important effect on morbidity and mortality in patients with febrile neutropenia (FN). The aim of this study was to determine frequency and clinical influence of viral respiratory viruses as potential etiologic agents in episodes of FN in children. A total of 100 children (62 boys, 38 girls) with 166 FN episodes were included in this prospective study. Nasopharyngeal aspirate samples were analyzed for respiratory viral agents using multiplex real-time polymerase chain reaction. The origin of the fever could be defined in 111 (67%) of the episodes. We detected viral agents in 86 (51.8%), bacterial agents in 19 (11.4%), and fungal agents in 5 (3%) of the episodes. The most common detected viruses were rhinovirus (n= 27), respiratory syncytial virus (n=17), and coronavirus (n=16). Parainfluenza virus, influenza A and B, adenovirus, human metapneumovirus, enterovirus, bocavirus and parechovirus were the remaining detected agents. More than one virus positivity occurred in 13 FN episodes. Forty-three patients had multiple FN episodes. Only four patients had the same viral agent in consecutive attacks. Respiratory symptoms (cough, nasal discharge and congestion, sneezing, wheezing), physical examination signs (rales and rhonchi) and radiological findings were significantly more common in viral agent positive patients (p < 0.05). This study showed that respiratory viruses make a substantial contribution on the etiology of FN episodes in children. Identifying viral agents may help to constitute individualized infection-management algorithms in these patients.

Evaluation of antimicrobial susceptibilities and virulence factors of Staphylococcus aureus strains isolated from community-acquired and health-care associated pediatric infections

Karbuz A, Karahan ZC, Aldemir-Kocabaş B, Tekeli A, Özdemir H, Güriz H, Gökdemir R, İnce E, Çiftçi E. Evaluation of antimicrobial susceptibilities and virulence factors of Staphylococcus aureus strains isolated from community-acquired and health-care associated pediatric infections. Turk J Pediatr 2017; 59: 395-403. The aim of this study was to investigate the enterotoxins and Panton-Valentine leukocidin (PVL) gene as virulence factor, identification if antimicrobial sensitivity patterns, agr (accessory gene regulator) types and sequence types and in resistant cases to obtain SCCmec (staphylococcal cassette chromosome mec) gene types which will be helpful to decide empirical therapy and future health politics for S. aureus species. Total of 150 isolates of S. aureus were isolated from the cultures of the child patients in January 2011 and December 2012. In this study, the penicillin resistance was observed as 93.8%. PVL and mecA was detected positive in 8.7% and in 6% of all S. aureus strains, respectively. Two MRSA (methicillin resistant S.aureus) strains were detected as SCCmec type III and SCCmec type V and five MRSA strains were detected as SCCmec type IV. SET-I and SET-G were the most common detected enterotoxins. In both community-associated and healthcare-associated MRSA strains, agr type 1 was detected most commonly. The most common sequence types were ST737 in 13 patients than ST22 in eight patients and ST121 in six patients. This study highlights a necessity to review the cause of small changes in the structural genes in order to determine whether it is a cause or outcome; community-acquired and healthcare associated strains overlap.

Antifungal consumption, indications and selection of antifungal drugs in paediatric tertiary hospitals in Turkey: Results from the first national point prevalence survey

OBJECTIVES

The aim of this point prevalence survey was to evaluate the consumption, indications and strategies of antifungal therapy in the paediatric population in Turkey.

METHODS

A point prevalence study was performed at 25 hospitals. In addition to general data on paediatric units of the institutes, the generic name and indication of antifungal drugs, the presence of fungal isolation and susceptibility patterns, and the presence of galactomannan test and high-resolution computed tomography (HRCT) results were reviewed.

RESULTS

A total of 3338 hospitalised patients were evaluated. The number of antifungal drugs prescribed was 314 in 301 patients (9.0%). Antifungal drugs were mostly prescribed in paediatric haematology and oncology (PHO) units (35.2%), followed by neonatal ICUs (NICUs) (19.6%), paediatric services (18.3%), paediatric ICUs (PICUs) (14.6%) and haematopoietic stem cell transplantation (HSCT) units (7.3%). Antifungals were used for prophylaxis in 147 patients (48.8%) and for treatment in 154 patients (50.0%). The antifungal treatment strategy in 154 patients was empirical in 77 (50.0%), diagnostic-driven in 29 (18.8%) and targeted in 48 (31.2%). At the point of decision-making for diagnostic-driven antifungal therapy in 29 patients, HRCT had not been performed in 1 patient (3.4%) and galactomannan test results were not available in 12 patients (41.4%). Thirteen patients (8.4%) were receiving eight different antifungal combination therapies.

CONCLUSION

The majority of antifungal drugs for treatment and prophylaxis were prescribed in PHO and HSCT units (42.5%), followed by ICUs. Thus, antifungal stewardship programmes should mainly focus on these patients within the availability of diagnostic tests of each hospital.

The effects of pneumococcal conjugate vaccine (PCV7 and PCV13) on Turkish children with invasive pneumococcal disease: a single center experience

INTRODUCTION

The aim of this prospective single-center study was to determine the changings in incidence of invasive pneumococcal disease (IPD), serotype distribution and the antimicrobial resistance patterns of S. pneumoniae in children with IPD after the period (1 to 7 years) of vaccination with PCV7 (2008) and PCV13 (2011).

POPULATION AND METHODS

The study was conducted on 39 Turkish children with IPD between ages 1 month and 18 years in Ankara, Turkey. Streptococcus pneumoniae was identified using standard laboratory procedures from blood, cerebrospinal fluid (CSF), pleural fluid, and other sterile body fluids and tissues. S. pneumoniae isolates were tested for resistance to penicilin and ceftriaxone using the E-test methodology. Serotypes of the isolates were determined by Quellung reaction.

RESULTS

The overall annual incidence rate of IPD decreased significantly from 7.71 (95% CI, 1.99-13.4) to 1.58 (95% CI, 0.6-3.77; RRR=-79.5; p=0.006) per 100 000 population among ≤5 years of age without underlying disease. During the overall study period, the PCV7-serotypes and PCV13-serotypes represented 27.8% and 63.8% of isolates, respectively. PCV13-serotypes made up 81.8% of cases of IPD in the pre-PCV13 era and decreased to 56% in the 4 years after PCV13. The penicillin and ceftriaxone (for meningitis) resistance rates were 48.5% and 9.1%, respectively.

CONCLUSIONS

This is the first study about the changing pattern of the incidence of IPD in Turkish children after the implementation of the PCV7 and PCV13 in Turkish national vaccine schedule and a prominent decrease in incidence of IPD has seen after the implementation of PCV13.

Congenital lobar emphysema. A rare cause of hypertension

Congenital lobar emphysema is a rare disease, which is characterized by pulmoner hyperinflation. Depending on the degree of bronchial obstruction, the clinical presentation may be variable. We report a rare case with congenital lobar emphysema in a 38-days-old male infant who presented with severe respiratory distress and hypertension. Air trapping in the left upper lung and significant mediastinal shift to the right were observed on the chest x-ray. Emphysematous changes were detected on the thorax computed tomography and considered as congenital lobar emphysema. The upper left lobectomy was successfully performed by pediatric surgeons. On postoperative follow up, no sign of respiratory distress occurred and the patient was normotensive. In this report, a case with congenital lobar emphysema, which is a rare cause of respiratory distress and hypertension is discussed.

An unusual case of neuroblastoma: a 17-year-old adolescent presented with bilateral diffuse lung metastasis at initial diagnosis

Neuroblastoma (NB) is the most frequently diagnosed neoplasm during infancy and its incidence declines within the first 3-5 years of life. It can be rarely diagnosed in adolescents and young adults. Adolescents have advanced stage of disease, higher frequency of uncommon metastatic sites such as lungs, and worse outcomes. Herein, we describe an unusual case of NB in a 17-year-old adolescent presented with lung metastasis at diagnosis. The patient was diagnosed with stage IV NB. Thorax high-resolution computed tomography (HRCT) scan revealed irregular septal thickening with ground glass opacity consistent with pulmonary parenchymal metastases. After the first cycle of chemotherapy he developed pulmonary hemorrhage and respiratory distress. He required ventilation support and mechanical ventilation was started. Metastatic nodules were determined on second thorax HRCT. We lost the patient due to septic shock and multiple organ failure 2 months after diagnosis. In conclusion, adolescents with NB have unfavorable prognosis. These patients may have lung metastases at diagnosis. Therefore, detailed chest imaging at initial diagnosis is crucial.

Mesalamine Intolerance in Three Children with Crohn's Disease

OBJECTIVE

To present the mesalamine-induced acute exacerbation of symptoms and inflammatory markers in children with Crohn's disease (CD).

CLINICAL PRESENTATION AND INTERVENTION

Three children who presented with CD had acute exacerbation of colitis symptoms or elevated inflammatory markers when mesalamine was added to treatment while tapering/ceasing steroid treatment. While on steroid treatment, the patients maintained clinical and laboratory remission, but with the initiation of mesalamine treatment, they had abdominal pain and bloody mucoid diarrhoea and/or elevation of white blood cell count, C-reactive protein level and erythrocyte sedimentation rate. Bacterial pathogens were excluded from the urine, throat and blood cultures, parasites with stool examination, viral pathogens with serology. Within 3-7 days after the mesalamine treatment had been stopped, the patients showed improvement of colitis symptoms and normalisation of white blood cell count, C-reactive protein level and erythrocyte sedimentation rate.

CONCLUSION

In this study mesalamine mimicked CD relapse in children with CD while tapering or after stopping steroid treatment. Awareness of this side effect of mesalamine could prevent a misdiagnosis of steroid dependency.