A Systematic Review and Clinical Presentation of Central Nervous System Complications of Severe Acute Respiratory Syndrome Coronavirus 2 in Hospitalized Pediatric Patients During the Coronavirus Disease 2019 Pandemic in Israel

BACKGROUND

Coronavirus disease-associated central nervous system complications (CNS-C) in hospitalized children, especially during the Omicron wave, and in comparison with influenza associated CNS-C, are not well understood.

METHODS

The study population included 755 children aged <18 years hospitalized with laboratory-confirmed severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at Sheba Medical Center, during March 2020 to July 2022. A comparative cohort consisted of 314 pediatric patients with influenza during the 2018-2019 and 2019-2020 influenza seasons.

RESULTS

Overall, 5.8% (n = 44) of patients exhibited CNS-C. Seizures at presentation occurred in 33 patients with COVID-19 (4.4%), with 2.6% (n = 20) experiencing nonfebrile seizures, 1.1% (n = 8) febrile seizures, and 0.7% (n = 5) status epilepticus. More patients with CNS-C experienced seizures during the Omicron wave versus the pre-Omicron period (77.8% vs 41.2%, P = 0.03). Fewer patients were admitted to the intensive care unit in the Omicron wave (7.4%) versus prior waves (7.4% vs 41.2%, P = 0.02). Fewer patients with SARS-CoV-2 experienced CNS-C (5.8%) versus patients with influenza (9.9%), P = 0.03. More patients with SARS-CoV-2 experienced nonfebrile seizures (2.6% vs 0.6%, P = 0.06), whereas more patients with influenza experienced febrile seizures (7.3% vs 1.1%, P < 0.01).

CONCLUSIONS

The Omicron wave was characterized by more seizures and fewer intensive-care-unit admissions than previous waves. Pediatric patients with SARS-CoV-2 experienced fewer CNS-C and more nonfebrile seizures compared with patients with influenza.

Early Outcome of Multisystem Inflammatory Syndrome in Neonates Diagnosed following Prenatal Maternal COVID-19 Infection: A Three-Case Series

BACKGROUND

The aim of this case series report is to evaluate the characteristics of multisystem inflammatory syndrome (MIS) in neonates following prenatal maternal COVID-19 infection.

METHODS

We present a case series of three newborns (≤28 days of age) diagnosed with MIS due to the vertical transmission of SARS-CoV2 infection and admitted from 1 January 2021 to 1 June 2023. The inclusion criteria were negative RT-PCR-SARS-CoV-2 test in infants, initial negative IgM-SARS-CoV-2 in infants followed by the emergence of positive IgG-SARS-CoV-2 antibodies in infants and maternal COVID-19 infection in the third trimester of pregnancy. Patients enrolled in this case series were admitted due to acute febrile illnesses.

RESULTS

All three cases occurred in patients born at a mean gestational age of 39 weeks and who were appropriate for gestational age. The mean age at admission was 18.3 days. Fibrinogen (>400 mg/dL) and ferritin (>120 mg/dL) were elevated above the upper normal limit. Elevated levels of myocardial biomarkers (D-dimers, N-terminal pro b-type natriuretic peptide troponin T and creatine phosphokinase myocardial band) were recorded, with normal heart function evaluated using echocardiography. All three patients were treated with antibiotics; one received intravenous immunoglobulin. A 4-week follow-up was completed in two patients when their myocardial biomarkers and ferritin were still elevated but lower compared with previous examinations. D-dimers levels were normalized in 2/3 patients.

CONCLUSIONS

Subclinical myocarditis was diagnosed as an early outcome in infants with MIS diagnosed postnatally due to the vertical transmission of SARS-CoV2 infection and may represent a new challenge for pediatricians in the pandemic era.

Vaccine Hesitancy Phenomenon Evolution during Pregnancy over High-Risk Epidemiological Periods-"Repetitio Est Mater Studiorum"

(1) Background: The recent epidemiological events were high-stress level generators for humanity, particularly for pregnant women, influencing their attitude, behavior, and decisions regarding vaccination during pregnancy or regarding their future child. The aim of this study was to analyze the anti-pertussis vaccination decision-shaping factors in pregnant women during two epidemiological periods: the measles epidemic and the COVID-19 pandemic. (2) Methods: Two groups of pregnant women were invited to be part of a medical education program, having as the main theme the infectious disease risks and their prevention through vaccination. Before launching the program, participants received a 12-item questionnaire. From a total number of 362 pregnant women enrolled in the study, 182 participated in 2019, and 180 participated in 2022. (3) Results: The socio-demographic data revealed that the age of pregnant women participating in medical education programs increased in 2022 by 1.7 years (p < 0.01). In vitro fertilization was reported in a significantly higher proportion (20% in 2022 vs 9.8% in 2019, p < 0.01). Participation in community-initiated educational programs almost doubled during the pandemic time from 18.7% in 2019 to 33.9% in 2022 (p < 0.01). Pertussis vaccine acceptancy (VA) dropped from 85% in 2019 to 44.4% in 2022 (p < 0.01) (4) Conclusions: In this study, we reported fast-growing vaccine hesitancy and severe declared vaccine reluctance. The results of this complex long-term study, which evaluated pregnant women over several years, showed a five-fold increase in the percentage of pregnant women who disagreed with personal pertussis vaccination. This draws attention to the risks of pertussis epidemic outbreaks in pregnant women and their future infants in the first couple of months of life before the initiation of vaccination.

Comparison Between Peripheral and Central Blood Cultures in Pediatric Oncology Patients With Blood Stream Infections

BACKGROUND

Current guidelines for fever in children with cancer recommend obtaining blood cultures from all lumens of the central venous catheter (CVC) and to consider a concurrent peripheral blood culture. We assessed the characteristics of blood stream infections (BSI) in oncology children and compared central and peripheral pathogen growth.

METHODS

A prospective, computerized surveillance of BSI in children treated at the oncology unit between May 2014 and July 2020. The growth of the same organism within a month was considered a single episode, ≥2 organisms in the same culture were defined as different episodes. Only children with concomitant cultures, drawn at presentation before initiation of antibiotics were included in the comparison between CVC and peripheral cultures.

RESULTS

A total of 139 episodes in 81 children (with implanted Port-A-catheters) were considered true BSI. Of the 94/139 (67.6%) cases where a central and peripheral culture were concomitantly obtained, 52/94 (55.3%) had positive central/peripheral cultures that grew the same organism, 31/94 (33.0%) had positive central cultures only, and 11/94 (11.7%) had positive peripheral cultures only. In 3/94 cases, the organisms that grew from the CVC were not identical to those from the peripheral site. Four of 52 (7.7%) of the same positive central/peripheral pathogens had different susceptibility testing results. Higher CVC removal rates were observed when both peripheral and CVC cultures were positive ( P =0.044).

CONCLUSIONS

Overall, 11.7% of BSI episodes were identified only by peripheral culture and 7.7% of paired organisms did not share the same susceptibility test results which emphasizes the importance of a peripheral culture in managing fever in oncology children.

The effect of pneumococcal conjugated vaccines on occurrence of recurrent acute otitis media among infants diagnosed with acute otitis media at an age younger than 2 months

To examine the impact of pneumococcal conjugate vaccines (PCV) on the occurrence of recurrent acute otitis media (rAOM) among infants diagnosed with an early acute otitis media (AOM) episode. Retrospective cohort study of pediatric patients with a first episode of AOM at an age < 2 months. Data included clinical, demographic, and microbiological findings at the first AOM episode. In addition, a 5-year follow-up after the patient's first episode was completed from the medical records. This information included documentation of rAOM episodes and complications of AOM (hearing loss, speech disturbance, mastoiditis, and tympanic membrane perforation) and of ear-related surgical procedures (ventilation tube placement, adenoidectomies, and mastoid surgery). Two groups were studied: patients diagnosed between 2005 and 2009 (representing the unvaccinated group, group 1) and those diagnosed in 2010-2014 (the vaccinated group, group 2). A total of 170 infants were diagnosed with a first AOM episode at an age < 2 months; 81 of them belonged to group 1 and 89 to group 2. Streptococcus pneumoniae was isolated in the middle-ear fluid in the first AOM episode in 48.1% of the patients in group 1 and in 30.3% in group 2 (P = 0.0316). 49/81 (60.5%) infants in group 1 were diagnosed with rAOM versus 39/80 (43.8%) in group 2 (P = 0.0298). No statistical differences were found between the groups with respect to long-term complications or need for surgery later in life.   Conclusion: Our study showed a significant decrease in the occurrence of rAOM in infants diagnosed with AOM during the first 2 months of life and timely immunized with PCVs following this initial AOM episode. What is Known: • 30% of children experience recurrent AOM (rAOM) at the first year of life. The earlier the age of the first AOM, the greater the risk for future complications. • After the introduction of PCVs, the overall pneumococcal AOM incidence declined. We investigated the future effect of PCVs on rAOM occurrence, when administered after the first AOM episode. What is New: • A retrospective cohort of 170 infants with a first AOM episode at an age <2 months and followed for 5 years, showed a significant decrease (28.0%) of rAOM in immunized infants following the initial AOM episode. • Our findings supplement previous data suggesting that the widespread PCVs use prevents rAOM by preventing early AOM and emphasize the importance of timely administration of the PCVs.

Acute otitis media in the first two months of life and the impact of pneumococcal conjugate vaccines: A retrospective cohort study

BACKGROUND

Information on pneumococcal vaccination's impact on the prevention of acute otitis media (AOM) at very young ages is limited.

OBJECTIVES

To define the trends in tympanocentesis-proven AOM incidence, clinical characteristics, microbiology, and antibiotic resistance in infants <2 months of age in southern Israel, before and after the sequential introduction of 7- and 13-valent PCVs.

METHODS

A retrospective population-based cohort study including children <2 months of age diagnosed with AOM at the pediatric emergency room between January 2005-Decmber 2009 (pre-vaccination group, group 1) and January 2013-July 2021 (post-PCV13 introduction, group 2).

RESULTS

160 patients were enrolled, 89 (55.6%) in group 1 and 71 (44.4%) in group 2. The mean incidence of AOM decreased from 1.2 cases/1000 live births for group 1 to 0.45 cases/1000 live births for group 2, P < 0.001.130 (81.25%) patients were hospitalized, with higher hospitalization rates in group 1 vs. group 2 (84/89, 94% vs. 46/71, 65%, P < 0.001). Hospitalization length was longer in group 1 vs. group 2 (4.07 ± 4.09 days vs. 2.70 ± 1.82 days, P = 0.021). Positive MEF cultures were reported in 94/160 (58.75%) patients, with a decrease in positivity rates between the 2 groups (71/89, 80% vs. 23/71, 32%, P < 0.001). S. pneumoniae was the most common pathogen (55/94, 58.5%); it was the most frequent pathogen isolated in group 1 (46/71, 65%), and the second most common pathogen in group 2 (9/23, 39%), P = 0.03. A significant increase was recorded in the percentages of patients with negative MEF cultures (from 21% to 68%, P < 0.001).

CONCLUSIONS

The introduction and implementation of PCV13 in southern Israel was associated with a decrease in AOM in children <2 months of age and of S. pneumoniae recovery in these patients and was accompanied by less admissions and shorter hospitalizations. An increase in the proportions of negative bacterial cultures from MEF was recorded during the study period.

A Sensitive Public Health Issue—The Vaccine Acceptancy and the Anti-Pertussis Immune Status of Pregnant Women from a Romanian Metropolitan Area

(1) Background: Immunization of pregnant women (PWs) against Bordetella pertussis infection is still a challenging health matter. (2) Methods: We gathered questionnaire data from 180 PWs regarding their expectancies and current opinion on infectious disease prevention. For the group of PWs who agreed to further investigations, the serum levels of Ig G anti-B. pertussis antibodies (IgG-PT) titer were measured and analyzed. (3) Results: A total of 180 PWs completed the questionnaire and 98 (54.44%, study group) accepted to perform the laboratory tests. During the first two pregnancy trimesters, PWs were found to be more willing (compared with the control group) to test for identifying high-risk situations that could affect themselves and their future infant (p < 0.001). Most of the participating PWs (91, 91.9%) had low levels of anti-pertussis antibodies (values < 40 IU/mL). Declared vaccine coverage of the PWs newborn infants for DTaP-1 and Prevenar 13 (at 2 months) and DTaP-2 and Prevenar 13 (at 4 months) vaccination reached 100% in the study group, while in the control group only 30/82 (36.59%) PWs accepted to be vaccinated during pregnancy, none of them providing data on their infants’ vaccine coverage. (4) Conclusions: Enrolled PWs faced a waning immunity against the B. pertussis infection. By raising maternal confidence in the protective role of vaccines against infectious diseases, better vaccine acceptance and better infant vaccine coverage can be achieved.

Surgical treatment of septic arthritis of the hip in children: arthrotomy compared with repeated aspiration-lavage

PURPOSE

To review two cohorts of children treated by two different protocols (repeated needle aspiration-lavage vs. arthrotomy) for surgical treatment of septic arthritis of the hip (SAH).

METHODS

In order to compare between the two methods, the following parameters were checked: (a) Scar cosmesis was assessed by the Patient and Observer Scar Assessment Scale (POSAS). We considered satisfactory results (no scar discomfort) when POSAS was within 10% of the ideal score; (b) 24-h post-operative pain was evaluated by visual analog scale (VAS); (c) Complication rates of incomplete drainage (re-arthrotomy/therapy modification from aspiration-lavage to arthrotomy). The results were evaluated by the Student t-test or by the chi-square test.

RESULTS

Seventy-nine children (aged 2-14 years) admitted during 2009-2018 and available for at least two years of follow-up were enrolled. The POSAS score (range 12-120 points) at the latest follow-up was higher in the arthrotomy group compared with the aspiration-lavage group (18.10 ± 6.22 versus 12.27 ± 1.40, p < 0.001); 77.4% of patients treated by arthrotomy had no scar discomfort. The 24-h post-intervention VAS (range 1-10) was 5.06 ± 1.29 after arthrotomy and 4.03 ± 1.13 after aspiration-lavage, p < 0.04. Complications were three times more frequent in the aspiration-lavage group (8.8% in the arthrotomy group and 26.7% in the aspiration-lavage group, p = 0.045).

CONCLUSIONS

We conclude that the lower complication rate observed in the arthrotomy group outweighs by far scar cosmesis and post-operative pain advantages in the aspiration-lavage group. Arthrotomy as a drainage method is safer than aspiration-lavage.

Cocirculation of A(H3N2) and B/Victoria increased morbidity in hospitalized patients in the 2019-2020 A(H1N1)pdm09 predominant influenza season in Israel

Community surveillance found the 2019-2020 A(H1N1)pdm09 predominant influenza season in Israel to be a high-intensity season with an early and steep morbidity peak. To further characterize disease severity in the 2019-2020 season, we analyzed a cohort of hospitalized patients with laboratory-confirmed influenza from this season (n = 636). Quantitative polymerase chain reaction was performed on clinical samples to detect the presence of influenza. Demographic, clinical, and laboratory data were retrieved via electronic health records and MDClone. Electronic health records were accessed to obtain data on intensive care unit patients, missing data and for data verification purposes. Univariate analysis was performed to compare demographic, comorbidity, and clinical characteristics across the three influenza strains. The A(H1N1)pdm09 predominant 2019-2020 influenza season in Israel was characterized by an early and steep morbidity peak, vaccine delays and shortages, and with the A(H3N2) and B/Victoria strains disproportionately targeting children and young adults, most probably due to reduced immunity to these strains. A greater proportion of children <5 years infected with A(H3N2) and B/Victoria developed severe influenza compared with those infected with A(H1N1)pdm09. Our study emphasizes the vulnerability of infants and young children in the face of rapidly evolving influenza strains and underscores the importance of influenza prevention measures in this population.

Risk factors for hospitalization at the pediatric intensive care unit among infants and children younger than 5 years of age diagnosed with infectious diseases

BACKGROUND

Children hospitalized with infectious diseases may develop severe, life-threatening conditions, often requiring admission to pediatric intensive care unit (PICU). The objectives of this study were to identify independent risk factors for PICU hospitalization with an infectious disease in children <5 years of age.

METHODS

In southern Israel, two populations live side by side: the middle-high income Jewish population and the low-income Bedouin population, both receiving equal and free medical care at the only tertiary medical center in the area. The study population included all children born in southern Israel and hospitalized at PICU with an infectious disease during 1991-2012. Risk factors for PICU hospitalizations were retrospectively studied by Kaplan-Meier and Cox proportional hazard survival analyses.

RESULTS

9951 Jewish children and 18,002 Bedouin children were enrolled; overall, 1135 episodes of PICU hospitalizations with an infectious disease were recorded (879, 77.4% Bedouin and 256, 22.6% Jewish patients). Bedouin children had a higher risk for PICU hospitalization with an infectious disease compared with Jewish children (adjusted Hazard Ratio [adj. HR] 1.7, 95% CI 1.5-2.0); maternal multiparity and low-birth weight (<2500 g) were additional risk factors for PICU hospitalization with an infectious disease compared to firstborns (adj. HR = 1.2, 95% CI 1.0-1.5) or to children with a birth weight ≥2500 g (adj. HR = 1.5, 95% 1.2-1.9). Older age was a protective factor for PICU hospitalization (adj. HR = 0.98, 95% CI 0.97-0.99). Children hospitalized with a central nervous system infection had the highest risk of PICU hospitalization (adj. HR 6.8, 95% CI 5.5-8.4), followed by those with urinary tract infections (UTI, adj. HR 3.1, 95% CI 2.5-3.8) and those with lower respiratory tract infections (LRTI, adj. HR 2.9, 95% CI 2.4-3.4).

CONCLUSION

Bedouin ethnicity, low birth weight, maternal multiparity and younger age were significant risk factors for PICU hospitalizations with an infectious disease. Among the infectious diseases analyzed, CNS infection had the highest risk for PICU hospitalization, followed by UTI and LRTI.

Early versus late-onset necrotizing enterocolitis in very low birth infants in the neonatal intensive care unit

BACKGROUND

Necrotizing enterocolitis (NEC), one of the most severe emergencies in neonates, is a multifactorial disease with diverse risk factors.

OBJECTIVES

To compare between the clinical and laboratory characteristics of premature infants diagnosed with early-onset NEC (EO-NEC) and those with late-onset NEC (LO-NEC).

PATIENTS AND METHODS

Enrolled infants were identified from prospective local data collected for the Israel National very low birth weight (VLBW, < 1500 g) infant database and from the local electronic patient files data base for the period 1996-2017.

RESULTS

Overall, 95 VLBW infants (61, 64.21% EO-NEC and 34, 35.87% LO-NEC) were enrolled. EO-NEC infants had higher rate of IVH grade 3 and 4 (26.2% vs 2.9%, p = 0.005) and were more likely to undergo surgery (49.2% vs 26.5%, p = 0.031). LO-NEC infants had a higher incidence of previous bloodstream infections (35.3% vs 8.2%, p = 0.002) compared to EO-NEC. In multivariable analysis models, surgical intervention was associated with EO-NEC (OR: 4.627, p = 0.013) as well as PDA and positive blood culture prior to the NEC episode.

CONCLUSIONS

Our data support the hypothesis that EO-NEC has significant different clinical and microbiological attributes compared to LO-NEC.

Post-operative clinical course in children undergoing mastoidectomy due to complicated acute mastoiditis

PURPOSE

To determine the immediate post-operative course and outcome of pediatric patients with complicated acute mastoiditis (CAM) following surgical treatment.

METHODS

A retrospective chart review of children diagnosed with CAM who underwent mastoid surgery during 2012-2019 in a tertiary care university hospital. 33 patients, divided into 2 groups: 17 patients with sub-periosteal abscess (SPA) alone-single complication group (SCG) and 16 patients with SPA and additional complications: sigmoid sinus thrombosis (SST), peri-sinus fluid/abscess, epidural/subdural abscess, and acute meningitis-multiple complications group (MCG).

RESULTS

33 patients belong to the SCG 17(51%) and 16(49%) belonged to the MCG, respectively. 6/17(35.3%) SCG patients experienced POF vs. 12/16(75%) in the MCG (P = 0.012). At post-operative day 2 (POD2), 10/13(77%) febrile patients belonged to MCG and 3/13(23%) to SCG (P = 0.013). POF was recorded until POD6 in both groups. Seven patients, all from MCG with POF, underwent second imaging with no new findings; a total of 18 positive cultures were reported. Fusobacterium necrophorum counted for 8/18(44.5%) of all positive cultures, 7/9(77.8%) in the MCG vs. 1/9(11.1%) in the SCG, P = 0.004. Streptococcus pneumoniae was reported only in SCG (5/9, 55.5%, vs. 0/9, P = 0.008).

CONCLUSION

Post-mastoidectomy fever due to CAM is not unusual and seems to be a benign condition for the first 5-6 days, following surgery. MCG patients are more prone to develop POF. F. necrophorum is more likely to be associated with MCG, and S. pneumoniae is common in SCG patients.

Severe Pneumonia Caused by Methicillin-Resistant Staphylococcus pseudintermedius in an Oncology Patient: Case Report and Literature Review

Staphylococcus pseudintermedius is usually a commensal bacterium of microbiota of dogs and cats that can become pathogenic in these animals. In the past two decades, an increasing number of human infections caused by this pathogen was reported; only two pediatric cases were due to methicillin-susceptible isolates. We describe the first case of methicillin-resistant S. pseudintermedius diagnosed in a 12-year-old immunocompromised girl with refractory anaplastic ependymoma, presented with life-threatening pneumonia and bacteremia. The girl had close contact with her two pet dogs. This case emphasizes that immunocompromised children should be advised on proper handling of household pets to minimize the risk of infection, which could be life threatening.

The Influence of Achilles Tenotomy and Compliance with Foot Abduction Orthosis on the Relapse Rate of Ponseti Treatment for Idiopathic Clubfoot: A Regional Study

The Ponseti method for treating idiopathic clubfoot is based on gradual manipulations and corrective plaster castings followed by a years-long period of use of a foot orthosis. The role of surgery is limited. The factors that may affect outcome and their influence are subject of controversy. The aim of the study is to systematically and objectively evaluate the results of Ponseti treatment in our region of Southern Israel and focus on the role of the Achilles tenotomy and compliance to foot orthosis as factors that may influence outcome. The use of Ponseti method was retrospectively studied (level of evidence IV) by searching computerized medical files and clinical photos. The severity of deformity was evaluated by Dimeglio score (D-score) at baseline and at last examination. During 2006-2014, 57 children with idiopathic clubfoot (total 90 feet) were enrolled. An Achilles tenotomy was performed in 55/90 (61.1%) of the feet. If the D-score was 15 or higher there was a 20% increase in the incidence of Achilles tenotomy. The parental compliance had a weak protective effect against relapse. The treatment of idiopathic clubfoot by the Ponseti method was successful and reliable, proving efficiency and universality of the method. A dominant predictor for relapse was not seen. An incidental observation was that extended time in cast may buffer the adverse effects of low compliance rate. Although the initial severity, or compliance to braces are important, there may be other factors that affect the outcome such as, accuracy of the casting technique, time in the cast, access to a dedicated clubfoot clinic, cooperation with nurses and pediatricians, economic status that allows purchase of new generation of braces, cultural perception, and education level of the patient population are some examples.

COVID-19 in a Subset of Hospitalized Children in Israel

BACKGROUND

Most pediatric coronavirus disease 2019 (COVID-19) is mild. We assessed nationally severe COVID-19, including pediatric inflammatory multisystem syndrome (PIMS), in hospitalized children.

METHODS

An ongoing, prospective, national surveillance was conducted from March 2020 through March 2021, at 20 hospitals treating children <18 years across Israel (~75% of Israeli hospitals).

RESULTS

Overall, 1007 cases (439 outpatients and 568 hospitalized) identified represent 0.35% of pediatric COVID-19 nationwide (n = 291 628). Of hospitalized cases, 464 (82%), 48 (8%), and 56 (10%) had mild, moderate/severe, and PIMS disease, respectively. The mean ± SD age was 5.6 ± 6.4 years. In mild, moderate/severe, and PIMS disease, 55%, 23%, and 4% of patients were <1 year old, respectively. Obesity was reported in 1%, 4%, and 13% of patients, respectively (P < .001). The most common symptom was fever in 67%, 60%, and 100%, respectively, whereas respiratory symptoms were documented in 33%, 41%, and 38% of patients, respectively. Lymphopenia was recorded in 25%, 60%, and 86% of cases, respectively. PIMS diagnosis was mainly serology-based (in 59%). Gastrointestinal symptoms, cardiovascular involvement, rash, and conjunctivitis were noted in 82%, 61%, 57%, and 34% of PIMS episodes, respectively. Elevated C-reactive protein (100%), ferritin, troponin, D-dimer, low albumin, and thrombocytopenia were common in PIMS. Echocardiography revealed pathological findings in 33% of patients. PIMS mainstay treatment included corticosteroids (77%) and intravenous immunoglobulin (53%). No mortality was recorded.

CONCLUSIONS

At a national level, pediatric COVID-19 is mild, even in hospitalized cases, with only a third presenting with respiratory involvement. PIMS is rare, but necessitates a high index of suspicion, and with suitable treatment prognosis is favorable.

The etiologic, microbiologic, clinical and outcome characteristics of immunocompetent young children <2 years of age hospitalized with acute neutropenia

BACKGROUND

To describe the etiologic, microbiologic, clinical and outcome characteristics of acute neutropenia (absolute neutrophil count, ANC, <1.5 × 10⁹/L) in hospitalized immunocompetent children.

METHODS

Serious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, alveolar pneumonia, Brucellosis and Rickettsiosis.

RESULTS

431/671 (64.2%) healthy infants and children hospitalized with acute neutropenia were <2 years of age; 176 (40.8%), 167 (38.8%) and 88 (20.4%) patients were aged 0-3, 4-12 and 13-24 months, respectively. There were 19 (4.4%), 53 (12.3%), 140 (32.5%) and 209 (50.8%) patients with ANC count <200, 200-500, 501-1000 and 1001-1500 × 10⁹ cells/L, respectively. Severe neutropenia (<500 × 10⁹/L) was recorded in 72 (16.7%) patients. Fever >38 °C was present in 208/431 (48.3%) patients. Blood cultures were positive in 10 (2.3%), with Brucella melitensis, Staphylococcus aureus and Enterobacter spp. identified in 4, 3 and 2 patients, respectively; 5/10 patients with positive blood cultures were <3 months of age. Overall, 55/431 (12.7%) and 65/431 (15.1%) patients were diagnosed with SBIs and bacterial infections, respectively. Nasal washings-PCR for respiratory viruses was positive in 139/293 (47.4%) patients tested. An infectious etiology (bacterial and/or viral) was diagnosed in 190/431 (44.1%) patients. Three patients were diagnosed with acute lymphocytic leukemia. Resolution of neutropenia was achieved in 111/208 (53.4%) evaluable patients (63%, 50.6% and 48% of patients aged 0-3, 4-12 and >12 months, respectively and 56.8%, 53.5% and 52% of patients with severe, moderate and mild neutropenia, respectively).

CONCLUSION

Acute neutropenia is common in immunocompetent children <2 years of age and is frequently associated with viral infections. We showed a substantial involvement of bacterial infections and particularly SBIs in the etiology of acute neutropenia. After a 1-month follow-up, resolution of neutropenia occurred in half of the patients, without association with age subgroups and with neutropenia severity.

Impact of the 13-valent pneumococcal conjugate vaccine (PCV13) on acute mastoiditis in children in southern Israel: A 12-year retrospective comparative study (2005-2016)

OBJECTIVES

To define the trends in acute mastoiditis (AM) incidence, microbiology, complications and management in children, before and after the 13-valent pneumococcal conjugate vaccine (PVC13) introduction.

METHODS

Medical records of all AM patients <15 years of age diagnosed during 2005-2016 were reviewed. The study years were divided into three periods: pre-vaccination (2005-2008), interim (2009-2011) and post-PCV13 vaccination (2012-2016).

RESULTS

238 patients (53.4% males) were enrolled, 81, 56 and 101 in the 3 time periods, respectively. Overall, 177/238 (75.2%) of children were <5 years of age. Mean AM incidence in the whole population was 10.32/100,000, with no changes during the study years. Ninety-three (45.6%) of 204 evaluable patients had positive middle ear fluid/mastoid cultures; S. pneumoniae (SP) was isolated in 47/93 (50.5%) cases. Mean incidence of SP-AM during the study years was 2.49 cases/100,000. A trend for decrease in mean incidence of SP-AM was recorded between the pre and the post-vaccination periods (3.05/100,000 vs. 1.82/100,000, P = 0.069). Among patients <5 years, SP-AM rates decreased from pre to post-vaccination period (19/50, 38% vs. 15/73, 20.6%, P = 0.034). No changes were reported in percentages of culture negative-AM and of AM complications in the post-PCV13 period compared with the pre-vaccine period. A significant decrease in distribution of PCV13 serotypes was recorded (17/19, 89.5% vs. 8/12, 66.6% and vs. 7/16, 43.75% during the 3 study periods, P = 0.015) accompanied by a complementary increase in non-vaccine serotypes.

CONCLUSIONS

The introduction of PCV13 was accompanied by a significant decrease in SP-AM cases among children <5 years of age. PCV13 serotypes decreased significantly as etiologic agents of SP-AM while non-vaccine serotypes and culture negative-AM became more common in the postvaccination period.

[PEDIATRIC ANIMAL-RELATED INJURIES IN THE JEWISH AND ARAB POPULATION IN SOUTHERN ISRAEL]

INTRODUCTION

Annually in the US, about 2 million patients who are animal-related casualties go to the Emergency Medicine Department (ER), which accounts for 0.5-1.5% of the ER visits; 25% of these casualties are children. Similar numbers are also seen in Europe and the UK. In a single-center study in Israel, it was found that the percentage of ER visits for animal injuries was about 2.1%. Soroka University Hospital is the only Level I trauma center in the Negev, serving a population of over 1,250,000, and as such it treats about 175,000 ER visits each year, of which about 27% are pediatric visits. The population treated in our hospital is diverse in terms of socioeconomic origin and status, and includes Jewish patients mainly situated in urban settlements and Arab-Bedouin population living in familiar and unfamiliar villages (the Bedouin diaspora). In light of this, in the present study, we have tried to investigate animal injuries in children, emphasizing scorpion bites which are common in our area.

METHODS

We retrospectively reviewed the medical records of all children aged 0-17 years during an 18-month study period - from January 2009 until the end of June 2010 - to identify children who have been referred to the ER at the Soroka Hospital due to animal injury. Demographics, characteristics of the injury, incidence times and referral to treatment, and data on the course of assessment and treatment of the injury and hospitalization were recorded. Data was typed and processed using Microsoft Excel 2007 software and we used SPSS 23.0 for Windows for the statistical analysis.

RESULTS

A total of 729 pediatric injuries caused by animals were reported, which accounted for about 1% of the total number of children's visits to the pediatric ER during the study period. Twenty-six cases were omitted because they did not meet the inclusion criteria in the study. Of the remaining 703 referrals, 66.1% of the patients were boys, the peak age was in the 6-8-year age group (26%); 44.1% lived in a Jewish settlement, 31.2% in an unrecognized Arab-Bedouin settlement and 24% in a recognized Arab-Bedouin settlement. In both forms of Bedouin settlements, the most frequent injuries were dog bites n = 166, (23.60%), yellow scorpion bites = 163 (23.2%) and black scorpion bites n = 44 (6.25%); 97 of the children were admitted (13.8%), of whom 44 were admitted to the ICU, with 84.1% of those admitted to the intensive care unit (ICU) were treated due to yellow scorpion injury. The 2-5-year age group was the most prevalent among inpatients, accounting for 32.

DISCUSSION

Pediatric animal injuries are a common cause of ER visits and even hospitalization. A relatively high percentage of hospitalizations were in the ICU. The most common cause of animal injury seen in our cohort was dog bites, but yellow scorpion bites resulted in most hospitalizations, especially in the pediatric ICU. The incidence of yellow scorpion injuries was significantly higher in the Arab-Bedouin population and even more so in those living in unrecognized settlements, and 87% of the pediatric hospitalizations were seen in Arabic-Bedouin children. Animal-related injuries are a serious health problem in the Arab-Bedouin population and in the unrecognized villages in particular, and there is room to emphasize the prevention of these injuries in this impoverished sector.

First UTI episode in life in infants <1 year of age: Epidemiologic, clinical, microbiologic and disease recurrence characteristics

BACKGROUND

To examine the epidemiologic and microbiologic characteristics of first and recurrent UTI in young infants.

METHODS

A retrospective study of all infants <1 year hospitalized during 2014-2017 with their first UTI and followed during their first year of life.

RESULTS

191 infants were enrolled; 69 (36.12%) patients were <2 months and 32 (16.8%) developed R-UTI during the follow-up. The five most common uropathogens were Escherichia coli, Klebsiella spp., Enterococcus spp., Proteus mirabilis and Staphylococcus aureus. High resistance rates were recorded for ampicillin, amoxicillin/clavulanic acid, TMP/SMX, cefuroxime, ceftriaxone, piperacillin/tazobactam and gentamicin among E. coli and Klebsiella spp.; 29.15% E. coli and 42.9% Klebsiella spp. were ESBL-positive. 53.2% of recurrent UTI (R-UTI) episodes were diagnosed within 2 months after the initial UTI episode. E. coli (40.6%) and Klebsiella spp. (37.55) were the most frequent R-UTI pathogens. Twenty-five (78.1%) R-UTIs were caused by recurrent uropathogens representing new infections. Antibiotic resistance rates at recurrence were similar to those at initial UTI, except for a significant increase in E. coli and Klebsiella spp. resistance to piperacillin/tazobactam.

CONCLUSION

We reported high antibiotic resistance rates to major antibiotic classes used in UTI treatment. Most R-UTI episodes were caused by uropathogens different than those isolated at the initial UTI episode and were caused by highly-resistant organisms. Our findings require frequent monitoring and possible modification of the empiric and prophylactic antibiotic therapy protocols in use. As a result of our findings, the protocol for initial empiric treatment of infants with suspicion of UTI was modified by changing gentamicin to amikacin in the treatment of infants <2 months of life and amikacin monotherapy (intravenous or intramuscular) was introduced as first-line therapy for infants >2 months of life.

Substantial reduction of antibiotic-non-susceptible pneumococcal otitis media following PCV7/PCV13 sequential introduction

BACKGROUND

In the pre-pneumococcal conjugated vaccines (PCVs) era, serotypes included in the 7/13-valent PCVs (PCV7/PCV13) caused most pneumococcal otitis media (OM) and antibiotic-non-susceptible pneumococcal OM (ANSP-OM) episodes. In southern Israel, sequential PCV7/PCV13 introduction resulted in >90% reduction of vaccine-serotype OM.

OBJECTIVES

We assessed the dynamics of ANSP-OM necessitating middle ear fluid culture following PCV7/PCV13 sequential introduction in young children.

METHODS

This was a prospective, population-based, active surveillance. All episodes in children <3 years old, during 2004-16, were included. Two subperiods were defined: (i) pre-PCV: 2004-08; and (ii) PCV13: 2014-16. ANSP was defined for the following antibiotics: penicillin (MIC ≥0.1 mg/L and ≥1.0 mg/L), macrolide, tetracycline, clindamycin, ceftriaxone, trimethoprim/sulfamethoxazole and chloramphenicol. MDR was defined as ANSP for ≥3 classes.

RESULTS

Overall, 2270 pneumococcal OM episodes were identified. Annual overall pneumococcal, PCV13 and non-PCV13 serotype OM incidence declined by 86%, 97% and 33%, respectively, comparing pre-PCV with the PCV13 period. During 2004-08, 95% of ANSP was observed in vaccine serotypes. Incidence of penicillin (MIC ≥0.1 mg/L and ≥1.0 mg/L), macrolide, tetracycline, clindamycin, ceftriaxone and multidrug ANSP-OM declined by >90% in the PCV13 period. Rates of trimethoprim/sulfamethoxazole and chloramphenicol ANSP-OM declined by 85% and 79%, respectively. The proportions of ANSP of all pneumococcal isolates declined by ∼70% for penicillin, ceftriaxone and erythromycin; 53% for tetracycline; and 55% for MDR, versus no significant reductions observed for chloramphenicol, trimethoprim/sulfamethoxazole and clindamycin.

CONCLUSIONS

PCV7/PCV13 sequential introduction resulted in rapid and substantial ANSP-OM reduction, in parallel with the near disappearance of PCV13-serotype OM and no increase in replacement disease.

Comparison of the etiologic, microbiologic, clinical and outcome characteristics of febrile vs. non-febrile neutropenia in hospitalized immunocompetent children

We compared the etiologic, microbiologic, clinical, and outcome picture among febrile and non-febrile immunocompetent children hospitalized during 2013–2015 with acute neutropenia (absolute neutrophil count < 1.5 × 10⁹/L). Serious bacterial infections (SBI) were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, pneumonia, brucellosis, and rickettsiosis. Overall, 664 children < 18 years of age were enrolled; 407 (62.2%) had fever > 38.0 °C and 247 (37.8%) were non-febrile at admission. There were 425 (64.0%), 125 (18.8%), 48 (7.2%), and 66 (9.9%) patients aged 0–24 months, 2-6, 7–12, and > 12 years, respectively. No differences were recorded in the distribution of febrile vs. non-febrile patients among the age groups nor among the 3 neutropenia severity groups (< 0.5, 0.5–1.0 and 1.0–1.5 × 10⁹/L). SBI infections were diagnosed in 98 (14.8%) patients, with higher rates among febrile patients vs. non-febrile patients (16.8% vs. 11.5%, P = 0.06). Brucellosis and rickettsiosis were diagnosed in 15.4% and 23.1% tests performed, respectively. 295/688 (42.9%) virologic examinations returned positive. Among patients < 24 months, more febrile ones had viral infectious compared with afebrile patients (P = 0.025). Acute leukemia was diagnosed in 6 patients. Neutropenia resolved in 163/323 (50.5%) patients during a 1-month follow-up. No differences were recorded in neutropenia resolution between febrile and non-febrile children among all 3 severity groups. Severe neutropenia was rare and occurred mainly in very young patients. SBIs were more common among febrile patients compared with non-febrile patients, but there was no association between severity of neutropenia or its resolution and the presence or absence of fever at diagnosis.

Septic arthritis in children: Updated epidemiologic, microbiologic, clinical and therapeutic correlations

BACKGROUND

Septic arthritis (SA) is an infection characterized by significant epidemiologic and microbiologic differences between developed and developing regions and between age groups.

OBJECTIVES

To determine the epidemiologic, clinical, microbiologic and therapeutic aspects of pediatric SA in Southern Israel.

METHODS

A retrospective case-series study based on the records of children <16 years of age admitted with SA at Soroka Medical Center, Beer-Sheva, during 2006-2013.

RESULTS

189 patients were enrolled. There were 119 (63%) Bedouin and 70 (37%) Jewish children. The knee (39.7%), hip (28%) and ankle (13.8%) were the most commonly involved joints. Blood and/or synovial fluid cultures were positive in 48 (25.4%) patients. Overall SA incidence among children <16 years and <5 years was 11.7 and 25.4/100,000, respectively, without changes throughout the study period. SA incidence among Bedouin children was higher than among Jewish children (15.4 vs. 8.3/100,000 cases). Staphylococcus aureus was the most commonly isolated pathogen (18, 19.5% of all patients), followed by Kingella kingae (10, 5.3%)-(37.5% and 20.8% among culture-positive patients, respectively). The number of children with culture-positive SA that required surgery was higher than those with culture-positive SA treated conservatively (P < 0.001). Hospitalization was longer in children treated surgically than in those treated conservatively (P < 0.001).

CONCLUSION

This study is the largest single-center series on pediatric SA published in the last five years and provided an updated picture on incidence and the microbiologic, clinical and therapeutic aspects of pediatric SA in Southern Israel. The study supports a regional presentation pattern of SA and may guide its therapeutic management.

Urinary tract infections in children < 2 years of age hospitalized in a tertiary medical center in Southern Israel: epidemiologic, imaging, and microbiologic characteristics of first episode in life

The objectives of the study were to describe the epidemiologic, microbiologic, and imaging characteristics of first 44 UTI episode in hospitalized infants and children < 2 years of age. A UTI episode was diagnosed based on suprapubic aspiration or urinary catheterization and report of a significant bacterial growth of true uropathogens. Two thousand two hundred ninety-four UTI episodes were recorded during 2009-2013 in 1694 patients; 1350 (79.7%), 223 (13.2%), and 66 (3.9%) had one, two, and three episodes, respectively. Of 1955 pathogens isolated, the most frequent were E. coli, Klebsiella spp., and Enterococcus spp. (56.9%, 14.1%, and 11%, respectively). E. coli percentages increased with increase in patient age while Klebsiella spp. and Enterococcus spp. decreased with decrease in age. 136/344 (39.5%) renal ultrasound examinations performed were reported abnormal. The percentages of abnormal ultrasound examinations in Enterococcus spp.-UTI were higher than in E. coli and Klebsiella spp.-UTI (P < 0.001 and P = 0.007, respectively). The E. coli nonsusceptibility to ampicillin, TMP/SMX, ceftriaxone, amoxicillin/clavulanic acid, cefuroxime, and gentamicin was 71%, 31%, 14.9%, 14.7%, 7%, and 4.4%, respectively. Nonsusceptibility of Klebsiella spp. to ampicillin, amoxicillin/clavulanic acid, TMP/SMX, ceftriaxone, gentamicin, and cefuroxime was 98.7%, 10.4%, 9.5%, 8.4%, 4.8%, and 4.3%, respectively. E. coli nonsusceptibility to amoxicillin/clavulanate, TMP/SMX, and ciprofloxacin decreased during the study period. E. coli percentages increased and those of Klebsiella spp. and Enterococcus spp. decreased with increase in patient age. Enterococcus. spp.-UTI was associated with older age and more severe findings on renal ultrasound. E. coli and Klebsiella spp. nonsusceptibility to amoxicillin/clavulanate, TMP/SMX, cefuroxime, and ceftriaxone was low.

Central venous catheter-associated bloodstream infections in children diagnosed with intestinal failure in Southern Israel

OBJECTIVES

To study the clinical, epidemiological, and microbiological associations between intestinal failure (IF) and central line-associated infections (CLABSI) in patients with central vein catheters (CVCs) during 2005-2016.

METHODS

We compared retrospectively CLABSI rates according to background disease, type of line access, pathogen distribution, and antibiotic susceptibilities.

RESULTS

One hundred and fourteen children (64.1% < 4 years) were enrolled. Main diagnoses were persistent diarrhea (20, 17.5%), short bowel syndrome (13, 11.4%), continuous-TPN w/o diarrhea (11, 9.7%), very early-onset inflammatory bowel disease (VEO-IBD, 8, 7%), Hirschsprung's disease (3, 2.6%), non-oncologic hematologic conditions (13, 11.4%), and other diseases (46, 40.4%). 152.749 catheter days were recorded; 71.1% had Hickman's catheters. Two hundred and nine CLABSI episodes were recorded in 58 patients (82% with IF, 13.7 and 8.2/1000 catheter days in IF, and non-gastrointestinal conditions, P = 0.09). More CLABSI were recorded in continuous TPN vs. VEO-IBD or persistent diarrhea (38.8 vs.15.8 and 12.8/1000 catheter days, P < 0.004). Among patients with Hickman in jugular vein, highest CLBSI incidence was in continuous TPN, VEO-IBD, and persistent diarrhea (29.9, 15.84, and 12.49 episodes/1000 catheter days, respectively). CVCs were removed in 38.8% CLABSI. Two hundred and thirty-five pathogens were isolated (Enterobacteriaceae spp. in 39% of IF patients, mostly in persistent diarrhea and short bowel syndrome patients, 47.6% and 34.8%, respectively). Coagulase-negative Staphylococcus was the commonest pathogen in continuous TPN, VEO-IBD, and Hirschsprung's (71.4%, 55.6% and 46.1%, respectively).

CONCLUSIONS

CLABSI rates in IF patients were among the highest reported. We reported a "hierarchy" in CLABSI incidence among patients with IF and showed that CLABSI incidence and etiology were different as function of background diseases and CVC insertion site.

Purpuric rash and fever among hospitalized children aged 0-18 years: Comparison between clinical, laboratory, therapeutic and outcome features of patients with bacterial versus viral etiology

BACKGROUND

The evaluation of children with purpuric rash and fever (PRF) is controversial. Although many of them have viral infections, on occasion such patients may be infected with Neisseria meningitidis. We described all children aged 0-18 years with PRF in southern Israel during the period 2005 ̶ 2016 and compared their microbiologic, laboratory, clinical and outcome characteristics in relation to various etiologies of this syndrome.

METHODS

Data were summarized from electronic patient and microbiology files. Viral diagnoses were made by serology and/or PCR.

RESULTS

Sixty-nine children with PRF were admitted; 30 (43.48%), 9 (13.04%) and 30 (43.48%) had a syndrome of bacterial, viral or non-established etiology, respectively. N. meningitidis infection was diagnosed in 16/69 (23.19%) patients and in 16/30 (53.33%) patients with bacterial etiology; 14/30 (46.67%) patients suffered from a non-invasive bacterial disease (9 with Rickettsial disease). Adenovirus and Influenza B (3 and 2 cases, respectively) represented the most frequent etiologic agents among patients with viral etiology. More patients with PRF of bacterial etiology were older, of Bedouin ethnicity, looked ill on admission, had higher rates of meningitis and were treated more frequently with antibiotics compared with patients with non-bacterial PRF. Fatality rates among patients with bacterial, viral and non-established etiology were 5/30 (16.7%), 0% and 2/39 (5.1%).

CONCLUSIONS

Although PFR was uncommon, high rates of meningococcal infections were recorded in children with PRF, which was associated with high fatality rates. Rickettsial infections were frequent, emphasizing the need for a high index of suspicion for this disease in endemic geographic areas.

Clinical and Laboratory Findings in Jewish and Bedouin Patients in Southern Israel Who Were Diagnosed with Factor VII Deficiency

BACKGROUND

Congenital factor VII deficiency is a rare recessive autosomal bleeding disorder with a wide spectrum of clinical manifestations.

OBJECTIVES

To compare the clinical and laboratory findings in Jewish and Bedouin patients with factor VII deficiency.

METHODS

The clinical and laboratory findings of patients with factor VII deficiency treated at Soroka Medical Center, a tertiary hospital in Israel, from 2005 to 2015 were analyzed regarding blood factor levels, illness severity, treatment administration, and disease outcome.

RESULTS

Seventy-eight patients were enrolled (1:13,000 of the population in southern Israel) of whom 26 were diagnosed with severe factor VII deficiency (1:40,000). Sixty (76.9%) patients were Jewish and 18 (23.1%) were Bedouin. In univariable analysis, Bedouin patients exhibited a more severe illness, with significantly higher complication and fatality rates, and required more preventive treatment than the Jewish patients.

CONCLUSIONS

The prevalence of congenital factor VII deficiency (including severe deficiency) in the Jewish and Bedouin populations of southern Israel is higher than previously reported. The clinical spectrum of the disease was found to be more severe in the Bedouin population.

Urinary tract infection in young infants discharged from the emergency room with normal urinalysis

AIM

We describe the clinical, microbiologic, therapeutic, and outcome characteristics of infants under three months of age with a positive urine culture reported after discharge from emergency department with normal urinalysis.

METHODS

We enrolled all infants with a urine culture obtained during an emergency room visit during 2004-2012, discharged without antibiotic therapy and subsequently reported with a positive urine culture.

RESULTS

Three hundred and ninety-three positive urine cultures were reported; 46/393 (11.7%, 42 in patients under two months of age) had positive urine cultures following normal urinalysis at first visit. Fifteen (33%) had positive urine cultures at second visit; 11/15 (73%) infants with second positive urine culture were under one month of age, eight were asymptomatic and seven had mild symptoms at second visit. Pathogens isolated in all 15 infants were identical between first and second visit. All 27 infants re-examined at second visit at the emergency room were hospitalised, completed sepsis work/up and received antibiotic treatment. None developed serious bacterial infections.

CONCLUSION

We propose a new management approach for young infants with normal urinalysis and positive urine culture and suggest restricting the management option including hospitalisation, sepsis work/up and antibiotic treatment at second visit only to infants under one month of age.

Acute otitis media in infants younger than two months of age: Epidemiologic and microbiologic characteristics in the era of pneumococcal conjugate vaccines

OBJECTIVES

To evaluate the epidemiology, microbiology, Streptococcus pneumoniae serotypes distribution and serious bacterial infections (SBIs) occurrence in infants <2 months of age with tympanocentesis-documented acute otitis media (AOM), before and after the introduction of pneumococcal conjugate vaccines (PCVs).

METHODS

The medical records of all hospitalized infants with AOM who underwent tympanocentesis during 2005-2014 were reviewed.

RESULTS

Of the 303 infants with AOM who were diagnosed by an ENT specialist, 182 underwent tympanocentesis, 92 during 2005-2009 (prevaccine period) and 90 during 2010-2014 (postvaccine period). Streptococcus pneumoniae and nontypeable Hemophilus influenzae were isolated in 46/92 (50%) and 37/92 (40.2%) patients during 2005-2009 and decreased to 27/90 (30%) and 21/90 (23.3%). Respectively, during 2010-2014 (P = 0.006 and P = 0.001). The proportion of culture-negative patients increased from 18/92 (19.6%) during 2005-2009 to 32/90 (35.6%) during 2010-2014 (P = 0.02). There were only 6 (3.3%) patients <2 weeks of age. The most common S. pneumoniae vaccine serotypes isolated during 2005-2009 were 5, 3, 1, 19F and 14 (15.2%, 13.0%, 10.9%, 6.5%, and 4.3%, respectively) and 3, 5, 1, 14 and 19A (22.2%, 11.1%, 7.4%, 7.4%, and 7.4%, respectively) during 2010-2014. The proportion of culture-positive patients decreased during 2013-2014 compared with 2011-2012 (7/18, 38.9% vs. 40/54, 74.1%, P = 0.007). Serotypes 1 and 5 were not isolated during 2013-2014 and serotype 19A was not isolated during 2011-2014. . SBIs were recorded in 23/182 (12.64%) patients and urinary tract infections represented 19/23 (82.61%) of them (Escherichia coli isolated in 12, 63.2%).

CONCLUSIONS

The overall number of AOM cases needing tympanocentesis seen at the PER and the proportion of S. pneumoniae and nontypeable H. influenzae-AOM decreased while the proportion of culture-negative AOM increased following the introduction of PCVs. SBIs associated with AOM were frequent and were represented mostly by urinary tract infections caused by pathogens unrelated to the etiologic agents of AOM.

An outbreak of hemolytic uremic syndrome in southern Romania during 2015-2016: Epidemiologic, clinical, laboratory, microbiologic, therapeutic and outcome characteristics

BACKGROUND AND AIMS

To describe the epidemiologic, clinical, microbiological, therapeutic and outcome characteristics of a HUS outbreak occurring in southern Romania from 2015 to 2016.

METHODS

We retrospectively collected data from the medical records of all HUS cases hospitalized at the pediatric nephrology department of Marie Curie Children's Hospital of Bucharest, Romania.

RESULTS

There were 32 HUS cases (19 girls/13 boys, 87.6% <2 years), all associated with diarrhea (bloody in 13, 40.6%). Thirteen (40.6%) and 4 (12.5%) patients had oliguria and anuria at admission. Extreme pallor, generalized edema, vomiting, dehydration, fever and seizures were found in 100%, 56.3%, 31.3%, 31.3%, 25% and 9.4% of patients, respectively. E. coli and STEC were identified in the stools of 6 and 8 patients, respectively; E. coli O₂₆ and O₁₅₇ infection were documented serologically in 10 and 3 children, respectively. There were 15/32 (46.9%) patients with confirmed HUS. Eighteen (56.3%) patients were hypertensive; other complications included infections, left ventricular hypertrophy, cardiopulmonary arrest, seizures and encephalopathy in 62.5%, 37.5%, 28.3%, 18.8% and 12.5%, respectively. Peritoneal dialysis and hemodialysis were performed in 23 (72%) and 2 patients, respectively. Three patients (9.4%) died early during hospitalization. A 6-12-month follow-up of 26 patients revealed that 65.4% had post-HUS sequelae (persistent hypertension and chronic renal failure in 34.6% and 30.8%, respectively).

CONCLUSIONS

The principal STEC serotype involved was O₂₆:H₁₁ and the number of confirmed HUS cases reached half of the patients. Compared with the medical literature, this outbreak had a higher rate of complications and renal sequelae and was associated with a high fatality rate.

Association of albumin and cholesterol levels with incidence of hypoglycaemia in people admitted to general internal medicine units

AIM

To study the association between serum albumin and cholesterol levels at hospital admission and incident hypoglycaemia among people admitted to internal medicine units.

METHODS

In this cross-sectional analysis, we examined the electronic medical records of people hospitalized in internal medicine departments. Data extracted included all glucose measurements as well as serum albumin and cholesterol, which were measured upon admission. A hypoglycaemia event was recorded for a given person if at least one glucose measurement of ≤ 3.9 mmol/l was recorded during the hospital stay. Regression analysis was used to determine which clinical measures predict hypoglycaemia.

RESULTS

During the acquisition period, 45 224 people (mean age 68.9 ± 17.8 years, 49.4% male, 21.1% diabetes mellitus) were discharged from internal medicine units. Hypoglycaemia was documented in 7.5% of these individuals (15.4% of people with diabetes vs. 5.5% of those without; P < 0.001). Logistic regression showed that both serum albumin [odds ratio (OR) 0.908, 95% confidence interval (CI) 0.896-0.919; P < 0.001) and cholesterol (OR 0.938, 95% CI 0.896-0.981; P = 0.005] were significantly associated with incident hypoglycaemia. Results remained significant even after controlling for age, sex, average glucose during hospitalization, length of hospital stay, acute infection upon admission, diabetes status, haemoglobin, white blood cell count and C-reactive levels. A combination of hypoalbuminaemia (< 35 g/l) and hypocholesterolaemia (< 3.37 mmol/l) upon admission greatly increased the risk of incident hypoglycaemia (OR 2.544, 95% CI 2.096-3.088; P < 0.001).

CONCLUSION

Hypoalbuminaemia and hypocholesterolaemia predict incident hypoglycaemia in the hospital setting among people with and without diabetes mellitus.

Studying PCV impact on clinical presentation of otitis media helps to understand its pathogenesis

BACKGROUND

Complex otitis media (OM) may present with intact tympanic membrane or spontaneous otorrhea. We compared dynamics of intact tympanic membrane and spontaneous otorrhea OM following 7- and 13-valent conjugated vaccines (PCV7, PCV13) implementation, since differences in dynamics may imply different underlying mechanisms.

METHODS

A prospective, population-based, active surveillance. Episodes with middle-ear fluid cultures in children < 3 years were included. Defined sub-periods were: pre-pneumococcal conjugated vaccines (PCV) (2004-2008); PCV7 (2009-2011); PCV13 (2014-2016).

RESULTS

Of 7705 episodes, 57.2% had intact tympanic membrane, 16.8% spontaneous otorrhea, 26.0% unknown. In the pre-PCV period, the spontaneous otorrhea group was older and had higher proportions of factors associated with recurrence/chronicity. During the PCV7 period, spontaneous otorrhea and intact tympanic membrane episodes caused by PCV13 serotypes decreased significantly (43% and 51%, respectively) and those caused by non-PCV13 serotypes and culture-negative episodes increased significantly. However, rates increases were steeper in the spontaneous otorrhea group for both non-PCV13 serotypes (117% vs. 38%) and culture-negative (720% vs. 69%). In the spontaneous otorrhea group, nontypeable Haemophilus influenzae rates increased non-significantly by 10% and all-cause OM rates increased significantly by 56%, while in the intact tympanic membrane group the respective rates decreased significantly by 22% and 11%. These trends were especially pronounced in ages 24-35 months. Despite these differences, after PCV13 introduction, both spontaneous otorrhea and intact tympanic membrane rates declined for all outcomes.

CONCLUSIONS

Spontaneous otorrhea was associated with older age, frequent history of complex OM and delayed PCV impact, suggesting a higher proportion of advanced-stage complex OM.

The Infectious and Noninfectious Etiology, Clinical Picture and Outcome of Neutropenia in Immunocompetent Hospitalized Children

BACKGROUND

Acquired neutropenia in immunocompetent children is common, and its differential diagnosis ranges from benign causes to life-threatening diseases. We described the etiology, clinical picture and outcome of new-onset neutropenia in immunocompetent children assessed in the emergency department and hospitalized at our medical center.

METHODS

Previously healthy children admitted with neutropenia (absolute neutrophil count <1.5 × 10(9)/L) were included. Serious bacterial infections were defined as culture-positive blood, urine, cerebrospinal fluid, articular fluid or stool infections, pneumonia, Brucellosis and Rickettsiosis.

RESULTS

A total of 601 patients (5 days-202 months old) were enrolled; 3 (0.5%), 48 (8%), 165 (27.5%) and 385 (64%) had absolute neutrophil counts <0.2, 0.2-0.5, 0.5-1.0 and 1.0-1.5 × 10(9)/L, respectively. Associated leukopenia and thrombocytopenia were diagnosed in 186 (39%) and 71 (11.8%) patients. Three hundred sixteen of 601 (52.6%) and 519 of 601 (86.4%) were <2 or 36 months of age, respectively. Fever at admission was present in 27.6% patients. Serious bacterial infections were diagnosed in 106 (17.6%) patients. Brucellosis and rickettsiosis were diagnosed in 8 of 52 (15.4%) and 9 of 39 (23.1%) tests obtained. Respiratory syncytial virus was diagnosed in 17 of 33 (51.5%) nasal washes. An infectious etiology was determined in 171 (28.5%) patients. Acute leukemia was diagnosed in 6 patients. A significant correlation was found between resolution of neutropenia and patient age, infectious etiology and severity of neutropenia.

CONCLUSIONS

(1) Severe neutropenia was rare; (2) More than half of patients were <2 months of age; (3) An infectious etiology was diagnosed in a high number of patients, and serious bacterial infections were frequent and (4) Brucella spp. and rickettsial infections were frequent etiologies associated with neutropenia in our setting.

Performance of risk stratification criteria in the management of febrile young infants younger than three months of age

AIM

We evaluated the diagnosis, risk stratification and management of febrile infants under three months of age who presented to an Israeli paediatric emergency room (ER).

METHODS

This retrospective study enrolled all febrile infants examined in the paediatric ER of Soroka Medical Center during 2010-2013. The patients were classified into low-risk and high-risk subgroups and compared by age and ethnicity.

RESULTS

Overall, 2251 febrile infants (60.5% of Bedouin and 34.4% of Jewish ethnicity) were enrolled. Hospitalisation rates were higher among Bedouin vs. Jewish infants (55 vs. 39.8%, p < 0.001). Fever without localising signs was diagnosed in 1028 (45.6%) infants and 499 (48.5%) were hospitalised; 26% were stratified as high-risk and 74% as low-risk. Bedouin infants rates were more likely to be at high-risk (p = 0.001) and hospitalised (p < 0.001) than Jewish infants. With regard to low-risk infants, the incidence rates were higher before two months than two to three months of age (73.3 vs. 59%, p < 0.001), as were the hospitalisation rates (46.3 vs. 20.1%, p < 0.001). No differences were recorded for the hospitalisation rates of Bedouin and Jewish infants between the three daily shifts.

CONCLUSION

Major differences were recorded in hospitalisation rates, risk stratification and management of Bedouin and Jewish infants with fever without localising signs.

Streptococcus pneumoniae Serotypes and Antibiotic Susceptibility Patterns in Middle Ear Fluid Isolates During Acute Otitis Media and Nasopharyngeal Isolates During Community-acquired Alveolar Pneumonia in Central Romania

BACKGROUND

Streptococcus pneumoniae is a common cause of community-acquired alveolar pneumonia (CAAP) and acute otitis media (AOM) in children. Romania has high rates of S. pneumoniae antibiotic resistance. The pneumococcal conjugated vaccines (PCVs) are not being used routinely in this country. The aims of the study were as follows: 1) to compare pneumococcal antibiotic resistance patterns in AOM and CAAP in children from central Romania and 2) to compare differences in the distribution of pneumococcal serotypes isolated from the middle ear fluid (MEF) of children with AOM and from the nasopharynx (NP) of children with CAAP.

METHODS

Children younger than 5 years old with AOM or with radiologically confirmed CAAP were prospectively enrolled. Samples from MEF and NP were evaluated for antibiotic susceptibility and serotyping.

RESULTS

Eighty-eight children with CAAP and 68 with AOM were enrolled. Of the MEF and CAAP isolates, 64 (94.1%) and 79 (89.7%) were penicillin nonsusceptible, respectively. The pneumococcal serotypes distribution in AOM was similar to those in CAAP except for serotype 19F, which was more common in AOM. Overall, 89.7% and 85.8% of all serotypes in AOM and CAAP patients, respectively, were covered by 13-valent PCV.

CONCLUSIONS

MEF and NP-CAAP S. pneumoniae isolates were similar in regard to serotype distribution and antibiotic resistance. S. pneumoniae antibiotic resistance rates were extremely high. Thirteen-valent PCV has the potential to reduce both the burden of disease as well as the rates of antibiotic-resistant S. pneumoniae in both diseases.

Epidemiologic and Microbiologic Characteristics of Occult Bacteremia Among Febrile Children in Southern Israel, Before and After Initiation of the Routine Antipneumococcal Immunization (2005-2012)

BACKGROUND

Little is known about the incidence and dynamics of occult bacteremia (OB) among infants/young children following the introduction of pneumococcal conjugate vaccines (PCVs) into the national immunization program in Israel in 2009-2010. The aim of this study was to characterize the epidemiologic and microbiologic picture of OB among febrile infants/children aged 3-36 months in southern Israel, before and after PCVs introduction.

METHODS

Retrospective study enrolling all infants/young children attending the emergency room of a tertiary medical center in southern Israel with fever without source, discharged, and reported with a positive blood culture.

RESULTS

Of 453 true bacteremias, 89 (19.6%) were defined as OB. OB rate was 0.22%; a significant decrease was recorded in OB rates, with the highest rate during 2005 (0.34%) and the lowest during 2011 (0.15%). OB cases decreased in post-PCV (2010-2012) versus prevaccination period (2005-2009) from 66/22,256 cases (0.3%) to 23/13,213 cases (0.17%; p = 0.03). Most frequent single OB pathogens were Streptococcus pneumoniae, Streptococcus viridans spp., and Kingella kingae (39.3%, 10.1%, and 9.0%, respectively); Enterobacteriaceae spp. were isolated in 10 cases (11.2%). No changes were recorded in S. pneumoniae-OB cases; K. kingae-OB decreased significantly (p = 0.047). None of the S. pneumoniae serotypes isolated during 2011-2012 belonged to 13-valent PCV (PCV13). An increase in non PCV13 serotypes was recorded during 2011-2012 (3/3, 100% vs. 7/32, 21.9%, p = 0.01).

CONCLUSION

OB rates decreased significantly following the introduction of PCVs. S. pneumoniae was the most frequent isolated pathogen in OB, but in lower percentages compared with the medical literature. No PCV13 serotypes were detected as a cause of OB during 2011-2012.

The Epidemiologic, Microbiologic and Clinical Picture of Bacteremia among Febrile Infants and Young Children Managed as Outpatients at the Emergency Room, before and after Initiation of the Routine Anti-Pneumococcal Immunization

We described the occult bacteremia (OB) and bacteremia with diagnosed focus (BwF) picture among children managed as outpatients at the pediatric emergency room (PER) in southern Israel, before and after the introduction of pneumococcal conjugate vaccines (PCVs) introduction in a retrospective study enrolling all three- to 36-month-old patients with fever >38.0 °C during 2005–2014. Of 511 (0.82% of all febrile patients) true bacteremias, 230 (45%) were managed as outpatients; 96 of 230 (41.7%) had OB and 134 (3.59%) had BwF. OB and BwF rates were 0.22% and 3.02%, respectively. A significant decrease was noted in OB and BwF rates (p = 0.0008 and p = 0.02, respectively). S. pneumoniae (SP, 37.5%), K. kingae (11.4%) and Brucella spp. (8.7%) were the most common OB pathogens and SP (29.8%), S. viridans (13.4%), and Brucella spp. (12.7%) were the most common in BwF patients. PCV13 serotypes were not found among the serotypes isolated post-PCV13 introduction. During 2010–2014 there was an increase in non-PCV13 serotype isolation (p = 0.005). SP was the main pathogen isolated among patients with pneumonia, acute otitis media (AOM) and periorbital cellulitis (62.5%, 33.3% and 60%, respectively). OB and BwF decreased following the introduction of PCVs and SP was the main pathogen in both conditions. Vaccine-SP serotypes were not isolated in OB after PCV13 introduction and non-vaccine serotypes increased significantly.

Parental acceptability of the watchful waiting approach in pediatric acute otitis media

AIM: To determine parental knowledge about acute otitis media (AOM) and its antibiotic therapy, antibiotic resistance and the willingness to comply with the watchful waiting (WW) approach in primary care settings in southern Israel.

METHODS: The study was conducted in 3 primary care clinics and the pediatric emergency room of Soroka University Medical Center. Questionnaires (20 questions on education background, previous AOM experience, knowledge on antimicrobial resistance and attitude vs the WW approach) were filled by 600 parents (150 at each centers) of children < 6 years of age.

RESULTS: Mothers represented 69% of parents; 2% had an education of < 10 school years, 46% had high-school education and 17% had an academic degree. 69% parents reported previous experience with AOM and 56% thought that antibiotics represent the only treatment for AOM. Knowledge on bacterial resistance to antibiotics was reported by 57% of the parents; 86% parents were willing to accept/probably accept the WW approach for their children. Logistic regression analysis revealed a significant association between parental education and knowledge about bacterial resistance to antibiotics and that previous experience with AOM was significantly associated with reluctance to accept the WW approach. More parents with knowledge on bacterial resistance were willing to accept the WW approach compared with parents without such knowledge. No correlation was found between the education level and willingness to accept the WW approach.

CONCLUSION: A significant correlation was found between previous parental education and experience with AOM and the knowledge about antibiotic use, bacterial resistance and acceptance of the WW approach.

Follow-up after infants younger than 2 months of age with urinary tract infection in Southern Israel: epidemiologic, microbiologic and disease recurrence characteristics

Background

The timing of most recurrences after neonatal urinary tract infection is during the first year of life, with peak incidence 2–6 months after the initial infection. Information on the microbiologic characteristics of recurrent urinary tract infection episodes in relation to the microbiology of the initial episodes is limited.

Objectives

To analyze the epidemiologic/microbiological characteristics of 1st and recurrent urinary tract infection in infants <2 months of age.

Methods

A retrospective study including all infants <2 months of age with urinary tract infection admitted during 2005–2009 and followed till the age of 1 year.

Results

151 neonates were enrolled (2.7% of all 5617 febrile infants <2 months of age admitted). The overall incidence of urinary tract infection occurring during the first 2 months of life was 151/73,480 (0.2%) live births during 2005–2009 in southern Israel (2.1 cases/1000 live births). One pathogen was isolated in 133 (88.1%); Escherichia coli, Klebsiella spp., Enterococcus spp., Morganella morganii, Proteus spp., and Enterobacter spp. represented the most common pathogens (57.9%, 12.2%, 7.9%, 6.7%, 6.1%, and 5%, respectively). Trimethoprim/sulfamethoxazole, ampicillin, and cefuroxime-axetil were the most commonly recommended prophylactic antibiotics (45%, 13.2%, and 8%, respectively). Twenty-three recurrent urinary tract infection episodes were recorded in 20 (13.2%) patients; 6/23 (26%) were diagnosed within one month following 1st episode. E. coli was the most frequent recurrent urinary tract infection pathogen (12/23, 52.2%). No differences were recorded in E. coli distribution between first urinary tract infection vs. recurrent urinary tract infection. Seventeen (74%) recurrent urinary tract infection episodes were caused by pathogens different (phenotypically) from those isolated in 1st episode. Recurrent urinary tract infection occurred in 25.0%, 8.3%, and 0 patients recommended trimethoprim/sulfamethoxazole, cefuroxime-axetil, or amoxicillin prophylaxis, respectively.

Conclusions

(1) The study determined the incidence of urinary tract infection in febrile infants <2 months of age in Southern Israel; (2) E. coli was responsible for the majority of first and recurrent urinary tract infection; (3) recurrent urinary tract infection was caused mostly by pathogens different than the pathogens isolated at initial episode.