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Herrmann BW, Boguniewicz J, Gitomer SA. Commentary on the letter to the editor regarding "Postmeningitic pediatric hearing loss from non-type b Haemophilus influenzae". Am J Otolaryngol 2024; 45:104291. [PMID: 38657535 DOI: 10.1016/j.amjoto.2024.104291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Accepted: 04/07/2024] [Indexed: 04/26/2024]
Affiliation(s)
- Brian W Herrmann
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, United States of America; Children's Hospital Colorado, United States of America.
| | - Juri Boguniewicz
- Children's Hospital Colorado, United States of America; Department of Pediatrics - Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, United States of America.
| | - Sarah A Gitomer
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, United States of America; Children's Hospital Colorado, United States of America.
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Willis ZI, Oliveira CR, Abzug MJ, Anosike BI, Ardura MI, Bio LL, Boguniewicz J, Chiotos K, Downes K, Grapentine SP, Hersh AL, Heston SM, Hijano DR, Huskins WC, James SH, Jones S, Lockowitz CR, Lloyd EC, MacBrayne C, Maron GM, Hayes McDonough M, Miller CM, Morton TH, Olivero RM, Orscheln RC, Schwenk HT, Singh P, Soma VL, Sue PK, Vora SB, Nakamura MM, Wolf J. Guidance for prevention and management of COVID-19 in children and adolescents: A consensus statement from the Pediatric Infectious Diseases Society Pediatric COVID-19 Therapies Taskforce. J Pediatric Infect Dis Soc 2024; 13:159-185. [PMID: 38339996 DOI: 10.1093/jpids/piad116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Accepted: 12/27/2023] [Indexed: 02/12/2024]
Abstract
BACKGROUND Since November 2019, the SARS-CoV-2 pandemic has created challenges for preventing and managing COVID-19 in children and adolescents. Most research to develop new therapeutic interventions or to repurpose existing ones has been undertaken in adults, and although most cases of infection in pediatric populations are mild, there have been many cases of critical and fatal infection. Understanding the risk factors for severe illness and the evidence for safety, efficacy, and effectiveness of therapies for COVID-19 in children is necessary to optimize therapy. METHODS A panel of experts in pediatric infectious diseases, pediatric infectious diseases pharmacology, and pediatric intensive care medicine from 21 geographically diverse North American institutions was re-convened. Through a series of teleconferences and web-based surveys and a systematic review with meta-analysis of data for risk factors, a guidance statement comprising a series of recommendations for risk stratification, treatment, and prevention of COVID-19 was developed and refined based on expert consensus. RESULTS There are identifiable clinical characteristics that enable risk stratification for patients at risk for severe COVID-19. These risk factors can be used to guide the treatment of hospitalized and non-hospitalized children and adolescents with COVID-19 and to guide preventative therapy where options remain available.
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Affiliation(s)
- Zachary I Willis
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carlos R Oliveira
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Mark J Abzug
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Brenda I Anosike
- Department of Pediatrics, The Children's Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, NY, USA
| | - Monica I Ardura
- Department of Pediatrics, ID Host Defense Program, Nationwide Children's Hospital & The Ohio State University, Columbus, OH, USA
| | - Laura L Bio
- Department of Pharmacy, Lucile Packard Children's Hospital, Stanford, CA, USA
| | - Juri Boguniewicz
- Department of Pediatrics, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO, USA
| | - Kathleen Chiotos
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Divisions of Critical Care Medicine and Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kevin Downes
- Department of Pediatrics, Perelman School of Medicine of the University of Pennsylvania, Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Steven P Grapentine
- Department of Pharmacy, University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | - Adam L Hersh
- Department of Pediatrics, Division of Infectious Diseases, University of Utah, Salt Lake City, UT, USA
| | - Sarah M Heston
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Diego R Hijano
- Department of Infectious Diseases, St. Jude Children's Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - W Charles Huskins
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Scott H James
- Department of Pediatrics, Division of Pediatric Infectious Diseases, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Sarah Jones
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, USA
| | | | - Elizabeth C Lloyd
- Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | | | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Molly Hayes McDonough
- Center for Healthcare Quality & Analytics, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Christine M Miller
- Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Theodore H Morton
- Department of Pharmacy, St Jude's Children's Research Hospital, Memphis, Tennessee, USA
| | - Rosemary M Olivero
- Department of Pediatrics and Human Development, Michigan State College of Human Medicine and Helen DeVos Children's Hospital of Corewell Health, Grand Rapids, MI, USA
| | | | - Hayden T Schwenk
- Department of Pediatrics, Stanford School of Medicine, Stanford, CA, USA
| | - Prachi Singh
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
| | - Vijaya L Soma
- Department of Pediatrics, NYU Grossman School of Medicine, New York, NY, USA
| | - Paul K Sue
- Department of Pediatrics, Columbia University, New York, NY, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington School of Medicine, and Division of Infectious Diseases, Seattle Children's Hospital, Seattle, WA, USA
| | - Mari M Nakamura
- Antimicrobial Stewardship Program and Division of Infectious Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Joshua Wolf
- Department of Infectious Diseases, St. Jude Children's Research Hospital and Department of Pediatrics, University of Tennessee Health Science Center, Memphis, TN, USA
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Gitomer SA, Boguniewicz J, Tong S, Gottman DC, Hirsch S, Herrmann BW. Decrease in Rates of Hearing Loss From Pediatric Bacterial Meningitis Over Time: A Database Review. Laryngoscope 2024. [PMID: 38401054 DOI: 10.1002/lary.31353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/21/2024] [Accepted: 02/07/2024] [Indexed: 02/26/2024]
Abstract
OBJECTIVES Bacterial meningitis is a leading cause of acquired sensorineural hearing loss (SNHL). Treatment and prevention of bacterial meningitis have improved over time, but rates of neurologic complications have not been recently studied. The objective here is to present an updated population-based review of hearing loss as a sequela of bacterial meningitis. METHODS A retrospective cohort study was conducted between 2010 and 2022 of children discharged with bacterial meningitis, using the Pediatric Health Information System's (PHIS) database. Rates of hearing loss and mortality were evaluated over time. RESULTS A total of 6138 children with a primary diagnosis of bacterial meningitis were identified (3520 male [57.3%], mean age 5.8 months [2.0, 61.2]). Of these, 277 (4.51%) were diagnosed with hearing loss. Children with hearing loss were significantly older (23.6 vs. 5.3 months, p < 0.01), but differences in gender, race, or ethnicity had no association with hearing loss. Streptococcus pneumoniae, Hemophilus influenzae, and Neisseria meningiditis were associated with significantly higher rates of hearing loss than other etiologies (p < 0.01). Children with hearing loss had a higher rate of receiving dexamethasone than children without hearing loss. Overall mortality rate was 2.1%. Hearing loss and mortality demonstrated significant decreases over the study period. CONCLUSION Hearing loss remains a common sequela of bacterial meningitis despite widespread uptake of vaccines for preventing S. pneumoniae, H. influenzae, and N. meningitidis. Dexamethasone was not associated with decreased rates of hearing loss in this cohort. From 2010 to 2022, there was a significant decrease in overall rates of mortality and hearing loss for children with bacterial meningitis. LEVEL OF EVIDENCE Level 3: retrospective case-control series Laryngoscope, 2024.
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Affiliation(s)
- Sarah Ann Gitomer
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Juri Boguniewicz
- Division of Pediatric Infectious Diseases, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Suhong Tong
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
| | - Drew C Gottman
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Scott Hirsch
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
| | - Brian William Herrmann
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado, U.S.A
- Division of Pediatric Otolaryngology, Children's Hospital Colorado, Aurora, Colorado, U.S.A
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Herrmann BW, Goff SH, Boguniewicz J, Gitomer SA. Postmeningitic pediatric hearing loss from non-type b Haemophilus influenzae. Am J Otolaryngol 2024; 45:104104. [PMID: 37948823 PMCID: PMC10841718 DOI: 10.1016/j.amjoto.2023.104104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/29/2023] [Indexed: 11/12/2023]
Abstract
BACKGROUND Postmeningitic hearing loss from Haemophilus influenzae (H. influenzae) is increasingly due to encapsulated serotypes other than type b (Hib) and nontypeable strains (collectively, nHiB H. influenzae). Pediatric hearing loss after nHib H. influenzae meningitis remains poorly described. METHODS Retrospecive case series of nHiB H. influenzae meningitis cases identified from a microbiologic database at Children's Hospital Colorado from 2000 to 2020. Literature regarding nHiB H. influenzae and H. influenzae postmeningitic hearing loss was also reviewed. RESULTS Eleven cases of nHib H. influenzae meningitis (median age 15.9 months) were identified due to serotype f (36 %), serotype a (27 %), and nontypable strains (36 %). Seven (64 %) patients were male, 55 % were white and 18 % were Hispanic or Latino. Hearing loss was initially identified in 4 children (40 %), with two patients with moderate conductive hearing loss (CHL) and one child with unilateral moderate sensorineural (SNHL) hearing loss patients recovering normal hearing. One patient with bilateral profound sensorineural hearing loss and associated labyrinthitis ossificans required cochlear implantation. All children (4) with identified hearing loss were noted to have additional intracranial sequelae, which included empyema (2), sinus thrombosis (2), and seizures (2). Of patients receiving steroids, 25 % had hearing loss on initial testing, compared to 66 % of those who did not receive steroids. CONCLUSIONS nHib H. influenzae can cause both transient and permanent postmeningitic hearing loss. Steroids may offer otoprotection in nHib H. influenzae meningitis similar to Hib meningitis. Given the limited literature, further study is needed to better characterize hearing outcomes after nHib H. influenzae meningitis.
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Affiliation(s)
- Brian W Herrmann
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, United States of America; Children's Hospital Colorado, United States of America.
| | - Salina H Goff
- University of Colorado School of Medicine, Aurora, CO, United States of America.
| | - Juri Boguniewicz
- Children's Hospital Colorado, United States of America; Department of Pediatrics - Infectious Diseases, University of Colorado School of Medicine, Aurora, CO, United States of America.
| | - Sarah A Gitomer
- Department of Otolaryngology-Head and Neck Surgery, University of Colorado School of Medicine, Aurora, CO, United States of America; Children's Hospital Colorado, United States of America.
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Kushner LE, Ristagno EH, Dong SW, Konold VJL, Fatemi Y, Stillwell TL, Wohrley JD, Sattler MM, Kalu IC, Boguniewicz J. Laying the Groundwork for a Fulfilling Career in Pediatric Infectious Diseases: The Transition From Fellowship to Faculty. J Pediatric Infect Dis Soc 2023; 12:627-633. [PMID: 37815429 DOI: 10.1093/jpids/piad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 09/27/2023] [Indexed: 10/11/2023]
Abstract
There are limited resources for guidance on the transition from fellowship into a new faculty role in pediatric infectious diseases. This review aims to address this gap and provides a framework for a successful transition that is composed of four essential pillars-(1) stepping into your role, (2) finding your niche, (3) building your network, and (4) self-care-all of which are supported by strong mentorship/sponsorship and continual realignment with one's personal mission statement. In addition to providing general principles and guidance, this review also outlines specific steps that a junior faculty member can take to expand their influence and build a successful, fulfilling career in pediatric infectious diseases.
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Affiliation(s)
- Lauren E Kushner
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Stanford University School of Medicine, Palo Alto, CA, USA
| | - Elizabeth H Ristagno
- Department of Pediatric and Adolescent Medicine, Division of Pediatric Infectious Diseases, Mayo Clinic, Rochester, MN, USA
| | - Sara W Dong
- Department of Pediatrics, Division of Infectious Diseases, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Victoria J L Konold
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Yasaman Fatemi
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA, USA
| | - Terri L Stillwell
- Department of Pediatrics, University of Michigan Medical School, Ann Arbor, MI, USA
| | - Julie D Wohrley
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Rush University Children's Hospital, Chicago, IL, USA
| | - Matthew M Sattler
- Department of Pediatrics, Division of Infectious Diseases, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Ibukunoluwa C Kalu
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Juri Boguniewicz
- Department of Pediatrics, Section of Infectious Diseases and Epidemiology, University of Colorado School of Medicine, Aurora, CO, USA
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Demirhan S, Munoz FM, Valencia Deray KG, Bocchini CE, Danziger-Isakov L, Blum S, Sharma TS, Sherman G, Boguniewicz J, Bacon S, Ardura MI, Maron GM, Ferrolino J, Foca M, Herold BC. Body surface area compared to body weight dosing of valganciclovir is associated with increased toxicity in pediatric solid organ transplantation recipients. Am J Transplant 2023; 23:1961-1971. [PMID: 37499799 DOI: 10.1016/j.ajt.2023.07.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 07/19/2023] [Accepted: 07/20/2023] [Indexed: 07/29/2023]
Abstract
Optimal dosing of valganciclovir (VGCV) for cytomegalovirus (CMV) prevention in pediatric solid organ transplantation recipients (SOTR) is controversial. Dosing calculated based on body surface area (BSA) and creatinine clearance is recommended but simplified body weight (BW) dosing is often prescribed. We conducted a retrospective 6-center study to compare safety and efficacy of these strategies in the first-year posttransplant There were 100 (24.2%) pediatric SOTR treated with BSA and 312 (75.7%) with BW dosing. CMV DNAemia was documented in 31.0% vs 23.4% (P = .1) at any time during the first year and breakthrough DNAemia in 16% vs 12.2% (P = .3) of pediatric SOTR receiving BSA vs BW dosing, respectively. However, neutropenia (50% vs 29.3%, P <.001), lymphopenia (51% vs 15.0%, P <.001), and acute kidney injury causing treatment modification (8.0% vs 1.8%, P <.001) were documented more frequently during prophylaxis in pediatric SOTR receiving BSA vs BW dosing. The adjusted odds ratio of VGCV-attributed toxicities comparing BSA and BW dosing was 2.3 (95% confidence interval [CI], 1.4-3.7] for neutropenia, 7.0 (95% CI, 3.9-12.4) for lymphopenia, and 4.6 (95% CI, 2.2-9.3) for premature discontinuation or dose reduction of VGCV, respectively. Results demonstrate that BW dosing is associated with significantly less toxicity without any increase in CMV DNAemia.
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Affiliation(s)
- Salih Demirhan
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Flor M Munoz
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Kristen G Valencia Deray
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Claire E Bocchini
- Department of Pediatrics, Division of Infectious Diseases, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Samantha Blum
- Department of Pediatrics, Division of Infectious Diseases, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Tanvi S Sharma
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Gilad Sherman
- Department of Pediatrics, Division of Infectious Diseases, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Juri Boguniewicz
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Samantha Bacon
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Monica I Ardura
- Department of Pediatrics, Division of Infectious Diseases & Host Defense, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Gabriela M Maron
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Jose Ferrolino
- Department of Infectious Diseases, St. Jude Children's Research Hospital, Memphis, Tennessee, USA
| | - Marc Foca
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
| | - Betsy C Herold
- Department of Pediatrics, Division of Infectious Diseases, Children's Hospital at Montefiore, Albert Einstein College of Medicine, Bronx, New York, USA.
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Lee NK, Tong S, Tholen K, Boguniewicz J, Gitomer SA, Herrmann BW. Hearing outcomes in children with pneumococcal meningitis in the PCV13 era. Am J Otolaryngol 2023; 44:103886. [PMID: 37030130 DOI: 10.1016/j.amjoto.2023.103886] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/01/2023] [Indexed: 04/10/2023]
Abstract
INTRODUCTION Streptococcus pneumoniae, is associated with the highest incidence of post-meningitic SNHL. The exact impact of 13-valent pneumococcal conjugate vaccine (PCV) on pediatric SNHL from pneumococcal meningitis is unknown. We aimed to identify clinical factors associated with post-meningitic SNHL (pmSNHL) from pneumococcal meningitis and describe its rates based on three time periods: pre-PCV, PCV-7 and PCV13 eras. METHODS A retrospective case-control study was performed for patients 18 years and younger diagnosed with pneumococcal meningitis from January 1, 2010 to December 31, 2020 at Children's Hospital Colorado. Demographic and clinical risk factors between those with or without SNHL were compared. Detailed hearing outcomes of those with resulting SNHL are described. RESULTS 23 patients with CSF cultures or Meningitis/Encephalitis Panel positive for pneumococcal meningitis were identified. Twenty patients both survived the infection and had audiologic evaluation. Six patients had pmSNHL, with 50 % affected bilaterally. The rate of pmSNHL from S. pneumoniae in the PCV-13 era at our institution was similar to historical rates from the pre-PCV and PCV-7 eras. Similar proportions of patients with pmSNHL completed PCV vaccination (66.7 %) compared to those without (71.4 %). Non-PCV-13 serotypes were responsible 83 % of patients with pmSNHL versus 57 % of patients without pmSNHL. CONCLUSIONS Despite high rates of PCV-13 uptake in our cohort, pmSNHL was still common, severe, and commonly associated with non-PCV-13 serotypes. Non-PCV-13 serotypes may be contributing to the persistently high rate of post-meningitic SNHL and the severity of SNHL. Newer pneumococcal conjugate vaccines with expanded serotypes may help mitigate the SNHL associated with pneumococcal meningitis.
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Affiliation(s)
- Nam K Lee
- University of Colorado Anschutz School of Medicine, Aurora, CO 80045, USA.
| | - Suhong Tong
- Center for Research Outcomes in Children's Surgery, Center for Children's Surgery, University of Colorado Anschutz Medical Campus, Aurora, CO 80045, USA
| | - Kaitlyn Tholen
- Children's Hospital of Colorado (CHCO), Anschutz Medical Campus, Department of Otolaryngology-Pediatric, Aurora, CO 80045, USA
| | - Juri Boguniewicz
- University of Colorado Anschutz School of Medicine, Aurora, CO 80045, USA; Children's Hospital of Colorado (CHCO), Anschutz Medical Campus (CHCO), Department of Infectious Disease-Pediatrics, Aurora, CO 80045, USA
| | - Sarah A Gitomer
- University of Colorado Anschutz School of Medicine, Aurora, CO 80045, USA; Children's Hospital of Colorado (CHCO), Anschutz Medical Campus, Department of Otolaryngology-Pediatric, Aurora, CO 80045, USA
| | - Brian W Herrmann
- University of Colorado Anschutz School of Medicine, Aurora, CO 80045, USA; Children's Hospital of Colorado (CHCO), Anschutz Medical Campus, Department of Otolaryngology-Pediatric, Aurora, CO 80045, USA
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Chiotos K, Blumenthal J, Boguniewicz J, Palazzi DL, Stalets EL, Rubens JH, Tamma PD, Cabler SS, Newland J, Crandall H, Berkman E, Kavanagh RP, Stinson HR, Gerber JS. Antibiotic Indications and Appropriateness in the Pediatric Intensive Care Unit: A 10-Center Point Prevalence Study. Clin Infect Dis 2023; 76:e1021-e1030. [PMID: 36048543 PMCID: PMC10169439 DOI: 10.1093/cid/ciac698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Revised: 08/04/2022] [Accepted: 08/24/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Antibiotics are prescribed to most pediatric intensive care unit (PICU) patients, but data describing indications and appropriateness of antibiotic orders in this population are lacking. METHODS We performed a multicenter point prevalence study that included children admitted to 10 geographically diverse PICUs over 4 study days in 2019. Antibiotic orders were reviewed for indication, and appropriateness was assessed using a standardized rubric. RESULTS Of 1462 patients admitted to participating PICUs, 843 (58%) had at least 1 antibiotic order. A total of 1277 antibiotic orders were reviewed. Common indications were empiric therapy for suspected bacterial infections without sepsis or septic shock (260 orders, 21%), nonoperative prophylaxis (164 orders, 13%), empiric therapy for sepsis or septic shock (155 orders, 12%), community-acquired pneumonia (CAP; 118 orders, 9%), and post-operative prophylaxis (94 orders, 8%). Appropriateness was assessed for 985 orders for which an evidence-based rubric for appropriateness could be created. Of these, 331 (34%) were classified as inappropriate. Indications with the most orders classified as inappropriate were empiric therapy for suspected bacterial infection without sepsis or septic shock (78 orders, 24%), sepsis or septic shock (55 orders, 17%), CAP (51 orders, 15%), ventilator-associated infections (47 orders, 14%), and post-operative prophylaxis (44 orders, 14%). The proportion of antibiotics classified as inappropriate varied across institutions (range, 19%-43%). CONCLUSIONS Most PICU patients receive antibiotics. Based on our study, we estimate that one-third of antibiotic orders are inappropriate. Improved antibiotic stewardship and research focused on strategies to optimize antibiotic use in critically ill children are needed.
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Affiliation(s)
- Kathleen Chiotos
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jennifer Blumenthal
- Division of Infectious Diseases, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
- Division of Critical Care Medicine, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Juri Boguniewicz
- Section of Infectious Diseases and Epidemiology, Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Debra L Palazzi
- Infectious Diseases Division, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Erika L Stalets
- Division of Critical Care Medicine, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Jessica H Rubens
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Pranita D Tamma
- Division of Infectious Diseases, Department of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Stephanie S Cabler
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Jason Newland
- Division of Infectious Diseases, Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Hillary Crandall
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Emily Berkman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, Washington, USA
| | - Robert P Kavanagh
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Penn State University College of Medicine, Hershey, Pennsylvania, USA
| | - Hannah R Stinson
- Division of Critical Care Medicine, Department of Anesthesiology and Critical Care, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Ong PY, Boguniewicz J, Chu DK. Skin Antiseptics for Atopic Dermatitis: Dissecting Facts From Fiction. J Allergy Clin Immunol Pract 2023; 11:1385-1390. [PMID: 36702247 DOI: 10.1016/j.jaip.2023.01.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 01/05/2023] [Accepted: 01/10/2023] [Indexed: 01/24/2023]
Abstract
Staphylococcus aureus is a known trigger and cause of infectious complications in atopic dermatitis (AD). Various antiseptics have been used in an attempt to decrease the burden of S. aureus in AD. In this Commentary, we present the evidence for and against some of the commonly used antiseptics in clinical and research settings. These agents remain attractive as an adjunct therapy for AD owing to their relative low cost and potential benefits of reducing S. aureus. Although a number of studies have evaluated the use of dilute bleach, its mechanisms remain controversial. A higher concentration of bleach than the commonly used 0.005% is likely needed for its anti-S. aureus effect. Silver-coated textiles have demonstrated anti-S. aureus effects in various studies; however, their efficacy and side effects in AD remain to be confirmed. Other antiseptics including chlorhexidine, triclosan, and triclocarban are also discussed. Variables that may affect the outcomes of these studies include length of use, concurrent application of moisturizers, and anti-inflammatory medications.
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Affiliation(s)
- Peck Y Ong
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, Calif; Department of Pediatrics, University of Southern California Keck School of Medicine, Los Angeles, Calif.
| | - Juri Boguniewicz
- Section of Infectious Diseases, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Derek K Chu
- Department of Medicine, Evidence in Allergy Group, Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; The Research Institute of St. Joe's Hamilton, Hamilton, Ontario, Canada
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10
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DeVine MN, Maxwell S, Haynes AS, MacBrayne CE, Boguniewicz J. Management of an Immunocompromised Pediatric Patient With Multiple Hospitalizations for Symptomatic COVID-19. J Pediatr Hematol Oncol 2022; 44:e293-e295. [PMID: 33235142 DOI: 10.1097/mph.0000000000002014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Accepted: 10/22/2020] [Indexed: 11/25/2022]
Abstract
Relapse of infection due to SARS-CoV-2 has been rarely described and there is little guidance regarding the management of such cases in immunocompromised hosts. We present a case of an adolescent female with B-cell acute lymphoblastic leukemia hospitalized multiple times for symptomatic SARS-CoV-2 infection who was safely treated with 2 courses of remdesivir (RDV) and has had no additional readmissions to date. Though additional studies are needed to confirm the safety and efficacy of an additional course of RDV in the setting of relapsed or prolonged severe COVID-19, our observations suggest that a second course of RDV may be considered.
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Affiliation(s)
| | - Sarah Maxwell
- Department of Pediatrics, Section of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
| | - Andrew S Haynes
- Department of Pediatrics, Section of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
| | | | - Juri Boguniewicz
- Department of Pediatrics, Section of Pediatric Infectious Diseases, University of Colorado School of Medicine, Aurora, CO
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11
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Boguniewicz J, Revell PA, Scheurer ME, Hulten KG, Palazzi DL. Risk factors for microbiologic failure in children with Enterobacter species bacteremia. PLoS One 2021; 16:e0258114. [PMID: 34618858 PMCID: PMC8496803 DOI: 10.1371/journal.pone.0258114] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 09/17/2021] [Indexed: 12/14/2022] Open
Abstract
Background Enterobacter species are an important cause of healthcare-associated bloodstream infections (BSI) in children. Up to 19% of adult patients with Enterobacter BSI have recurrence of infection resistant to third-generation cephalosporins (3GCs) while on therapy with a 3GC. Data are lacking regarding the incidence of and risk factors for recurrence of infection in children with Enterobacter BSI. Methods We conducted a retrospective case-control study of patients aged ≤21 years old admitted to Texas Children’s Hospital from January 2012 through December 2018 with Enterobacter BSI. The primary outcome was microbiologic failure from 72 hours to 30 days after the initial BSI (cases). The secondary outcome was isolation of a 3GC non-susceptible Enterobacter sp. from a patient with an initial 3GC-susceptible isolate. Results Twelve patients (6.7%) had microbiologic failure compared to 167 controls without microbiologic failure. Of the 138 patients (77.1%) with an Enterobacter sp. isolate that was initially susceptible to 3GCs, 3 (2.2%) developed a subsequent infection with a non-susceptible isolate. Predictors of microbiologic failure were having an alternative primary site of infection besides bacteremia without a focus or an urinary tract infection (OR, 9.64; 95% CI, 1.77–52.31; P < 0.01) and inadequate source control (OR, 22.16; 95% CI, 5.26–93.36; P < 0.001). Conclusions Source of infection and adequacy of source control are important considerations in preventing microbiologic failure. In-vitro susceptibilities can be used to select an antibiotic regimen for the treatment of Enterobacter BSI in children.
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Affiliation(s)
- Juri Boguniewicz
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States of America
- * E-mail:
| | - Paula A. Revell
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, United States of America
- Department of Pathology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Michael E. Scheurer
- Department of Pediatrics, Section of Hematology/Oncology, Baylor College of Medicine, Houston, Texas, United States of America
| | - Kristina G. Hulten
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States of America
| | - Debra L. Palazzi
- Department of Pediatrics, Section of Infectious Diseases, Baylor College of Medicine, Houston, Texas, United States of America
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12
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Rao S, Kwan BM, Curtis DJ, Swanson A, Bakel LA, Bajaj L, Boguniewicz J, Lockwood JM, Ogawa K, Pemberton K, Fuhlbrigge RC, Brumbaugh D, Givens P, Nozik ES, Sills MR. Implementation of a Rapid Evidence Assessment Infrastructure during the Coronavirus Disease 2019 (COVID-19) Pandemic to Develop Policies, Clinical Pathways, Stimulate Academic Research, and Create Educational Opportunities. J Pediatr 2021; 230:4-8.e2. [PMID: 33091418 PMCID: PMC7572277 DOI: 10.1016/j.jpeds.2020.10.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 10/14/2020] [Indexed: 10/25/2022]
Affiliation(s)
- Suchitra Rao
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Epidemiology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Bethany M Kwan
- Department of Family Medicine, University of Colorado Denver - Anschutz Medical Campus, Aurora, CO
| | - Donna J Curtis
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Angela Swanson
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | - Leigh Anne Bakel
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Lalit Bajaj
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO; Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Juri Boguniewicz
- Department of Pediatrics (Infectious Diseases), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Justin M Lockwood
- Department of Pediatrics (Hospital Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Kaleigh Ogawa
- Clinical Effectiveness, Children's Hospital Colorado, Aurora, CO
| | | | - Robert C Fuhlbrigge
- Department of Pediatrics (Rheumatology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - David Brumbaugh
- Department of Pediatrics (Gastroenterology), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Patricia Givens
- Department of Nursing, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Eva S Nozik
- Department of Pediatrics (Critical Care), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO
| | - Marion R Sills
- Department of Pediatrics (Emergency Medicine), University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, CO.
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13
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Wang V, Boguniewicz J, Boguniewicz M, Ong PY. The infectious complications of atopic dermatitis. Ann Allergy Asthma Immunol 2021; 126:3-12. [PMID: 32771354 PMCID: PMC7411503 DOI: 10.1016/j.anai.2020.08.002] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/31/2020] [Accepted: 08/04/2020] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Atopic dermatitis (AD) is a chronic inflammatory skin disease that is complicated by an increased risk for skin and systemic infections. Preventive therapy for AD is based on skin barrier improvement and anti-inflammatory treatments, whereas overt skin and systemic infections require antibiotics or antiviral treatments. This review updates the pathophysiology, diagnosis, management, controversy of antibiotic use, and potential treatments of infectious complications of AD. DATA SOURCES Published literature obtained through PubMed database searches and clinical pictures. STUDY SELECTIONS Studies relevant to the mechanisms, diagnosis, management, and potential therapy of infectious complications of AD. RESULTS Skin barrier defects, type 2 inflammation, Staphylococcusaureus colonization, and cutaneous dysbiosis are the major predisposing factors for the increased infections in AD. Although overt infections require antibiotics, the use of antibiotics in AD exacerbation remains controversial. CONCLUSION Infectious complications are a comorbidity of AD. Although not common, systemic bacterial infections and eczema herpeticum can be life-threatening. Preventive therapy of infections in AD emphasizes skin barrier improvement and anti-inflammatory therapy. The use of antibiotics in AD exacerbation requires further studies.
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Affiliation(s)
- Vivian Wang
- Veterans Affairs Greater Los Angeles Healthcare System, United States Department of Veteran Affairs, Los Angeles, California
| | - Juri Boguniewicz
- Section of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Mark Boguniewicz
- Division of Allergy-Immunology, Department of Pediatrics, National Jewish Health, Denver, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - Peck Y Ong
- Division of Clinical Immunology and Allergy, Department of Pediatrics, Children's Hospital Los Angeles, Los Angeles, California; Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California.
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14
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Searns JB, Williams MC, MacBrayne CE, Wirtz AL, Leonard JE, Boguniewicz J, Parker SK, Grubenhoff JA. Handshake antimicrobial stewardship as a model to recognize and prevent diagnostic errors. Diagnosis (Berl) 2020; 8:347-352. [PMID: 33112779 DOI: 10.1515/dx-2020-0032] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 09/17/2020] [Indexed: 01/22/2023]
Abstract
OBJECTIVES Few studies describe the impact of antimicrobial stewardship programs (ASPs) on recognizing and preventing diagnostic errors. Handshake stewardship (HS-ASP) is a novel ASP model that prospectively reviews hospital-wide antimicrobial usage with recommendations made in person to treatment teams. The purpose of this study was to determine if HS-ASP could identify and intervene on potential diagnostic errors for children hospitalized at a quaternary care children's hospital. METHODS Previously self-identified "Great Catch" (GC) interventions by the Children's Hospital Colorado HS-ASP team from 10/2014 through 5/2018 were retrospectively reviewed. Each GC was categorized based on the types of recommendations from HS-ASP, including if any diagnostic recommendations were made to the treatment team. Each GC was independently scored using the "Safer Dx Instrument" to determine presence of diagnostic error based on a previously determined cut-off score of ≤1.50. Interrater reliability for the instrument was measured using a randomized subset of one third of GCs. RESULTS During the study period, there were 162 GC interventions. Of these, 65 (40%) included diagnostic recommendations by HS-ASP and 19 (12%) had a Safer Dx Score of ≤1.50, (Κ=0.44; moderate agreement). Of those GCs associated with diagnostic errors, the HS-ASP team made a diagnostic recommendation to the primary treatment team 95% of the time. CONCLUSIONS Handshake stewardship has the potential to identify and intervene on diagnostic errors for hospitalized children.
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Affiliation(s)
- Justin B Searns
- Divisions of Hospital Medicine & Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, 13123 E 16th Ave, B302, Aurora, CO 80045, USA
| | - Manon C Williams
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Christine E MacBrayne
- Department of Pharmacy, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Ann L Wirtz
- Department of Pharmacy, Children's Mercy Kansas City, Kansas City, MO, USA
| | - Jan E Leonard
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Juri Boguniewicz
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Sarah K Parker
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
| | - Joseph A Grubenhoff
- Division of Emergency Medicine, Department of Pediatrics, Children's Hospital Colorado, University of Colorado, Aurora, CO, USA
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15
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Boguniewicz J, Rubiano-Landinez A, Lamb G, Kaplan SL. 2318. Comparison of Musculoskeletal Infections Due to Non-Typhoidal Salmonella Species and Staphylococcus aureus in Immunocompetent Children. Open Forum Infect Dis 2018. [PMCID: PMC6253299 DOI: 10.1093/ofid/ofy210.1971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Non-typhoidal Salmonella species (NTS) rarely cause musculoskeletal (MSK) infections in healthy children. Data on clinical presentation and outcomes of NTS MSK infections is limited to case reports and case series. No previous studies have directly compared children with NTS MSK infections to children with MSK infections due to Staphylococcus aureus (SA), the most common cause of MSK infections in children. Methods In a retrospective case–control study children aged 1 month to 18 years seen at Texas Children’s Hospital from 2010 to 2017 with NTS MSK infections were compared with patients with SA MSK infections. Date of infection matched controls were selected 3:1. Patients with known hemoglobinopathies, immunodeficiencies or infections due to penetrating trauma or related to prosthetic devices were excluded. Logistic regression was used to evaluate associations between historical, clinical and laboratory variables and NTS or SA MSK infection. Results From 2010 to 2017, 27 cases of NST MSK infections were identified, 12 of which occurred in healthy children. The control group had 37 patients. The case and control groups had similar baseline demographics. Predictors of NTS MSK infection included exposure to reptiles (odds ratio [OR], 6.86; 95% confidence interval [CI], 1.03–45.60) and a history of preceding diarrhea (OR, 7.25; 95% CI, 1.12–47). No presenting signs or laboratory markers were identified as predictors of NTS MSK infection. Blood cultures were positive in 8 (66.7%) of the NTS MSK cases. Length of hospital stay, duration of fever or complications did not differ significantly between the two groups and children with NTS MSK infections had a low rate of complications (16.7%). Six (50%) patients with NTS infections had unremarkable evaluations for hemoglobinopathies and immunodeficiencies. Conclusion Healthy children with NTS MSK infections often report a history of reptile exposure and preceding diarrhea compared with children with MSK infections due to SA. If such history is obtained, addition of a third-generation cephalosporin to empirically cover for NST should be considered pending blood and tissue cultures. In contrast to previous case reports and case series, children with NTS MSK infections had a lower rate of complications. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Juri Boguniewicz
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | | | - Gabriella Lamb
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Sheldon L Kaplan
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
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16
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Boguniewicz J, Revell P, Palazzi D. 2313. Risk of Relapsed or Persistent Infection Caused by Enterobacter Species in Children. Open Forum Infect Dis 2018. [PMCID: PMC6253522 DOI: 10.1093/ofid/ofy210.1966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Methods Results Conclusion Disclosures
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Affiliation(s)
- Juri Boguniewicz
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Paula Revell
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Debra Palazzi
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
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17
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Foster C, Ruderfer D, Lamb G, Boguniewicz J, Rochat R, Marquez L, Palazzi D, Bocchini CE. 2305. Staphylococcus aureus Screening and Decolonization for Pediatric Patients Undergoing Cardiovascular Surgery at Texas Children’s Hospital (TCH): A Trainee Quality Improvement Initiative. Open Forum Infect Dis 2018. [PMCID: PMC6254766 DOI: 10.1093/ofid/ofy210.1958] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background Colonization with Staphylococcus aureus increases the risk of developing healthcare-associated infections (HAIs) in adults, but its role in pediatrics remains unclear. We hypothesized that use of a S. aureus screening and decolonization protocol for pediatric patients undergoing cardiovascular (CV) surgery would result in a reduction of invasive S. aureus infections. Methods A S. aureus screening and decolonization protocol (Table 1) was implemented for patients undergoing CV surgery at TCH on January 1, 2018. We retrospectively identified and reviewed charts of pediatric patients with S. aureus infections following CV surgery pre-protocol (2017) and post-protocol (January 1, 2018–March 31, 2018). We defined invasive S. aureus infections as: bacteremia, mediastinitis, superficial and deep surgical site infections (SSIs) and ventilator-associated pneumonias (VAPs). A subset of charts were reviewed pre- and post-protocol for methicillin-resistant S. aureus (MRSA) polymerase chain reaction (PCR) result, use of mupirocin and chlorhexidine gluconate (CHG), and choice of intraoperative antibiotic. Data were analyzed with Fisher’s exact. Results Of 694 pediatric CV surgery patients in 2017, we identified 13 patients with 15 invasive S. aureus infections: bacteremia (5), VAP (4), and SSI (6). Twelve of these infections were caused by methicillin-susceptible S. aureus (MSSA) and 3 were MRSA. The median time to infection was 19 days. In the first 3 month post-protocol period, there were 175 pediatric CV surgery patients with 0 invasive S. aureus infections. Seventy-five charts each were reviewed pre- and post-protocol to assess protocol adherence (Figure 1). Post-protocol MRSA screening peaked at 64%, which increased further to 70% when excluding infants <30 days. Of 40 patients screened with a MRSA PCR, only 1 (2.5%) was positive. Cefazolin use remained high pre- and post-protocol (72/75 vs. 73/75 respectively). Conclusion Most pediatric invasive S. aureus infections are caused by MSSA. Following protocol implementation, we observed a decrease in invasive S. aureus infections in CV surgery patients at TCH (P = 0.05), though continued monitoring for protocol compliance and development of S. aureus and other bacterial infections are needed. ![]()
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Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Catherine Foster
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Daniel Ruderfer
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Gabriella Lamb
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Juri Boguniewicz
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Ryan Rochat
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Lucila Marquez
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Debra Palazzi
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
| | - Claire E Bocchini
- Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas
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Hauk P, Jackson L, Krawiec M, Brugman S, Boguniewicz J, Goleva E, Leung D. Presence of Bacteria in the Lower Airways of Children with Chronic Cough and Wheezing. J Allergy Clin Immunol 2009. [DOI: 10.1016/j.jaci.2008.12.292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Hauk PJ, Krawiec M, Murphy J, Boguniewicz J, Schiltz A, Goleva E, Liu AH, Leung DYM. Neutrophilic airway inflammation and association with bacterial lipopolysaccharide in children with asthma and wheezing. Pediatr Pulmonol 2008; 43:916-23. [PMID: 18668688 DOI: 10.1002/ppul.20880] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Asthma is a leading chronic childhood illness in the US. To gain further insight into the pathophysiology of childhood asthma, we studied markers of airway inflammation and possible triggers such as bacterial lipopolysaccharide (LPS) in 18 children with chronic asthma and persistent wheezing who underwent clinically indicated bronchoscopy and bronchoalveolar lavage (BAL). We predominantly found neutrophilic airway inflammation associated with increased levels of IL-8, metalloproteinase (MMP)-9, tissue inhibitor of metalloproteinase (TIMP-1) and MMP-9/TIMP-1 ratio. A significant correlation was found between levels of LPS in BAL and airway neutrophils in BAL from a subgroup of children who had a tendency of increased levels of MMP-9 and TIMP-1, suggesting that increased LPS levels in BAL may contribute to chronic airway inflammation and early remodeling. Our data highlight the importance of defining chronic triggers of early airway inflammation in children and characterizing their inflammation, considering the use of bronchoscopy and BAL. Increased knowledge of airway inflammation in children may help prevent a more severe asthma phenotype and lead to environmental control measures and new treatment strategies to intervene against the establishment of irreversible inflammation.
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Affiliation(s)
- Pia J Hauk
- Department of Pediatrics, National Jewish Medical and Research Center, Denver, Colorado 80206, USA.
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20
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Goleva E, Hauk PJ, Boguniewicz J, Martin RJ, Leung DY. Airway remodeling and lack of bronchodilator response in steroid-resistant asthma. J Allergy Clin Immunol 2007; 120:1065-72. [PMID: 17900681 PMCID: PMC2697657 DOI: 10.1016/j.jaci.2007.07.042] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2007] [Revised: 07/26/2007] [Accepted: 07/27/2007] [Indexed: 10/22/2022]
Abstract
BACKGROUND Steroid-resistant (SR) asthma is characterized by airway inflammation that fails to resolve despite treatment with corticosteroids, raising concerns that resistance to steroid therapy in asthma could lead to airway remodeling. OBJECTIVE We sought to determine whether SR asthma is accompanied by decreased airflow reversibility and could lead to airway remodeling. METHODS Spirometric results were evaluated for 40 asthmatic patients defined as having SR or steroid-sensitive (SS) asthma on the basis of a 1-week course of oral prednisone. Twenty-three asthmatic patients underwent bronchoscopy with collection of bronchoalveolar lavage (BAL) fluid to analyze markers of airway remodeling in BAL fluid and cells. RESULTS Prednisone significantly improved FEV(1) percent predicted in SS asthma (62.0% +/- 10.9% [mean +/- SD] to 79.4% +/- 11.3%, P < .001) but not in SR asthma (66.9% +/- 10.0% to 65.9% +/- 12.1%). The bronchodilator response was significantly greater in the SS than in the SR group (Delta FEV(1) percent predicted, 33.5% +/- 22.5% vs 15.2% +/- 7.9%; P = .001), regardless of inhaled corticosteroid use. No difference in amounts of matrix metalloproteinase (MMP) 9, PMN elastase, or vascular endothelial growth factor was found in BAL fluid from both groups. Tissue inhibitor of metalloproteinases (TIMP) 1 levels were, however, significantly less in BAL fluid of patients with SR asthma compared with those in patients with SS asthma (921.9 +/- 313.4 vs 2267.0 +/- 456.8 pg/mL, P < .05), resulting in significantly higher MMP-9/TIMP-1 ratios in the BAL fluid of patients with SR asthma (0.24 +/- 0.04 vs 0.11 +/- 0.03, P < .01). Finally, dexamethasone treatment induced TIMP-1 mRNA in BAL fluid cells from patients with SS asthma (P < .01) but not in cells from patients with SR asthma. CONCLUSION Bronchodilator reversibility is impaired in SR asthma and is associated with a shift in MMP-9/TIMP-1 ratio caused by inability of steroids to enhance TIMP-1 production, potentially promoting proteolytic activity in airways of patients with SR asthma and contributing to chronic airway remodeling. CLINICAL IMPLICATIONS SR asthma might lead to irreversible airways disease.
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Affiliation(s)
- Elena Goleva
- Department of Pediatrics, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO, 80206
| | - Pia J. Hauk
- Department of Pediatrics, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO, 80206
| | - Juri Boguniewicz
- Department of Pediatrics, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO, 80206
| | - Richard J. Martin
- Department of Medicine, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO, 80206
- Department of Medicine, University of Colorado at Denver and Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262
| | - Donald Y.M. Leung
- Department of Pediatrics, National Jewish Medical and Research Center, 1400 Jackson Street, Denver, CO, 80206
- Department of Pediatrics, University of Colorado at Denver and Health Sciences Center, 4200 East Ninth Avenue, Denver, CO 80262
- Address correspondence to: Donald Y. M. Leung, MD, PhD, National Jewish Medical Research Center, 1400 Jackson Street, Room K926i, Denver, CO 802060, Tel: (303) 398-1186; FAX: (303) 270-2182; E-mail:
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