Whole-Genome Sequencing for Molecular Characterization of Carbapenem-Resistant Enterobacteriaceae Causing Lower Urinary Tract Infection among Pediatric Patients

Antibiotic resistance is a growing public health problem globally, incurring health and cost burdens. The occurrence of antibiotic-resistant bacterial infections has increased significantly over the years. Gram-negative bacteria display the broadest resistance range, with bacterial species expressing extended-spectrum β-lactamases (ESBLs), AmpC, and carbapenemases. All carbapenem-resistant Enterobacteriaceae (CRE) isolates from pediatric urinary tract infections (UTIs) between October 2015 and November 2019 (n = 30). All isolates underwent antimicrobial resistance phenotypic testing using the Phoenix NMIC/ID-5 panel, and carbapenemase production was confirmed using the NG-Test CARBA 5 assay. Whole-genome sequencing was performed on the CREs. The sequence type was identified using the Achtman multi-locus sequence typing scheme, and antimicrobial resistance markers were identified using ResFinder and the CARD database. The most common pathogens causing CRE UTIs were E. coli (63.3%) and K. pneumoniae (30%). The most common carbapenemases produced were OXA-48-like enzymes (46.6%) and NDM enzymes (40%). Additionally, one E. coli harbored IMP-26, and two K. pneumoniae possessed mutations in ompK37 and/or ompK36. Lastly, one E. coli had a mutation in the marA porin and efflux pump regulator. The findings highlight the difference in CRE epidemiology in the pediatric population compared to Qatar's adult population, where NDM carbapenemases are more common.

Level of maternal respiratory syncytial virus (RSV) F antibodies in hospitalized children and correlates of protection

BACKGROUND

Respiratory syncytial virus (RSV) is a major cause of lower respiratory infection among children and no vaccine is available. The stabilized form of the fusion (F) protein - pre-F - is a leading vaccine candidate to target different populations, including pregnant women. This study aimed to determine the magnitude and nature of RSV-directed maternal antibodies (matAbs) in hospitalized children with RSV infection.

METHODS

Sixty-five paired blood samples were collected from RSV-infected children aged <6 months and their corresponding mothers. All pairs were screened for levels of pre-F and post-F antibodies using ELISA. The neutralizing antibodies (NAbs) in both groups were measured in vitro against mKate RSV-A2 using H28 cells.

RESULTS

It was found that 14% of matAbs (log₂ 12.8) were present in infants at hospitalization, with an average log₂ EP titer of 10.2 directed to both F-protein conformations. Additionally, 61.4% of maternal NAbs (log₂ EC₅₀ = 9.4) were detected in infants (log₂ EC₅₀ = 8.7), which were mostly pre-F exclusive (81%). Pre-F antibodies in children showed a positive correlation with matAbs titers and negative correlations with age and bronchiolitis score.

CONCLUSIONS

The maintenance of neutralizing activity in infants relative to maternal titers was greater than the maintenance of antibody binding based on ELISA, suggesting that higher-potency antibodies may have a longer half-life than weakly neutralizing antibodies.

Assessment of hepatitis B immunization programme among school students in Qatar

Background

In 2010, Qatar adopted the target of reducing hepatitis B prevalence to < 1% in children by 2015. The World Health Organization Region for the Eastern Mediterranean is identified with intermediate hepatitis B virus (HBV) endemicity, ranging from 2% to 7%. It is estimated that 4.3 million individuals are living with HBV infection in the Region.

Aims

This study was conducted to assess hepatitis B seroprevalence in children, hepatitis B vaccination coverage, potential exposure to risk factors, and knowledge among parents/guardians about hepatitis B infection.

Methods

We carried out this cross-sectional study in Qatar during the academic year 2015/16. Multistage cluster sampling was used to select a nationally representative sample of 2735 grade 1 school students aged ≥ 5 years. Blood was collected by finger prick and tested using the point-of-care test/rapid test. A self-administered, precoded questionnaire was used to assess parent/guardian knowledge about HBV and collect information on the child's HBV vaccination coverage.

Results

All blood samples were HBsAg negative. Qataris had a vaccination card and were totally vaccinated but 17.7% of non-Qataris did not hold a vaccination card and most parents/guardians were not aware of the vaccination status of their children. Children were exposed to various hepatitis B risk practices. Knowledge about hepatitis B among parents/ guardians was low.

Conclusions

Qatar has averted the hepatitis B threat and maintained high vaccination coverage for children.

Molecular characterization of extended spectrum β -lactamases enterobacteriaceae causing lower urinary tract infection among pediatric population

Background

The β-lactam antibiotics have traditionally been the main treatment of Enterobacteriaceae infections, nonetheless, the emergence of species producing β- Lactamases has rendered this class of antibiotics largely ineffective. There are no published data on etiology of urinary tract infections (UTI) and antimicrobial resistance profile of uropathogens among children in Qatar. The aim of this study is to determine the phenotypic and genotypic profiles of antimicrobial resistant Enterobacteriaceae among children with UTI in Qatar.

Methods

Bacteria were isolated from 727 urine positive cultures, collected from children with UTI between February and June 2017 at the Pediatric Emergency Center, Doha, Qatar. Isolated bacteria were tested for antibiotic susceptibility against sixteen clinically relevant antibiotics using phoenix and Double Disc Synergy Test (DDST) for confirmation of extended-spectrum beta-lactamase (ESBL) production. Existence of genes encoding ESBL production were identified using polymerase chain reaction (PCR). Statistical analysis was done using non-parametric Kappa statistics, Pearson chi-square test and Jacquard's coefficient.

Results

201 (31.7%) of samples were confirmed as Extended Spectrum β -Lactamases (ESBL) Producing Enterobacteriaceae. The most dominant pathogen was E. coli 166 (83%) followed by K. pneumoniae 22 (11%). Resistance was mostly encoded by ^bla CTX-M (59%) genes, primarily ^bla CTX-MG1 (89.2%) followed by ^bla CTX-MG9 (7.7%). 37% of isolated bacteria were harboring multiple ^bla genes (2 genes or more). E. coli isolates were categorized into 11 clusters, while K. pneoumoniae were grouped into five clonal clusters according to the presence and absence of seven genes namely ^bla TEM, ^bla SHV, ^bla CTX-MG1, ^bla CTX-MG2, ^bla CTX-MG8 ^bla CTX-MG9,^bla CTX-MG25.

Conclusions

Our data indicates an escalated problem of ESBL in pediatrics with UTI, which mandates implementation of regulatory programs to reduce the spread of ESBL producing Enterobacteriaceae in the community. The use of cephalosporins, aminoglycosides (gentamicin) and trimethoprim/sulfamethoxazole is compromised in Qatar among pediatric population with UTI, leaving carbapenems and amikacin as the therapeutic option for severe infections caused by ESBL producers.

Molecular Analysis of the Enteric Protozoa Associated with Acute Diarrhea in Hospitalized Children

Pediatric diarrhea is a common cause of death among children under 5 years of age. In the current study, we investigated the frequency of intestinal parasites among 580 pediatric patients with chronic diarrhea. Parasitic protozoa (all species combined) were detected by molecular tools in 22.9% of the children and the most common parasite was Cryptosporidium spp. (15.1%). Blastocystis hominis was detected in 4.7%, Dientamoeba fragilis in 4%, Giardia duodenalis in 1.7%, and Entamoeba histolytica in 0.17%. Protozoan infections were observed among all regional groups, but prevalence was highest among Qatari subjects and during the winter season. Typing of Cryptosporidium spp. revealed a predominance of Cryptosporidium parvum in 92% of cases with mostly the IIdA20G1 subtype. Subtypes IIdA19G2, IIdA18G2, IIdA18G1, IIdA17G1, IIdA16G1, and IIdA14G1 were also detected. For Cryptosporidium hominis, IbA10G2 and IbA9G3 subtypes were identified. This study provides supplementary information for implementing prevention and control strategies to reduce the burden of these pediatric protozoan infections. Further analyses are required to better understand the local epidemiology and transmission of Cryptosporidium spp. in Qatar.

Neonatal visits to the pediatric emergency center and its implications on postnatal discharge practices in qatar

BACKGROUND

An early discharge from postnatal policy has been practiced at Women's Hospital, Hamad Medical Corporation.

AIM

This observational cohort study was conducted to evaluate the effect of early postnatal discharge practice on neonatal morbidity in the State of Qatar.

SETTING AND DESIGN

This is a data-based cohort study. All neonates ≤28 days visiting the Pediatric Emergency Centers (PEC) were evaluated for the need for re-hospitalization, referral for clinic appointments, or observation at the PEC setting.

MATERIALS AND METHODS

Differences in outcome rates were compared in neonates who visited in the first 24 hours postnatal discharge (2-3 days of life) and those who visited after the third day of life.

STATISTICAL ANALYSIS

Crude differences in incidence rate assessed by χ(2) or Fisher exact test were applicable.

RESULTS

Of 3528 PEC visits for 1915 neonates, 1.7% required admission (3.1% of neonates), 8.4% were observed, 1.1% were referred to a clinic, and the remaining were discharged home. There was no significant difference in re-hospitalization rates of neonates visiting PEC in the first 3 days and those visiting at a later age (OR 0.78, 95% CL 0.19-3.23, P=1). However, early presentations to PEC was more likely to result in periods of observation (OR 1.88, 95% CL 1.17-3.04, P=0.01), or clinic referral (OR 4.96, 95% CL 2.16-11.38, P=0.001) when compared to older neonates. Moreover, those who presented early were significantly more likely to revisit any of the PECs with in the 28 days period (OR 3.20, 95% CL 2.17-4.97, P<0.0001).

CONCLUSION

These results clearly demonstrate the need for a structured early post-discharge follow-up service that addresses the needs of all neonates and their families. The results, however, do not provide sufficient evidence that delaying postnatal discharges for apparently healthy neonates will provide significant health benefits to these neonates and their families.

Life-threatening cardiac arrhythmia after a single dose of nebulized epinephrine in pediatric emergency department

Cardiac adverse effects are not commonly reported complications of nebulized epinephrine therapy. We present a case of critical cardiac arrhythmia developed at the Pediatric Emergency Department in an otherwise healthy infant after receiving 3 mg of L-epinephrine (1:1000) nebulization over a 90 min period for a diagnosis of bronchiolitis. Unstable ventricular tachycardia was found after the nebulization therapy that required chemical cardioversion. Frequent premature ventricular contractions (PVCs) were found initially following the cardiac insult that was controlled with oral amiodarone, and disappeared during follow-up. Although epinephrine inhalation is generally safe, adverse life-threatening events could be unpredictable and may evolve even after a single dose of nebulized epinephrine.

Nebulized 5% or 3% hypertonic or 0.9% saline for treating acute bronchiolitis in infants

OBJECTIVE

To compare the efficacy and safety of 5%, 3%, and 0.9% saline solution for treating acute bronchiolitis in the prehospital setting.

STUDY DESIGN

This was a double-blind trial including consecutive infants aged <18 months treated in an urban urgent care setting. A total of 165 patients were randomized to receive nebulized 5%, 3%, or 0.9% (normal) saline with epinephrine every 4 hours. The primary efficacy outcome was bronchiolitis severity score improvement at 48 hours (chi2 analysis). Scores and oxygen saturation immediately before and after each treatment were recorded to assess safety.

RESULTS

A total of 187 previously healthy infants (median age, 3.1 months) diagnosed with bronchiolitis were enrolled. Positivity for respiratory syncytial virus was similar in the 3 treatment groups (mean, 56%). At 48 hours, the mean severity score for the 5% saline group was 3.69+/-1.09, and that for the 0.9% saline group was 4.12+/-1.11 (P=.04; difference, 0.43, 95% confidence interval for the difference, 0.02-0.88). The mean severity score for the 3% saline group was intermediate at 4.00+/-1.22. Revisit rates after discharge were similar in the 3 treatment groups. No adverse reactions or other safety concerns were identified.

CONCLUSIONS

Nebulization with 5% hypertonic saline is safe, can be widely generalizable, and may be superior to current treatment for early outpatient treatment of bronchiolitis.

Analgesia and sedation practices for incarcerated inguinal hernias in children

In this study, the use of medications for analgesia and/or sedation for incarcerated inguinal hernia reductions in the emergency department was analyzed. A retrospective chart review was conducted for all patients presenting to a pediatric emergency department with incarcerated inguinal hernia from 2002 to 2005. A total of 99 children presented with incarcerated hernias during the study period. The median age was 11 months. Forty-four percent of children received medication for the procedure, of them 75% received parenteral and 25% oral or intranasal medications. Forty-five percent of children who received medication went through at least 1 hernia reduction attempt initially without medications. More than half the children with incarcerated inguinal hernias did not receive any medication for pain and/or sedation prior to hernia reduction. Guidelines for medication use for children with incarcerated inguinal hernias need to be developed.

Minimally angulated pediatric wrist fractures: is immobilization without manipulation enough?

BACKGROUND

Emergency department (ED) manipulation of complete minimally angulated distal radius fractures in children may not be necessary, due to the excellent remodeling potential of these fractures.

OBJECTIVES

The primary objective of this study was to determine the proportion of minimally angulated distal radius fractures managed in the ED with plaster immobilization that subsequently required manipulation. Our secondary objective was to document, at follow-up, changes in angulation for each wrist fracture.

METHODS

This retrospective cohort study reviewed consecutive records of all children with bi-cortical minimally angulated (</=15 degrees of angulation in the sagittal plane and </=0.5 cm of displacement) distal metaphyseal radius fractures, alone or in combination with distal ulnar fracture. Details of treatment, radiographic findings, and clinical outcomes during the subsequent orthopedic follow up were recorded.

RESULTS

Of 124 patients included in the analysis, none required manipulation after their ED visit. All but 14 (11.3%) fractures were angulated </=20 degrees within the follow-up period. Two (1.6%) fractures that were initially angulated </=15 degrees progressed to 30 degrees -35 degrees , but remodeled within 2 years to nearly perfect anatomic alignment. By 6 weeks post-injury, no patients had clinically apparent deformity and all had normal function.

CONCLUSIONS

Minimally angulated fractures of the distal metaphyseal radius managed in plaster immobilization without reduction in the ED are unlikely to require future surgical intervention.