Adjunctive Diagnostic Studies Completed Following Detection of Candidemia in Children: Secondary Analysis of Observed Practice From a Multicenter Cohort Study Conducted by the Pediatric Fungal Network

BACKGROUND

Adjunctive diagnostic studies (aDS) are recommended to identify occult dissemination in patients with candidemia. Patterns of evaluation with aDS across pediatric settings are unknown.

METHODS

Candidemia episodes were included in a secondary analysis of a multicenter comparative effectiveness study that prospectively enrolled participants age 120 days to 17 years with invasive candidiasis (predominantly candidemia) from 2014 to 2017. Ophthalmologic examination (OE), abdominal imaging (AbdImg), echocardiogram, neuroimaging, and lumbar puncture (LP) were performed per clinician discretion. Adjunctive diagnostic studies performance and positive results were determined per episode, within 30 days from candidemia onset. Associations of aDS performance with episode characteristics were evaluated via mixed-effects logistic regression.

RESULTS

In 662 pediatric candidemia episodes, 490 (74%) underwent AbdImg, 450 (68%) OE, 426 (64%) echocardiogram, 160 (24%) neuroimaging, and 76 (11%) LP; performance of each aDS per episode varied across sites up to 16-fold. Longer durations of candidemia were associated with undergoing OE, AbdImg, and echocardiogram. Immunocompromised status (58% of episodes) was associated with undergoing AbdImg (adjusted odds ratio [aOR] 2.38; 95% confidence intervals [95% CI] 1.51-3.74). Intensive care at candidemia onset (30% of episodes) was associated with undergoing echocardiogram (aOR 2.42; 95% CI 1.51-3.88). Among evaluated episodes, positive OE was reported in 15 (3%), AbdImg in 30 (6%), echocardiogram in 14 (3%), neuroimaging in 9 (6%), and LP in 3 (4%).

CONCLUSIONS

Our findings show heterogeneity in practice, with some clinicians performing aDS selectively, potentially influenced by clinical factors. The low frequency of positive results suggests that targeted application of aDS is warranted.

AN 8-YEAR-OLD CALIFORNIA GIRL WITH ASYMPTOMATIC HEPATIC CYSTS

Echinococcus infections are rare in the United States but may present a growing public health threat. We present the case of an 8-year-old female patient from Southern California who was diagnosed with hepatic echinococcosis after the incidental discovery of large hepatic cysts.

Pediatric Osteoarticular Infections Caused by Mycobacteria Tuberculosis Complex: A 26-Year Review of Cases in San Diego, CA

BACKGROUND

Osteoarticular infections (OAIs) account for 10%-20% of extrapulmonary Mycobacteria tuberculosis (MTB) complex infections in children and 1%-2% of all pediatric tuberculosis infections. Treatment regimens and durations typically mirror recommendations for other types of extrapulmonary MTB, but there are significant variations in practice, with some experts suggesting a treatment course of 12 months or longer.

METHODS

We conducted a retrospective review of children diagnosed with MTB complex OAI and cared for between December 31, 1992, and December 31, 2018, at a tertiary care pediatric hospital near the United States-Mexico border.

RESULTS

We identified 21 children with MTB complex OAI during the study period. Concurrent pulmonary disease (9.5%), meningitis (9.5%), and intra-abdominal involvement (14.3%) were all observed. MTB complex was identified by culture from operative samples in 15/21 children (71.4%); 8/15 (53.3%) cultures were positive for Mycobacterium bovis. Open bone biopsy was the most common procedure for procurement of a tissue sample and had the highest culture yield. The median duration of antimicrobial therapy was 52 weeks (interquartile range, 46-58). Successful completion of therapy was documented in 15 children (71.4%). Nine children (42.9%) experienced long-term sequelae related to their infection.

CONCLUSION

Among the 21 children with MTB complex OAI assessed, 8 of 15 (53.3%) children with a positive tissue culture had M. bovis, representing a higher percentage than in previous reports and potentially reflecting its presence in unpasteurized dairy products in the California-Baja region. Bone biopsy produced the highest culture yield in this study. Given the rarity of this disease, multicenter collaborative studies are needed to improve our understanding of the presentation and management of pediatric MTB complex OAI.

Multicenter Prospective Study of Biomarkers for Diagnosis of Invasive Candidiasis in Children and Adolescents

BACKGROUND

Diagnosis of invasive candidiasis (IC) relies on insensitive cultures; the relative utility of fungal biomarkers in children is unclear.

METHODS

This multinational observational cohort study enrolled patients aged >120 days and <18 years with concern for IC from 1 January 2015 to 26 September 2019 at 25 centers. Blood collected at onset of symptoms was tested using T2Candida, Fungitell (1→3)-β-D-glucan, Platelia Candida Antigen (Ag) Plus, and Platelia Candida Antibody (Ab) Plus assays. Operating characteristics were determined for each biomarker, and assays meeting a defined threshold considered in combination. Sterile site cultures were the reference standard.

RESULTS

Five hundred participants were enrolled at 22 centers in 3 countries, and IC was diagnosed in 13 (2.6%). Thirteen additional blood specimens were collected and successfully spiked with Candida species, to achieve a 5.0% event rate. Valid T2Candida, Fungitell, Platelia Candida Ag Plus, and Platelia Candida Ab Plus assay results were available for 438, 467, 473, and 473 specimens, respectively. Operating characteristics for T2Candida were most optimal for detecting IC due to any Candida species, with results as follows: sensitivity, 80.0% (95% confidence interval, 59.3%-93.2%), specificity 97.1% (95.0%-98.5%), positive predictive value, 62.5% (43.7%-78.9%), and negative predictive value, 98.8% (97.2%-99.6%). Only T2Candida and Platelia Candida Ag Plus assays met the threshold for combination testing. Positive result for either yielded the following results: sensitivity, 86.4% (95% confidence interval, 65.1%- 97.1%); specificity, 94.7% (92.0%-96.7%); positive predictive value, 47.5% (31.5%-63.9%); and negative predictive value, 99.2% (97.7%-99.8%).

CONCLUSIONS

T2Candida alone or in combination with Platelia Candida Ag Plus may be beneficial for rapid detection of Candida species in children with concern for IC.

CLINICAL TRIALS REGISTRATION

NCT02220790.

1150. Pediatric Osteoarticular Infections Caused by Mycobacteria Tuberculosis Complex: A Twenty-Six Year Review of Cases in San Diego, California

Background

Osteoarticular infections (OAI) account for 10-20% of extrapulmonary Mycobacteria tuberculosis (MTB) complex infections in children. Given the rarity of MTB OAI, the epidemiology, disease manifestations, and treatment are poorly characterized. We describe 21 children treated for MTB complex OAI over a 26-year period at a tertiary pediatric center in southern California.

Methods

We conducted a retrospective review of children diagnosed with MTB complex OAI and cared for between 31 Dec 1992 to 31 Dec 2018 at a single tertiary care pediatric hospital with close proximity to the United States-Mexico border.

Results

We identified 21 children with MTB complex OAI during the study period (Table 1). Concurrent pulmonary disease (4.8%), meningitis (9.5%), and intra-abdominal involvement (14.3%) were all observed. MTB complex was identified by culture from operative samples in 15/21 children (71.4%); 8/15 (51.3%) cultures were positive for Mycobacterium bovis. Of the eight cases of vertebral OAI (the most common site), one was culture-positive for M. bovis. Open bone biopsy was the most common procedure for procurement of a tissue sample and had the highest culture yield (Table 2). The median duration of antimicrobial therapy was 52 weeks (IQR 52-58). Successful completion of therapy was documented in 15 children (71.4%). Seven children (33.3%) experienced long term sequelae related to their infection.

Table 1. Twenty-one children with Mycobacteria tuberculosis complex osteoarticular infections.

Table 2. Surgical sample type and percent positivity.

Conclusion

Among the 21 children with MTB complex OAI assessed, 8 of 15 (53.3%) children with a positive tissue culture had M. bovis (intrinsically resistant to pyrazinamide), representing a higher percentage than in previous reports and potentially reflecting its presence in unpasteurized dairy products in the California-Baja region. Local epidemiological trends in endemic MTB complex species should be considered when evaluating and managing MTB complex OAI. Bone biopsy produced the highest culture yield in this study. Given the rarity of this disease, multicenter collaborative studies are needed to improve our understanding of the presentation and management of pediatric MTB complex OAI.

Disclosures

Vanessa Raabe, MD, MSc, Pfizer (Scientific Research Study Investigator, Other Financial or Material Support, Editorial support)Sanofi (Scientific Research Study Investigator)

Comparison of Reverse-Transcription Polymerase Chain Reaction Cycle Threshold Values From Respiratory Specimens in Symptomatic and Asymptomatic Children With Severe Acute Respiratory Syndrome Coronavirus 2 Infection

BACKGROUND

Understanding viral kinetics of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is important to assess risk of transmission, manage treatment, and determine the need for isolation and protective equipment. The impact of viral load in asymptomatic infected children is important to understand transmission potential. We sought to determine whether children deemed to be asymptomatic had a difference in the polymerase chain reaction (PCR) cycle threshold (Ct) value of respiratory samples from symptomatic children with SARS-CoV-2 infection.

METHODS

This was a retrospective cross-sectional study to compare PCR Ct values of children who tested positive for SARS-CoV-2 by respiratory samples collected over a 4-month period at a large tertiary care children's hospital.

RESULTS

We analyzed 728 children who tested positive for SARS-CoV-2 by reverse-transcription PCR (RT-PCR) from a respiratory sample over a 4-month period and for whom data were available in the electronic medical record. Overall, 71.2% of infected children were symptomatic. The mean Ct value for symptomatic patients (Ct mean, 19.9 [standard deviation, 6.3]) was significantly lower than for asymptomatic patients (Ct mean, 23.5 [standard deviation, 6.9]) (P < .001; 95% confidence interval, 2.6-4.6). The mean PCR Ct value was lowest in children <5 years of age.

CONCLUSIONS

In this retrospective review of children who tested positive by RT-PCR for SARS-CoV-2, the mean Ct was significantly lower in symptomatic children and was lowest in children <5 years of age, indicating that symptomatic children and younger children infected with SARS-CoV-2 may have a higher viral load in the nasopharynx compared to asymptomatic children. Further studies are needed to assess the transmission potential from asymptomatic children.

Mediators of the effect of ertugliflozin on a composite kidney outcome in patients with type 2 diabetes and atherosclerotic cardiovascular disease: analyses from VERTIS CV

Introduction

Sodium–glucose cotransporter 2 (SGLT2) inhibitors have been shown to slow the decline of kidney function in outcome trials, but the biological mediator(s) underlying the therapeutic benefit are not well established.

Purpose

We performed a post-hoc analysis exploring potential mediators of the effects of the SGLT2 inhibitor ertugliflozin on the VERTIS CV exploratory kidney composite outcome (sustained 40% decrease from baseline in estimated glomerular filtration rate [eGFR], chronic kidney replacement therapy or kidney death).

Methods

In VERTIS CV, 8246 participants with type 2 diabetes mellitus and established atherosclerotic cardiovascular disease were randomised to placebo, ertugliflozin 5 mg or 15 mg (pooled for analyses, as prospectively planned), and were followed for a mean of 3.5 years. The hazard ratio (HR; 95% confidence interval) for the pre-specified exploratory kidney composite outcome was 0.66 (0.50, 0.88). Cox regression models were used to evaluate covariates that were significantly differentially changed from baseline with ertugliflozin treatment as candidate mediators, with a mediator identified as a covariate when added to an unadjusted model of randomised treatment assignment a) yielded a larger hazard ratio; and b) the mediator retained P&lt;0.05 in the model (eGFR was excluded as a covariate). The percentage of mediation was determined by the proportional increase in the HR between the unadjusted and adjusted models for each post-randomisation period: early (first change from baseline measurement) and average (weighted average of change from baseline from all post-baseline measurements). Each potential mediator was tested individually, so across analyses, mediation % sums to &gt;100%.

Results

Of 22 covariates significantly changed by ertugliflozin, nine were identified as potential mediators (Table). The covariates with a high percentage of mediation were those related to changes in blood erythrocytes (haemoglobin, haematocrit and red blood cell mass), with average changes in haemoglobin having the highest percentage of mediation (61.8%). Serum uric acid was associated with a mediation of 29.4% and 50.0% for the early and average post-randomisation effect periods, respectively. Early changes in glycated haemoglobin had a large mediation (50%), but the average change during the trial was not significant. Average change in serum albumin had a large mediation (29.4%). Average changes in body weight and systolic blood pressure had percentages of mediation of 41.2% and 14.7%, respectively.

Conclusion

Multiple factors may be involved in the reduction of the kidney composite outcome observed with ertugliflozin. In the short-term, changes in glycaemia had a high mediation effect. Over the long-term, changes suggestive of haemoconcentration and/or haematopoiesis (natriuresis-related effects), showed the highest percentage of mediation, followed by changes in serum uric acid and body weight (glucosuria-related effects).

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Sponsored by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA in collaboration with Pfizer Inc., New York, NY, USA

Mediation analyses of the effect of ertugliflozin on hospitalisation for heart failure in patients with type 2 diabetes and atherosclerotic cardiovascular disease from the VERTIS CV trial

Introduction

Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce risk of hospitalisation for heart failure (HHF) in outcome trials, but the biological mediators underlying the therapeutic benefit are not well established.

Purpose

To identify potential biological mediators through which ertugliflozin reduces risk of HHF.

Methods

In VERTIS CV, 8246 patients with type 2 diabetes and atherosclerotic cardiovascular disease were randomised to ertugliflozin 5 or 15 mg (observations pooled as prospectively planned) or placebo. Cox regression models were used to evaluate the associations between changes in 26 potential mediators with outcomes. Potential mediators were selected based on proposed mechanisms and/or differential change from baseline with SGLT2 inhibitors. Mediation criteria required 1) significant (P&lt;0.05 for change from baseline) effects of ertugliflozin vs placebo on each potential mediator; and 2) significant (P&lt;0.05) association of change in post-randomisation levels of the potential mediator with risk of HHF when added to an unadjusted model of randomised treatment assignment. Percent mediation was determined by comparing the unadjusted hazard ratio and hazard ratio adjusted for change in the potential mediator of interest. Each covariate was tested individually, such that percent mediation across the analyses summed to &gt;100%. Time-dependent models were used to evaluate associations between early (change from baseline for the first post-baseline measurement) and average (weighted average of change from baseline using all post-baseline measurements) changes in covariates with clinical outcomes.

Results

Over a mean of 3.5 years, the incidence rate of HHF was 0.7 and 1.1 per 100 patient-years with ertugliflozin and placebo, respectively. Among 26 candidate mediators, 9 and 13 met the mediation criteria based on early and average changes, respectively. The 3 covariates with the largest mediating effects of early changes included haematocrit (40%), haemoglobin (27%) and HDL-C (23%) (Table); other significant biomarkers included urine albumin/creatinine ratio, and serum albumin, uric acid, chloride, protein and sodium. The 3 biomarkers with the largest mediating effects in average changes included haemoglobin (63%), albumin (50%) and uric acid (47%) (Table); other significant biomarkers included haematocrit, urine albumin/creatinine ratio, body weight, serum protein and chloride, systolic blood pressure, ALT, BUN, eGFR and heart rate.

Conclusions

In these analyses from the VERTIS CV trial, potential markers of volume status and haemoconcentration and/or haematopoiesis were the strongest mediators of the effect of ertugliflozin on reducing risk of HHF in the early and average change periods. Other potential mediators included uric acid, lipid markers and kidney parameters. These findings provide insights into potential mechanisms through which ertugliflozin, and potentially the SGLT2 inhibitor class, may prevent HHF.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Sponsored by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA, and Pfizer Inc., New York, NY, USA.

Comparison of RT-PCR Cycle Threshold Values from Respiratory Specimens in Symptomatic and Asymptomatic Children with SARS-CoV-2 Infection

BACKGROUND

Understanding viral kinetics of SARS-CoV-2 is important to assess risk of transmission, manage treatment, and determine the need for isolation and protective equipment. The impact of viral load in asymptomatic infected children is important to understand transmission potential. We sought to determine whether children deemed to be asymptomatic had a difference in the PCR cycle threshold (Ct) value of respiratory samples from symptomatic children with SARS-CoV-2 infection.

METHODS

This was a retrospective cross-sectional study to compare PCR Ct values of children who tested positive for SARS-CoV-2 by respiratory samples collected over a 4-month period at a large tertiary care children's hospital.

RESULTS

We analyzed 728 children who tested positive for SARS-CoV-2 by RT-PCR from a respiratory sample over a 4-month period and for whom data was available in the electronic medical record. Overall, 71.2% of infected children were symptomatic. The mean Ct value for symptomatic patients (Ct mean 19.9, SD 6.3) was significantly lower than asymptomatic patients (Ct mean 23.5, SD 6.5) (P value < 0.001, CI 95th 2.6 - 4.6). The mean PCR Ct value was lowest in children less than 5 years of age.

CONCLUSIONS

In this retrospective review of children who tested positive by RT-PCR for SARS CoV-2, the mean Ct was significantly lower in symptomatic children and was lowest in children under 5 years of age, indicating that symptomatic children and younger children infected with SARS-CoV-2 may have a higher viral load in the nasopharynx compared to asymptomatic children. Further studies are needed to assess the transmission potential from asymptomatic children.

Early changes in bone turnover and bone mineral density after discontinuation of long-term oral bisphosphonates: a post hoc analysis

This post hoc analysis of a randomized, double-blind study of postmenopausal women with osteoporosis found that there were early increases in bone turnover markers and decreases in bone mineral density after discontinuation of long-term alendronate. These findings might help guide treatment decisions, including monitoring after alendronate withdrawal.

INTRODUCTION

The short-term effects of discontinuing long-term bisphosphonates are poorly characterized. This post hoc analysis investigated 1-12-month changes in bone mineral density (BMD) and bone turnover markers (BTM) after alendronate (ALN) discontinuation.

METHODS

Data were from a randomized, double-blind trial of MK-5442 (calcium-sensing receptor antagonist) following oral bisphosphonates, with placebo and continued ALN controls ( ClinicalTrials.gov NCT00996801). Postmenopausal women with osteoporosis had received oral bisphosphonate (≥ 3-4 preceding years; ALN for the 12 months pre-screening), continuing on ALN 70 mg/week (n = 87) or placebo (n = 88).

RESULTS

At 12 months, least-squares mean percent changes from baseline BMD (placebo vs. ALN) were lumbar spine (LS): - 0.36 vs. 1.29, total hip: - 1.44 vs. 0.46, and femoral neck (FN): - 1.26 vs. - 0.08 (all P < 0.05). BTM levels increased by 1-3 months, to 12 months, with placebo vs. ALN (P < 0.001). FN BMD decline was greater in the placebo subgroup with higher urinary N-terminal cross-linked telopeptides of type I collagen/creatinine [uNTx/Cr] (P < 0.01), and higher serum N-terminal pro-peptide of type 1 collagen [P1NP] levels (P < 0.05), at baseline. There was a trend toward greater FN BMD loss with higher BTM levels at 3 and/or 6 months. Younger age and higher LS BMD at baseline were associated with greater LS BMD loss at 12 months (P = 0.04 and < 0.01, respectively); higher baseline FN BMD predicted greater FN BMD loss (P = 0.04).

CONCLUSION

Early changes in BTM levels and BMD were observed after discontinuation of long-term ALN. Further characterization of factors associated with patients' risk of bone loss upon bisphosphonate discontinuation is warranted.

Comparative Effectiveness of Echinocandins vs Triazoles or Amphotericin B Formulations as Initial Directed Therapy for Invasive Candidiasis in Children and Adolescents

BACKGROUND

Invasive candidiasis is the most common invasive fungal disease in children and adolescents, but there are limited pediatric-specific antifungal effectiveness data. We compared the effectiveness of echinocandins to triazoles or amphotericin B formulations (triazole/amphotericin B) as initial directed therapy for invasive candidiasis.

METHODS

This multinational observational cohort study enrolled patients aged >120 days and <18 years with proven invasive candidiasis from January 1, 2014, to November 28, 2017, at 43 International Pediatric Fungal Network sites. Primary exposure was initial directed therapy administered at the time qualifying culture became positive for yeast. Exposure groups were categorized by receipt of an echinocandin vs receipt of triazole/amphotericin B. Primary outcome was global response at 14 days following invasive candidiasis onset, adjudicated by a centralized data review committee. Stratified Mantel-Haenszel analyses estimated risk difference between exposure groups.

RESULTS

Seven-hundred and fifty invasive candidiasis episodes were identified. After exclusions, 541 participants (235 in the echinocandin group and 306 in the triazole/amphotericin B group) remained. Crude failure rates at 14 days for echinocandin and triazole/amphotericin B groups were 9.8% (95% confidence intervals [CI]: 6.0% to 13.6%) and 13.1% (95% CI: 9.3% to 16.8%), respectively. The adjusted 14-day risk difference between echinocandin and triazole/amphotericin B groups was -7.1% points (95% CI: -13.1% to -2.4%), favoring echinocandins. The risk difference was -0.4% (95% CI: -7.5% to 6.7%) at 30 days.

CONCLUSIONS

In children with invasive candidiasis, initial directed therapy with an echinocandin was associated with reduced failure rate at 14 days but not 30 days. These results may support echinocandins as initial directed therapy for invasive candidiasis in children and adolescents.

CLINICAL TRIALS REGISTRATION

NCT01869829.

Clinical application of cell-free next-generation sequencing for infectious diseases at a tertiary children's hospital

Background

Children affected by infectious diseases may not always have a detectable infectious etiology. Diagnostic uncertainty can lead to prolonged hospitalizations, inappropriately broad or extended courses of antibiotics, invasive diagnostic procedures, and difficulty predicting the clinical course and outcome. Cell-free plasma next-generation sequencing (cfNGS) can identify viral, bacterial, and fungal infections by detecting pathogen DNA in peripheral blood. This testing modality offers the ability to test for many organisms at once in a shotgun metagenomic approach with a rapid turnaround time. We sought to compare the results of cfNGS to conventional diagnostic test results and describe the impact of cfNGS on clinical care in a diverse pediatric population at a large academic children’s hospital.

Methods

We performed a retrospective chart review of hospitalized subjects at a tertiary pediatric hospital to determine the diagnostic yield of cfNGS and its impact on clinical care.

Results

We describe the clinical application of results from 142 cfNGS tests in the management of 110 subjects over an 8-month study period. In comparison to conventional testing as a reference standard, cfNGS was found to have a positive percent agreement of 89.6% and negative percent agreement of 52.3%. Furthermore, 32.4% of cfNGS results were directly applied to make a clinical change in management.

Conclusions

We demonstrate the clinically utility of cfNGS in the management of acutely ill children. Future studies, both retrospective and prospective, are needed to clarify the optimal indications for testing.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06292-4.

Use of Plasma Metagenomic Next-generation Sequencing for Pathogen Identification in Pediatric Endocarditis

Pediatric infective endocarditis incurs significant morbidity and generally occurs among children with underlying heart disease. Identification of a pathogen is critical in determining appropriate therapy. However, standard diagnostic testing has limited sensitivity. We describe a case series of children with infective endocarditis in whom plasma next-generation sequencing (Karius, Redwood, CA) identified an organism in 8 of 10 cases.

Management and outcomes of pediatric septic thrombophlebitis: a case series

Septic thrombophlebitis is a potentially life-threatening condition. Pediatric hematologists are often consulted to provide recommendations regarding anticoagulation management. We conducted a ten-year retrospective, single-center study of hospitalized pediatric patients who were treated for septic thrombophlebitis. Our primary outcome was resolution of thrombophlebitis. Twenty-eight patients were included in the study. Eighty-nine percent of patients received both antibiotic and anticoagulation therapy. The median durations of intravenous and total antibiotic therapy were 47.5 days (range 14-120) and 65 days (range 14-281), respectively, and median duration of anticoagulation therapy was 92 days (range 41-268). Resolution of thrombosis defined by magnetic resonance imaging, computed tomography, or ultrasound imaging was documented in 16 of 28 (57%) patients. Despite the high rate of persistent thrombosis, there was a low risk of relapse of infection in cases where antibiotic and/or anticoagulation was discontinued prior to complete resolution of the thrombus. Further research is needed to determine if duration of antibiotic and/or anticoagulation treatment can be shortened.

Community-acquired pneumonia in children: cell-free plasma sequencing for diagnosis and management

Community-acquired pneumonia (CAP) is a common cause of pediatric hospital admission. Empiric antibiotic therapy for hospitalized children with serious CAP now targets the most likely pathogen(s), including those that may demonstrate significant antibiotic resistance. Cell-free plasma next-generation sequencing (CFPNGS) was first made available for Pediatric Infectious Diseases physicians in June 1, 2017, to supplement standard-of-care diagnostic techniques. A retrospective chart review was performed for children hospitalized with CAP between June 1, 2017, and January 22, 2018, to evaluate the impact of CFPNGS. We identified 15 hospitalized children with CAP without other underlying medical conditions for whom CFPNGS was performed. CFPNGS identified a pathogen in 13 of 15 (86%) children compared with 47% for those using standard culture and PCR-based methods alone. Changes in antibiotic management were made in 7 of 15 (47%) of children as a result of CFPNGS.

Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS): A Quality Improvement Collaborative

BACKGROUND

Although many children's hospitals have established antimicrobial stewardship programs (ASPs), data-driven benchmarks for optimizing antimicrobial use across centers are lacking. We developed a multicenter quality improvement collaborative focused on sharing data reports and benchmarking antimicrobial use to improve antimicrobial prescribing among hospitalized children.

METHODS

A national antimicrobial stewardship collaborative among children's hospitals, Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS), was established in 2013. Characteristics of the hospitals and their ASPs were obtained through a standardized survey. Antimicrobial-use data reports were developed on the basis of input from the participating hospitals. Collaborative learning opportunities were provided through monthly webinars and annual meetings.

RESULTS

Since 2013, 36 US hospitals have participated in the SHARPS collaborative. The median full-time equivalent (pharmacist and physician) dedicated to 30 of these ASPs was 0.75 (interquartile range, 0.45-1.4). To date, the collaborative has developed 26 data reports that include benchmarking reports according to specific antimicrobial agents, indications, and clinical service lines. The collaborative has conducted 27 webinars and 3 in-person meetings to highlight the stewardship work being conducted in the hospitals. The data reports and learning opportunities have resulted in approximately 36 distinct stewardship interventions.

CONCLUSION

A pediatric antimicrobial stewardship collaborative has been successful in promoting the development of and innovation among pediatric ASPs. Additional research is needed to determine the impact of these efforts.

Predictors of Clostridium difficile infections in hospitalized children

BACKGROUND

Recent studies report an increasing incidence of Clostridium difficile infections (CDIs) in children and suggest that CDIs may occur outside known populations at risk.

OBJECTIVE

To identify clinical factors associated with CDI in a hospitalized pediatric population.

METHODS

A retrospective case-control study was conducted with C difficile cases (CD) and controls (CTLs) in hospitalized children over a 2-year period. CDs (N = 134) and 2:1 age-matched CTLs (N = 274) with diarrheal illness were evaluated.

RESULTS

CDs and CTLs were similar in gender and race. Watery diarrhea was the most common type of diarrhea in CDs and CTLs. Immunodeficiency (46% vs 6%; P < 0.001), gastrointestinal (GI) disease (31% vs 18%; P = 0.005), and proton pump inhibitor (PPI) use (22% vs 7%; P < 0.001) were more frequent in CDs. Of CDs, 30% were defined as community acquired. Bloody diarrhea was more frequent in community-acquired CD (28% vs 4% P < 0.001); however, other clinical variables were not statistically different. No antibiotic exposure, recent hospitalization, prolonged hospitalization, or past history of CDI existed in 8% of CDs. Multivariate logistic regression demonstrated that antibiotic use (odds ratio [OR]: 2.80, P = 0.001), recent hospitalization (OR: 2.33, P = 0.007), and immunodeficiency (OR: 6.02, P < 0.001) were significantly associated with cases when controlling for PPI use, having GI disease, and history of abdominal surgery.

CONCLUSIONS

Clinical history is of greater value than symptoms in distinguishing CD, with immunodeficiency having the strongest association. An important percentage of CDs did not have any risk factors, confirming concerns that CDIs do occur in otherwise low-risk pediatric populations.

Evaluation of an Interferon Gamma Release Assay to Detect Tuberculosis Infection in Children in San Diego, California

QuantiFERON-TB Gold In-Tube (QFT-GIT) and tuberculin skin test (TST) results are reported in 23 children with active tuberculosis due to Mycobacterium tuberculosis and Mycobacterium bovis. Overall QFT-GIT (96%) was more sensitive than TST (74%) for detecting tuberculosis infection in these patients.

Children with atopic dermatitis appear less likely to be infected with community acquired methicillin-resistant Staphylococcus aureus: the San Diego experience

Given the increasing rate of community-acquired methicillin resistant Staphylococcus aureus skin infections in the population, such infections might be concurrently increasing in patients with atopic dermatitis. This study assessed current and prior rates of community-acquired methicillin resistant Staphylococcus aureus and methicillin-susceptible Staphylococcus aureus skin and soft tissue infections in children with atopic dermatitis compared to the general pediatric population. Other antibiotic sensitivity and resistance patterns, including clindamycin-inducible resistance, were also identified. Retrospective study of all skin and soft tissue isolates were positive for Staphylococcus aureus during two distinct 1-year periods, obtained by the outpatient services and the emergency department at Rady Children's Hospital, the major regional pediatric health center in San Diego, California. Of the Staphylococcus aureus isolates obtained from January to December 2000, none from atopic dermatitis patients were methicillin resistant Staphylococcus aureus, while 4.2% of those obtained from the general outpatient pediatric population showed methicillin resistance. In the period from June 2007 to May 2008, 11 of 78 isolates (14.1%) from children with atopic dermatitis were methicillin resistant Staphylococcus aureus. This was significantly lower than the rate of increase noted in the general pediatric population (658 of 1482, or 44.4%, in 2007/2008, p < 0.05). Clindamycin-inducible resistance was noted in 1.9% of the isolates in the general population; all six tested isolates from atopic patients lacked clindamycin-inducible resistance. In this study, children with atopic dermatitis had a much lower rate of community-acquired methicillin resistant Staphylococcus aureus infection compared to the general outpatient pediatric population. Clindamycin-inducible resistance was very low in both groups.

Zygomycetes infections in pediatric hematology oncology patients: a case series and review of the literature

Fungi from the Zygomycetes class are increasingly recognized causes of infection in immunosuppressed children, but no comprehensive literature review and few case series have been published on the topic. A case series of 6 pediatric oncology patients with Zygomycetes infections cared for at our institution was constructed, and a concurrent search of the English language literature for Zygomycetes infections in children with oncologic disorders was undertaken. Our case series described 6 patients (5 male) between the ages of 2.5 and 19.5 years. One patient was diagnosed with rhinocerebral disease, 2 with rhinosinusitis, 2 with pulmonary involvement, and 1 with a gastrointestinal presentation. Five patients survived. Our literature review identified 82 cases from 61 studies. The mean subject age was 10.8 years (1.4 to 21.0 y). About 92.7% of all patients suffered from some form of leukemia, with 70.7% suffering from acute lymphoblastic leukemia. Overall, 58.5% of reported patients survived, with individuals with disseminated disease showing the worst prognosis (68.2% mortality) and those with cutaneous disease the best (14.3% mortality). Survival is increasingly reported in the literature, perhaps as a result of improved diagnostic capabilities, increased physician awareness and increased reliance on adjunctive surgical therapy.

Synthesis and biological evaluation of flavan-3-ol derivatives as positive modulators of GABAA receptors

We herein describe the synthesis and positive modulatory activities of a small library of flavan-3-ol derivatives on alpha(1)beta(2)gamma(2L) GABA(A) receptors. Structure-activity relationships of various substituents on the A, B and C rings were evaluated in a functional electrophysiological assay. A trans configuration and a 3-acetoxy moiety are essential for activity. Substitution of the B ring appears to be well tolerated, with substituents on the A ring playing a major role in determining activity.

Prediction of neurologic sequelae in childhood tuberculous meningitis: a review of 20 cases and proposal of a novel scoring system

BACKGROUND

Despite effective antituberculous medications, the mortality and morbidity remain high in children with tuberculous meningitis (TBM). The traditional clinical staging for TBM developed by Lincoln et al in 1960 has been widely used to predict long term neurologic sequelae (NS). In the current era of critical care medicine and corticosteroid therapy, a new scoring system is needed to predict NS more accurately in children with TBM.

METHODS

We reviewed all available cases of TBM in San Diego, CA, during 1991-2001 retrospectively, and we developed a novel scoring system to predict NS in children with TBM. We assessed a tuberculous meningitis acute neurologic (TBAN) score at day 0 and on day 3 of hospitalization, to compare children who subsequently developed severe NS with those who did not.

RESULTS

Among 20 children with TBM, 7 children developed severe NS and 1 child died during hospitalization. The TBAN score was higher on day 0 in those with severe NS (5.5 versus 2.0, P = 0.09), and the difference became statistically significant by day 3 of hospitalization (5.5 versus 0.0, P = 0.02). Sensitivity and specificity of the TBAN score (> or =4) on day 0 (75 and 92%) and day 3 (88 and 100%) to predict severe NS were superior to the traditional clinical staging system on day 0 (63 and 58%).

CONCLUSIONS

The TBAN score is an objective marker for predicting severe NS in children with TBM.

Clinical challenges of nosocomial infections caused by antibiotic-resistant pathogens in pediatrics

Antibiotic resistance in nosocomial infections is an ever-increasing problem as health care institutions provide care for children with more complicated medical and surgical problems. Several mechanisms of antibiotic resistance are reviewed for both gram-negative and gram-positive nosocomial pathogens. These adaptive resistance mechanisms allow organisms to survive in an environment of extensive antibiotic use and result in clinically significant infections. Mobile genetic elements have facilitated the rapid spread of antibiotic resistance within and among species. The clinical challenge faced by many practitioners is to understand these mechanisms of antibiotic resistance and to develop strategies for successfully treating infection caused by resistant pathogens. Nosocomial outbreaks caused by resistant organisms are described, and an approach to empiric therapy based on presumed pathogens, site of infection, and local resistance patterns is discussed.

Pneumococcal infection of the cavum septi pellucidi and cavum vergae in a pediatric patient

The cavum septi pellucidi and cavum vergae are unusual sites of intracranial infection. A child is reported with infection of the cavum septi pellucidi and cavum vergae associated with pneumococcal meningitis. The patient required surgical drainage of the abscess despite appropriate antibiotic therapy, and the clinical outcome was excellent.

Comparison of bracketing and matrixing designs for a two-year stability study

In the U.S. Food and Drug Administration (FDA) guidelines for stability testing of new drug products, both bracketing and matrixing designs were suggested as the statistical designs. More recently, they have increasing attention from pharmaceutical companies, because both designs reduce the cost of stability studies. The purpose of this paper is to investigate both designs in terms of the power of detection of significant difference between slopes, and use the mean square error to evaluate the precision of estimated drug shelf life. Additionally, the distributions of both designs are compared by using 1000 simulations.

An open-label, multicenter study to evaluate Yasmin, a low-dose combination oral contraceptive containing drospirenone, a new progestogen

This open-label, multicenter study evaluated the efficacy, safety, and cycle control of Yasmin, a new low-dose, monophasic oral contraceptive containing the unique progestogen drospirenone (DRSP) 3 mg and ethinyl estradiol (EE) 30 microg. DRSP is a synthetic progestogen that has antiandrogenic and antimineralocorticoid effects. In this study, 326 women were evaluated and 220 (67%) completed all 13 treatment cycles. The corrected Pearl Index was 0. 407. Of the 151 subjects who experienced intermenstrual bleeding at any time during the study, the majority (64%) had bleeding during only one or two pill cycles. Breakthrough bleeding without spotting occurred in 1% of all cycles, spotting without breakthrough bleeding in 9.3% of all cycles, and breakthrough bleeding with spotting in 3% of all cycles. Amenorrhea was observed in 3% of all cycles. In all, 20 subjects (6%) discontinued participation in the study because of adverse events. No serious adverse events related to the study drug were reported. No clinically significant changes in weight, blood pressure, or lipids were reported. The impact of the new progestogen DRSP on the women's self-perception of menstrual health was also evaluated. Subjects reported that symptoms of water retention, negative affect, and increased appetite significantly improved at cycle 6 from baseline. This study demonstrates that Yasmin is an effective oral contraceptive that is safe and well tolerated.

Reduced apoptosis after nerve growth factor and serum withdrawal: conversion of tetrameric glyceraldehyde-3-phosphate dehydrogenase to a dimer

Antisense oligonucleotides against the glycolytic enzyme glyceraldehyde-3-phosphate dehydrogenase (GAPDH) are able to reduce some forms of apoptosis. In those forms, overall GAPDH levels increase and the enzyme accumulates in the nucleus. The monoamine oxidase B (MAO-B) inhibitor, (-)-deprenyl (DEP), its metabolite (-)-desmethyldeprenyl, and a tricyclic DEP analog, CGP3466, can reduce apoptosis independently of MAO-B inhibition and have been found to bind to GAPDH. We used neuronally differentiated PC12 cells to show that DEP, DES, and CGP3466 reduce apoptosis caused by serum and nerve growth factor withdrawal over the concentration range of 10(-) to 10(-13) M. We provide evidence that the DEP-like compounds bind to GAPDH in the PC12 cells and that they prevent both the apoptotic increases in GAPDH levels and nuclear accumulation of GAPDH. In vitro, the compounds enhanced the conversion of NAD(+) to NADH by GAPDH in the presence of AUUUA-rich RNA and converted GAPDH from its usual tetrameric form to a dimeric form. Using cell lysates, we found a marked increase in rates of NAD(+) to NADH conversion in early apoptosis, which was returned toward control values by the DEP-like compounds. Accordingly, the DEP-like compounds appear to decrease glycolysis by preventing the GAPDH increases in early apoptosis. GAPDH dimer may not have the capacity to contribute to apoptosis in a similar manner to the tetramer, which might account for the antiapoptotic capacity of the compounds. These actions on GAPDH, rather than MAO-B inhibition, may contribute to the improvements in Parkinson's and Huntington's diseases found with DEP treatment.

Activity of moxifloxacin against pathogens with decreased susceptibility to ciprofloxacin

A panel of 279 clinical isolates of Gram-positive cocci and Gram-negative bacilli with varying levels of resistance to ciprofloxacin were analysed for susceptibility to moxifloxacin, ciprofloxacin, ofloxacin and nalidixic acid. Moxifloxacin was eight- to 32-fold more potent than ciprofloxacin and ofloxacin against staphylococci and Streptococcus pneumoniae, and equivalent to eight-fold more potent against enterococci. Although ciprofloxacin was intrinsically more potent than the other quinolones against highly susceptible Gram-negative isolates, the percentages of Gram-negative isolates susceptible to 1 mg/L of moxifloxacin or ciprofloxacin, or 2 mg/L of ofloxacin were 78%, 80% and 76%, indicating in-vitro equivalence of the agents against a collection that included isolates with diminished quinolone susceptibility. Staphylococci were analysed according to their ciprofloxacin susceptibility status. As ciprofloxacin resistance increased to high levels, all quinolone MICs increased, but moxifloxacin and ofloxacin MICs increased less than ciprofloxacin MICs. In mutational studies moxifloxacin inhibited more mutants (69%) at a concentration of 1 mg/L than did ciprofloxacin (63%) at 1 mg/L or ofloxacin at 2 mg/L (31%). The study indicated that moxifloxacin is more potent than ciprofloxacin and ofloxacin against Gram-positive pathogens, may be comparable in activity against less quinolone-susceptible Gram-negative isolates (other than Pseudomonas aeruginosa), and is less affected than ciprofloxacin by mechanisms responsible for increasing quinolone resistance in staphylococci.

Bacterial meningitis and the newborn infant

Bacterial meningitis in the neonate differs from meningitis in the older infant and child in a number of ways. Bacterial pathogens primarily are associated with the maternal genitourinary tract. Symptoms and physical findings may be nonspecific, and a high index of suspicion is needed. Management may vary depending on the maturity of the infant and the bacterial pathogen that is isolated.

Glucose protection from MPP+-induced apoptosis depends on mitochondrial membrane potential and ATP synthase

MPP+ inhibits mitochondrial complex I and alpha-ketoglutarate dehydrogenase causing necrosis or apoptosis of catecholaminergic neurons. Low glucose levels or glycolytic blockade has been shown to potentiate MPP+ toxicity. We found that MPP+ caused concentration-dependent apoptosis of neuronally differentiated PC12 cells and that glucose, but not pyruvate, supplementation reduced apoptosis. Oligomycin concentrations sufficient to inhibit ATP synthase blocked the decreased apoptosis afforded by glucose supplementation. Laser-scanning confocal microscope imaging of chloromethyl-tetramethylrosamine methyl ester fluorescence to estimate DeltaPsiM showed that MPP+ and atractyloside reduced DeltaPsiM, while cyclosporin A (CSA) and glucose supplementation reversed decreases in DeltaPsiM caused by MPP+. Oligomycin blocked the effect of glucose supplementation on DeltaPsiM. These findings show that (i) MPP+-induced and atractyloside-induced apoptosis are associated with reduced DeltaPsiM; (ii) CSA maintains DeltaPsiM and reduces MPP+-induced apoptosis; and (iii) glucose supplementation maintains DeltaPsiM, likely by glycolytic ATP-dependent proton pumping at ATP synthase and reduces MPP+-induced apoptosis.

Rationale behind high-dose amoxicillin therapy for acute otitis media due to penicillin-nonsusceptible pneumococci: support from in vitro pharmacodynamic studies

To evaluate whether increased doses of amoxicillin should be used to treat acute pneumococcal otitis media, an in vitro pharmacokinetic model was used to evaluate the killing of pneumococci by amoxicillin when middle ear pharmacokinetics were simulated. Logarithmic-phase cultures were exposed to peak concentrations of 3, 6, and 9 microg of amoxicillin per ml every 12 h, and an elimination half-life of 1.6 h was simulated. Changes in viable bacterial counts were measured over 36 h. All three doses rapidly decreased the viable bacterial counts of penicillin-susceptible strains below the 10-CFU/ml limit of detection by 6 to 10 h and maintained counts below this limit through 36 h. The 3-microg/ml peak dose was much less effective against two of three strains with intermediate penicillin resistance and all three penicillin-resistant strains, with bacterial counts approaching those in drug-free control cultures by 12 h. The 6-microg/ml peak dose completely eliminated two of three strains with intermediate penicillin resistance and maintained viable counts of the other nonsusceptible strains at 1.5 to 2 logs below the initial inoculum through 36 h. The 9-microg/ml peak dose was most effective, completely eliminating all three strains with intermediate penicillin resistance and maintaining the viable counts of the resistant strains at 3 to 4 logs below the original inoculum. The pharmacodynamics observed in this study suggest that peak concentrations of amoxicillin of 6 to 9 microg/ml may be sufficient for the elimination of penicillin-nonsusceptible pneumococcal strains causing otitis media, especially those with intermediate resistance to amoxicillin. In vivo pharmacokinetic studies are needed to determine if these levels can be achieved in middle ear fluid with amoxicillin at 70 to 90 mg/kg/day divided into two daily doses. If these levels are reliably achieved, then clinical studies are warranted.