Pathogens in Pediatric Septic Arthritis: A Multi-Center Study in Turkiye (PEDSART Study)

OBJECTIVES

Septic arthritis (SA) is a serious bacterial infection that must be treated efficiently and timely. The large number of culture-negative cases makes local epidemiological data important. Accordingly, this study aimed to evaluate the etiology, clinical characteristics, and therapeutic approach of SA in children in Turkiye, emphasizing the role of real-time polymerase chain reaction (PCR) techniques in the diagnosis.

METHODS

In this multi-center, prospective study, children hospitalized due to SA between February 2018 and July 2020 in 23 hospitals in 14 cities in Turkiye were included. Clinical, demographic, laboratory, and radiological findings were assessed, and real-time PCR was performed using synovial fluid samples.

RESULTS

Seventy-five children aged between 3 and 204 months diagnosed with acute SA were enrolled. Joint pain was the main complaint at admission, and the most commonly involved joints were the knees in 58 patients (77.4%). The combination of synovial fluid culture and real-time PCR detected causative bacteria in 33 patients (44%). In 14 (18.7%) patients, the etiological agent was demonstrated using only PCR. The most commonly isolated etiologic agent was Staphylococcus aureus, which was detected in 22 (29.3%) patients, while Streptococcus pyogenes was found in 4 (5.3%) patients and Kingella kingae in 3 (4%) patients. Streptococcus pyogenes and Kingella kingae were detected using only PCR. Most patients (81.3%) received combination therapy with multiple agents, and the most commonly used combination was glycopeptides plus third-generation cephalosporin.

CONCLUSIONS

Staphylococcus aureus is the main pathogen in pediatric SA, and with the use of advanced diagnostic approaches, such as real-time PCR, the chance of diagnosis increases, especially in cases due to Kingella kingae and Streptococcus pyogenes.

The effectiveness of topical 1% lidocaine with systemic oral analgesics for ear pain with acute otitis media

BACKGROUND

Acute otitis media (AOM) is one of the most common childhood infections. Ear pain, the main symptom of AOM, results in parents frequently seeking medical assistance for their children. The aim of this study was to compare the effectiveness of topical 1% lidocaine ear drops administered with oral analgesics with that of oral analgesics alone.

METHODS

This multicenter randomized, open-labeled study was conducted at 15 centers with 184 pediatric AOM patients with bilateral ear pain (aged 1-5 years) between May 1, 2016, and June 31, 2018. All patients received oral paracetamol or ibuprofen and topical 1% lidocaine, which was administered to each ear according to the randomization list. The ear pain score was evaluated within 48 h using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale, and the patients were followed up for 10 days.

RESULTS

The median age was 31.8 months (min-max, 12-84.2 months). Of those patients enrolled, 22.3% received paracetamol, and 24.5% received paracetamol with lidocaine ear drops; 23.4% received ibuprofen, and 29.9% received ibuprofen with lidocaine ear drops. Lower pain scores were significantly measured at baseline and 10th minutes by a reduction 25% (RR 13.64, 95% CI 4.47-41.63, p = 0.001, RR 0.14, 95% CI 0.06-0.35, p = 0.001) and 50% (RR 4.76, 95% CI 1.63-13.87, p = 0.004, RR 0.14, 95% CI 0.05-0.4, p = 0.001) in the paracetamol and lidocaine versus paracetamol groups and the ibuprofen and lidocaine versus ibuprofen groups, respectively. No serious side effects were evident during follow-up.

CONCLUSION

This randomized study suggests that topical 1% lidocaine ear drops with paracetamol or ibuprofen seems to provide effective and rapid relief for children presenting with ear pain attributed to AOM.

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

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

682. The Changing Epidemiology of Bacterial Meningitis During 2015–2017 in Turkey: A Hospital-Based Prospective Surveillance Study

Background

The etiology of bacterial meningitis in Turkey has been changed after the implementation of conjugated vaccines against Streptococcus pneumonia and Haemophilus influenzae type b (Hib) in Turkish national immunization schedule. Methods. This prospective study was conducted in 25 hospitals located seven regions of Turkey (representing 30% of Turkey population) and children aged between 1 month and 18 years with suspected meningitis and hospitalized were included. Cerebrospinal fluid samples were collected and bacterial identification was made according to the multiplex PCR assay results. Results. During the study period, 927 children were hospitalized for suspected meningitis and Hib (n:1), S. pneumonia (n:17) and Neisseria meningitidis (n:59) were detected in 77 samples (Figure 1, Table 1). During 2015–2016, N. meningitidis serogroup W, B, A, Y, X frequencies were as 5 (13.9%), 16 (44.4%), 1 (2.8%), 1 (2.8%), 1 (2.8%), respectively. There were 12 nongroupable N. meningitidis samples and serogroup C was not detected. In 2017, of meningococcal meningitis serogroup B, W, A, Y and X were identified in two (8.7%), 15 (65.2%), two (8.7%), 1 (4.3%) and 1 (4.3%) cases, respectively (Figure 2). There were four deaths in this study period, all of them were caused by N. meningitidis serogroup B and three of them were under 1 year old. Conclusion. The epidemiology of meningococcal diseases has been varied in time with or without any apparent reasons. Hajj is a well-known cause for serogroup W epidemics and serogorup W was the most common cause of meningitis in Turkey during 2009–2014 as in other Middle East countries. After the impact of serogroup W epidemics related to Hajj seen in 2010’s was diminished, serogroup B has been leading cause of childhood meningitis since 2015. In countries affected from Hajj like Turkey, vaccination of children with serogroup B meningococcal vaccine as well as quadrivalentconjugated vaccine seems to be very important. It should be kept in mind that meningococcal epidemiology is dynamic and needed to be closely monitored to detect changes in years

Disclosures

All authors: No reported disclosures.

What type of imaging work-up will help to confirm the diagnosis of gossypiboma in the limb? Review of literature

Gossypiboma imaging features are not well known and are often confused with soft tissue tumours. Publications on this topic mainly consist of case reports and small cohorts. Its appearance on various imaging modalities is not well defined. This led us to carry out a review of literature to determine specifically: (1) which imaging modalities should be used in cases of suspected gossypiboma, (2) what are the most common imaging findings that contribute to the diagnosis of gossypiboma. An exhaustive review of literature was carried out in June 2015 in the Medline, PubMed and Cochrane databases using the keywords "gossypiboma/textiloma/foreign body". We found 205 articles describing one or multiple cases of gossypiboma in various locations. Of these, the 32 articles that had imaging data were chosen - 16 for the limbs and 16 for other locations. The type of imaging carried out, description of the gossypiboma and circumstances of the discovery and occurrence were recorded. Descriptive statistics were generated to define the type of imaging used and the various findings. Imaging consisted of X-rays in 21/32 cases (66%), computed tomography (CT) in 14/32 cases (43%), magnetic resonance imaging (MRI) in 21/32 cases (65%) and ultrasonography in 14/32 cases (43%). On X-rays, bone involvement was found in 9/15 cases (60%); there was peripheral contrast product uptake on the CT scans in 9/14 cases (64%), a hypointense signal on T1-weighted sequences on MRI in 6/13 cases (46%) and lack of vascularisation in 8/13 cases (62%) and a acoustic shadow on ultrasonography in 9/14 cases (64%). In a patient presenting with a soft tissue lump and history of surgery, an imaging work-up including X-rays, ultrasonography and MRI must be performed. Bone involvement on X-rays, acoustic shadowing on ultrasonography and hypointense signal on T1-weighted MRI sequences with lack of vascularisation in combination with a history of surgery can bring up the possibility of gossypiboma. If there is a possibility of soft tissue tumour, the case should be discussed in a multidisciplinary meeting and a biopsy should be performed first.

LEVEL OF EVIDENCE

IV - systematic analysis of published retrospective studies.

Foscarnet therapy for congenital cytomegalovirus liver fibrosis following prenatal ascites

We report on an infant with multi-system disease including liver fibrosis, right microphthalmia with cataract, interstitial pneumonitis, and hyperechoic lesions in the basal ganglia and in the periventricular and thalamic regions. Prenatal ascites with hepatomegaly concomitantly with detection of cytomegalovirus (CMV) DNA in the amniotic fluid, following recurrent maternal CMV infection, had been shown. Although CMV culture and DNA detection were negative in the urine, the infant was given foscarnet because CMV infection was demonstrated in the liver by DNA detection and immunohistochemical staining. Favorable clinical outcome and absence of CMV in the liver were subsequently shown. Our case suggests that congenital CMV disease following maternal recurrence may not be associated with disseminated infection but only with intracellular infection. The diagnosis should therefore be based on CMV detection in the involved organs. Moreover, this is the first report on the possible efficacy and safety of foscarnet for therapy of immunocompetent infants with congenital CMV disease.

Ramsey spectroscopy of bound atomic states with extreme-ultraviolet laser harmonics

We report the experimental measurement of Ramsey interference fringes in the single-photon excitation to a high-lying bound state of atomic argon by pairs of phase-locked, time-delayed, extreme UV high-order-harmonic pulses at 87 nm. High-visibility Ramsey fringes are observed for delays larger than 100 ps, thus demonstrating a potential resolving power >10(5) at this wavelength.

[Pulsatility index of the umbilical artery and fetal movements/hour in the prediction of neonatal acidemia in high risk pregnancy]

OBJECTIVE

The aim of this study was to correlate antepartum computerized cardiotocography (cCTG) and Doppler velocimetry parameters to umbilical blood gas analysis (UBGA) value and Apgar score 1-5 min as neonatal outcome endpoints.

METHODS

Forty-eight third trimester single high risk pregnancies were considered for this study, with a cCTG performed within 24 hrs from delivery, a complete Doppler velocimetry study performed within 48 hrs from delivery and an UBGA evaluation at birth and before the first breath.

RESULTS

When we analyzed the backward stepwise regression of each Doppler velocimetry and cCTG parameters versus UBGA parameters as dependent variables, we found that the linear combination of fetal heart rate (FHR) (p < 0.001), high variation episodes in min (HV) (p < 0.01) and low variation episodes in msec (LV) (p < 0.03) was able to predict pO2 values. When performing a logistic regression of data for every single parameter of FHR tracing and Doppler velocimetry against pH < 7.2 and Becf < -4 as endpoints, we found that only umbilical artery pulsatility index (UA PI) was able to predict umbilical artery pH (O.R.: 8.1 [1.07-61.8]) and only fetal movements (FM) from FHR tracing values was able to predict UA pH (O.R.: 0.94 [0.89-0.99]). Further analysis considers a cut-off for the prediction of UA pH < 7.2 at birth a value at > or = 1.35 for UA PI and at < or = 12 for FM/h. The combination of UA PI > 1.35 and FM/h < 12 did not improve the ability to predict acidemia at birth.

CONCLUSION

The validity of our data from the clinical point of view suggests that in third trimester high risk pregnancies, an UA PI > or = 1.35 and/or FM/h < or = 12 (in a FHR tracing > or = 40 min) may represent a risk of 70% acidemia in neonates.

[Therapy or prevention of fetal infection by cytomegalovirus with immunoglobulin infusion in pregnant women with primary infection]

OBJECTIVE

Administration of cytomegalovirus (CMV)-specific immunoglobulins to pregnant women with primary CMV infection in order to inhibit viral activity.

MATERIALS AND METHODS

We considered 2 groups of patients including 24 pregnant women.

GROUP A

12 women with primary maternal-fetal CMV infection, shown by CMV culture and CMV DNA detection in 9 (75%) and by only CMV DNA detection in 3 (25%) of the amniotic fluid (AF) samples. These pregnant women were treated with infusions of CMV-specific immunoglobulins (200 U/Kg of maternal weight and 400 U/Kg of fetal weight to prevent CMV pneumonia and gastroenteritis). As control group we considered 15 pregnant women, 5 of whom had CMV-positive AF samples demonstrated by polymerase chain reaction (PCR) and 10 also by CMV culture.

GROUP B

12 women with primary CMV infection, who were treated with monthly infusions of specific immunoglobulins to prevent the transmission of CMV to the fetus. In the control group we followed up 53 patients who were not treated, including 15 subjects with CMV-positive AF samples, 20 with CMV-negative AF samples and 18 women who did not accept amniocentesis.

RESULTS

GROUP A

All 9 neonates born to mothers with culture and DNA positive AF samples were CMV infected. On the contrary, the babies born to 3 women with only PCR-positive amniotic fluid were CMV-negative by culture and DNA detection. Of 9 neonates infected, 8 were asymptomatic and 3 became culture-negative before they were one year old. The only symptomatic baby (IUGR and ventriculomegaly diagnosed by ultrasound during the pregnancy) was treated with ganciclovir and foscarnet. Of 15 non-treated patients, 11 had ultrasound signs of placental and/or fetal CMV involvement. Seven of these (46%) aborted and 4 (27%) delivered neonates with severe symptomatic infection. The other 4 patients delivered oligo-symptomatic CMV infected neonates positive by culture or PCR only. Overall, the prevalence of symptomatically infected neonates or fetuses was significantly higher (p = 0.02) among non-treated than treated women. Moreover, the babies of treated women showed less prolonged (p = 0.01) viruria than those of non-treated patients.

GROUP B

all 11 pregnant women, treated with immunoglobulins delivered CMV-negative neonates. One patient, who had interrupted infusions at the 24th gestation week, delivered an asymptomatic CMV infected baby. In the control group, 4 women with CMV-negative AF samples delivered neonates with asymptomatic infection. Of 18 patients who did not undergo amniocentesis, 9 (50%) aborted; of remaining 9 women, 3 (33%) delivered CMV infected neonates.

CONCLUSIONS

Our data suggest that CMV immunoglobulins may be effective for treatment or prevention of fetal CMV infection.

[Combination of the computerized analysis of fetal heart rate and amniotic fluid index in the prediction of neonatal acidemia: a modified biophysical profile]

OBJECTIVE

To study the use of a modification of the classical biophysical profile by the combination of computerized analysis of fetal heart rate (cCTG) and the amniotic fluid index (AFI) in the prediction of neonatal acidemia at birth.

METHODS

We considered 89 singleton third trimester high risk pregnancies delivered by cesarean section, with an AFI evaluated within 24 hrs from birth, and an antepartum cCTG performed within 6 hrs from delivery. We assigned values for AFI (oligo/anhydramnios = 1, normal = 0) and cCTG (Dawes-Redman criteria, not satisfied = 1, satisfied = 0). The endpoint was to predict an abnormal neonatal outcome as defined by an umbilical artery (UA) pH < or = 7.2.

RESULTS

Fifteen neonates presented an UA pH < or = 7.2. By performing a logistic regression, we found that cCTG + AFI score (abnormal value 1-2) was able to significantly predict a pH value (< or = 7.20) with an Odds Ratio = 2.83 (p < 0.02). The diagnostic accuracy of the combination of cCTG + AFI was as follows: sensitivity: 80%, specificity: 58%.

COMMENT

We suggest that the combination of cCTG + AFI included in the simple score we propose, may be of value in the prediction of neonatal acidemia and help in the management of third trimester high risk pregnancies.