A Cluster of Cases of Babesia microti Among Neonates Traced to a Single Unit of Donor Blood.

Three premature infants in 1 neonatal intensive care unit developed transfusion-transmitted babesiosis. Two of the infants developed high-grade parasitemia. All 3 affected infants were treated and cured with azithromycin and atovaquone. No infant required exchange transfusion. Clinicians should be cognizant that babesiosis may be acquired via blood transfusion.

Implementation of an Antimicrobial Stewardship Program in a Neonatal Intensive Care Unit.

OBJECTIVE To evaluate antimicrobial utilization and prescription practices in a neonatal intensive care unit (NICU) after implementation of an antimicrobial stewardship program (ASP). DESIGN Quasi-experimental, interrupted time-series study. SETTING A 54-bed, level IV NICU in a regional academic and tertiary referral center. PATIENTS AND PARTICIPANTS All neonates prescribed antimicrobials from January 1, 2011, to June 30, 2016, were eligible for inclusion. INTERVENTION Implementation of a NICU-specific ASP beginning July 2012. METHODS We convened a multidisciplinary team and developed guidelines for common infections, with a focus on prescriber audit and feedback. We conducted an interrupted time-series analysis to evaluate the effects of our ASP. Our primary outcome measure was days of antibiotic therapy (DOT) per 1,000 patient days for all and for select antimicrobials. Secondary outcomes included provider-specific antimicrobial prescription events for suspected late-onset sepsis (blood or cerebrospinal fluid infection at >72 hours of life) and guideline compliance. RESULTS Antibiotic utilization decreased by 14.7 DOT per 1,000 patient days during the stewardship period, although this decrease was not statistically significant (P=.669). Use of ampicillin, the most commonly antimicrobial prescribed in our NICU, decreased significantly, declining by 22.5 DOT per 1,000 patient days (P=.037). Late-onset sepsis evaluation and prescription events per 100 NICU days of clinical service decreased significantly (P<.0001), with an average reduction of 2.65 evaluations per year per provider. Clinical guidelines were adhered to 98.75% of the time. CONCLUSIONS Implementation of a NICU-specific antimicrobial stewardship program is feasible and can improve antibiotic prescribing practices. Infect Control Hosp Epidemiol 2017;38:1137-1143.

Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications: A Scientific Statement for Healthcare Professionals From the American Heart Association.

BACKGROUND: Infective endocarditis is a potentially lethal disease that has undergone major changes in both host and pathogen. The epidemiology of infective endocarditis has become more complex with today's myriad healthcare-associated factors that predispose to infection. Moreover, changes in pathogen prevalence, in particular a more common staphylococcal origin, have affected outcomes, which have not improved despite medical and surgical advances. METHODS AND RESULTS: This statement updates the 2005 iteration, both of which were developed by the American Heart Association under the auspices of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease, Council on Cardiovascular Disease of the Young. It includes an evidence-based system for diagnostic and treatment recommendations used by the American College of Cardiology and the American Heart Association for treatment recommendations. CONCLUSIONS: Infective endocarditis is a complex disease, and patients with this disease generally require management by a team of physicians and allied health providers with a variety of areas of expertise. The recommendations provided in this document are intended to assist in the management of this uncommon but potentially deadly infection. The clinical variability and complexity in infective endocarditis, however, dictate that these recommendations be used to support and not supplant decisions in individual patient management.

The Changing Epidemiology of Pediatric Endocarditis.

The epidemiology of infective endocarditis (IE) appears to be related to changes in the management of children with congenital heart disease (CHD) and the virtual disappearance of rheumatic heart disease. To better understand these changes, we divide the history into: I. The pre-surgical era, II. The early years of CHD surgical intervention, correlated with introduction of antibiotics, III. The modern era of cardiac interventions. Microbiologic changes include an early predominance of viridans streptococci and an overtaking by staphylococci. Additionally, there have been advances in imaging that allow earlier detection of IE and a reduction in IE-related mortality.

Clinical and Molecular Epidemiology of Methicillin-Resistant Staphylococcus aureus in a Neonatal Intensive Care Unit in the Decade following Implementation of an Active Detection and Isolation Program.

Methicillin-resistant Staphylococcus aureus (MRSA) is a frequent source of infection in the neonatal intensive care unit (NICU), often associated with significant morbidity. Active detection and isolation (ADI) programs aim to reduce transmission. We describe a comprehensive analysis of the clinical and molecular epidemiology of MRSA in an NICU between 2003 and 2013, in the decade following the implementation of an MRSA ADI program. Molecular analyses included strain typing by pulsed-field gel electrophoresis, mec and accessory gene regulator group genotyping by multiplex PCR, and identification of toxin and potential virulence factor genes via PCR-based assays. Of 8,387 neonates, 115 (1.4%) had MRSA colonization and/or infection. The MRSA colonization rate declined significantly during the study period from 2.2 to 0.5/1,000 patient days (linear time, P = 0.0003; quadratic time, P = 0.006). There were 19 cases of MRSA infection (16.5%). Few epidemiologic or clinical differences were identified between MRSA-colonized and MRSA-infected infants. Thirty-one different strains of MRSA were identified with a shift from hospital-associated to combined hospital- and community-associated strains over time. Panton-Valentine leukocidin-positive USA300 strains caused 5 of the last 11 infections. Staphylococcal cassette chromosome mec (SCCmec) types II and IVa and agr groups 1 and 2 were most predominant. One isolate possessed the gene for toxic shock syndrome toxin; none had genes for exfoliative toxin A or B. These results highlight recent trends in MRSA colonization and infection and the corresponding changes in molecular epidemiology. Continued vigilance for this invasive pathogen remains critical, and specific attention to the unique host, the neonate, and the distinct environment, the NICU, is imperative.

Neonatal sepsis 2004-2013: the rise and fall of coagulase-negative staphylococci.

OBJECTIVES: To evaluate data for the period 2004-2013 to identify changes in demographics, pathogens, and outcomes in a single, level IV neonatal intensive care unit. STUDY DESIGN: Sepsis episodes were identified prospectively and additional information obtained retrospectively from infants with sepsis while in the neonatal intensive care unit from 2004 to 2013. Demographics, hospital course, and outcome data were collected and analyzed. Sepsis was categorized as early (≤3 days of life) or late-onset (>3 days of life). RESULTS: Four hundred fifty-two organisms were identified from 410 episodes of sepsis in 340 infants. Ninety percent of cases were late-onset. Rates of early-onset sepsis remained relatively static throughout the study period (0.9 per 1000 live births). For the first time in decades, most (60%) infants with early-onset sepsis were very low birth weight and Escherichia coli (45%) replaced group B streptococcus (36%) as the most common organism associated with early-onset sepsis. Rates of late-onset sepsis, particularly due to coagulase-negative staphylococci, decreased significantly after implementation of several infection-prevention initiatives. Coagulase-negative staphylococci were responsible for 31% of all cases from 2004 to 2009 but accounted for no cases of late-onset sepsis after 2011. CONCLUSIONS: The epidemiology and microbiology of early- and late-onset sepsis continue to change, impacted by targeted infection prevention efforts. We believe the decrease in sepsis indicates that these interventions have been successful, but additional surveillance and strategies based on evolving trends are necessary.

Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association.

BACKGROUND: Acute rheumatic fever remains a serious healthcare concern for the majority of the world's population despite its decline in incidence in Europe and North America. The goal of this statement was to review the historic Jones criteria used to diagnose acute rheumatic fever in the context of the current epidemiology of the disease and to update those criteria to also take into account recent evidence supporting the use of Doppler echocardiography in the diagnosis of carditis as a major manifestation of acute rheumatic fever. METHODS AND RESULTS: To achieve this goal, the American Heart Association's Council on Cardiovascular Disease in the Young and its Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee organized a writing group to comprehensively review and evaluate the impact of population-specific differences in acute rheumatic fever presentation and changes in presentation that can result from the now worldwide availability of nonsteroidal anti-inflammatory drugs. In addition, a methodological assessment of the numerous published studies that support the use of Doppler echocardiography as a means to diagnose cardiac involvement in acute rheumatic fever, even when overt clinical findings are not apparent, was undertaken to determine the evidence basis for defining subclinical carditis and including it as a major criterion of the Jones criteria. This effort has resulted in the first substantial revision to the Jones criteria by the American Heart Association since 1992 and the first application of the Classification of Recommendations and Levels of Evidence categories developed by the American College of Cardiology/American Heart Association to the Jones criteria. CONCLUSIONS: This revision of the Jones criteria now brings them into closer alignment with other international guidelines for the diagnosis of acute rheumatic fever by defining high-risk populations, recognizing variability in clinical presentation in these high-risk populations, and including Doppler echocardiography as a tool to diagnose cardiac involvement.

Commentary on 'Different antibiotic treatments for group A streptococcal pharyngitis (Review)'.

This is a commentary of Cochrane review, published in this issue of EBCH, first published as: van Driel ML, De Sutter AIM, Keber N, Habraken H, Christiaens T. Different antibiotic treatments for group A streptococcal pharyngitis (Review). Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.:CD004406. DOI: 10.1002/14651858.CD004406.pub2. Further information for this Cochrane review is available in this issue of EBCH in the accompanying Summary article. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane Collaboration.

Re-evaluation of antibiotic treatment of streptococcal pharyngitis.

PURPOSE OF REVIEW: Recently, recommendations from the American Heart Association regarding treatment of streptococcal tonsillo-pharyngitis were revised. This review provides the background for changes that were made in comparison with the group's 1995 recommendations. Recent papers on other issues relating to group A Streptococcus are also reviewed. RECENT FINDINGS: For antibiotic treatment of streptococcal tonsillopharyngitis the recommendations for injectable penicillin and for oral erythromycin are downgraded. First choice remains penicillin V but there is increasing acceptance of once-daily amoxicillin. CONCLUSION: Streptococcal pharyngitis is still a major infectious disease seen in pediatric office practice. The main job of the practitioner is to make an accurate diagnosis and provide appropriate treatment in timely fashion in order to prevent acute rheumatic fever.

Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics.

Primary prevention of acute rheumatic fever is accomplished by proper identification and adequate antibiotic treatment of group A beta-hemolytic streptococcal (GAS) tonsillopharyngitis. Diagnosis of GAS pharyngitis is best accomplished by combining clinical judgment with diagnostic test results, the criterion standard of which is the throat culture. Penicillin (either oral penicillin V or injectable benzathine penicillin) is the treatment of choice, because it is cost-effective, has a narrow spectrum of activity, and has long-standing proven efficacy, and GAS resistant to penicillin have not been documented. For penicillin-allergic individuals, acceptable alternatives include a narrow-spectrum oral cephalosporin, oral clindamycin, or various oral macrolides or azalides. The individual who has had an attack of rheumatic fever is at very high risk of developing recurrences after subsequent GAS pharyngitis and needs continuous antimicrobial prophylaxis to prevent such recurrences (secondary prevention). The recommended duration of prophylaxis depends on the number of previous attacks, the time elapsed since the last attack, the risk of exposure to GAS infections, the age of the patient, and the presence or absence of cardiac involvement. Penicillin is again the agent of choice for secondary prophylaxis, but sulfadiazine or a macrolide or azalide are acceptable alternatives in penicillin-allergic individuals. This report updates the 1995 statement by the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee. It includes new recommendations for the diagnosis and treatment of GAS pharyngitis, as well as for the secondary prevention of rheumatic fever, and classifies the strength of the recommendations and level of evidence supporting them.

Matched case-control analysis of polymicrobial bloodstream infection in a neonatal intensive care unit.

OBJECTIVE: To compare and contrast the epidemiology of polymicrobial and monomicrobial bloodstream infections (BSIs) in newborn intensive care unit (NICU) patients. DESIGN: Retrospective, matched case-control study. SETTING: The Yale-New Haven Hospital NICU from 1989 through 2006. SUBJECTS: NICU patients with BSIs. METHODS: Each neonate with polymicrobial BSI (case patient) was matched to one neonate with monomicrobial BSI (control patient), by birth date, weight, and sex; and univariate and multivariate analyses were performed. RESULTS: One hundred five cases of polymicrobial BSI were identified in 102 infants, representing 10% of all neonatal BSIs in our institution. Coagulase-negative staphylococci were the most common organisms recovered from culture. Infants with polymicrobial BSI had later onset of infection than infants with monomicrobial BSI (mean day of life, 37.5 vs 24.0; P<.001). Polymicrobial BSI occurred more frequently among infants with a severe underlying condition than in those without such a condition (odds ratio [OR], 1.8; 95% confidence interval [CI], 1.1-3.2) and among infants requiring an indwelling central venous catheter for a prolonged duration (mean, 16.9 days, compared with 9.8 days for infants with monomicrobial BSI; P=.001). Multivariate analysis revealed that later onset of infection (adjusted OR [aOR], 1.02; 95% CI, 1.00-1.04) and presence of a severe underlying condition (aOR, 1.91; 95% CI, 1.12-3.38) were independent risk factors for polymicrobial BSI. No differences in outcome or mortality were observed. CONCLUSIONS: Changes in the microbiology and epidemiology of NICU-related polymicrobial BSI have occurred since the last North American review. In the present study, although differences were observed, most risk factors and outcomes were similar between monomicrobial BSI and polymicrobial BSI. Epidemiologic surveillance is critical to identify trends associated with neonatal polymicrobial BSI, particularly those that may impact preventative strategies, diagnostic measures, and therapeutic interventions.