Finding the path of least resistance: Locally adapting the MITIGATE toolkit in emergency departments and urgent care centers.

The MITIGATE toolkit was developed to assist urgent care and emergency departments in the development of antimicrobial stewardship programs. At the University of Washington, we adopted the MITIGATE toolkit in 10 urgent care centers, 9 primary care clinics, and 1 emergency department. We encountered and overcame challenges: a complex data build, choosing feasible outcomes to measure, issues with accurate coding, and maintaining positive stewardship relationships. Herein, we discuss solutions to challenges we encountered to provide guidance for those considering using this toolkit.

Acute neuromuscular weakness in a boy with a facial abscess contaminated with Clostridium botulinum.

Wound botulism arising from skin and soft tissue infection is rare in children, most cases being reported in adult intravenous drug users. Cranial nerve palsies are the primary presenting sign, followed by descending neuromuscular weakness. Diagnosis relies on isolation of either toxigenic Clostridium botulinum species or toxin from wound or blood samples. We present an unusual case of wound botulism in a pediatric patient with the intent to inform the reader and improve the time to diagnosis in such cases.

Environmental factors associated with childhood-onset type 1 diabetes mellitus: an exploration of the hygiene and overload hypotheses.

OBJECTIVE: To assess the relationship between selected maternal and infant characteristics and risk of type 1 diabetes mellitus, specifically characteristics identified from birth records that may pertain to the hygiene or overload hypotheses. DESIGN: Population-based case-control study. SETTING: Washington State from 1987 to 2005. PARTICIPANTS: All children younger than 19 years hospitalized for type 1 diabetes (International Classification of Diseases, Ninth Revision codes 250.x1 and 250.x3) identified (n=1852) from hospital discharge data and linked with their birth certificates. Controls (n=7408) were randomly selected from birth records, frequency matched on year of birth. MAIN EXPOSURES: Maternal factors included age, race, educational attainment, marital status, use of Medicaid insurance, body mass index, prepregnancy weight, prior births, timing and adequacy of prenatal care, and cesarean delivery. Infant factors included birth weight, size for gestational age, and gestational age. MAIN OUTCOME MEASURE: The main outcome was first hospitalization for type 1 diabetes mellitus; adjusted odds ratios were estimated for the association of selected maternal and infant characteristics with type 1 diabetes. RESULTS: Consistent with the hygiene hypothesis, type 1 diabetes was negatively associated with having older siblings (for >or=3 siblings, odds ratio [OR], 0.56; 95% confidence interval [CI], 0.45-0.70) and with indicators of lower economic status or care access, such as an unmarried mother (OR, 0.79; 95% CI, 0.69-0.91), inadequate prenatal care (OR, 0.53; 95% CI, 0.40-0.71), or Medicaid insurance (OR, 0.67; 95% CI, 0.58-0.77). Related to the overload hypothesis, maternal body mass index of 30 or higher (OR, 1.29; 95% CI, 1.01-1.64) was associated with increased risk of diabetes. CONCLUSION: Environmental factors related to decreased antigenic stimulation in early life and maternal obesity may be associated with type 1 diabetes.

Toxic shock associated with Clostridium sordellii and Clostridium perfringens after medical and spontaneous abortion.

OBJECTIVE: To better understand the risk of fatal toxic shock caused by Clostridium sordellii in women who had a recent medical abortion with mifepristone and misoprostol. METHODS: We performed active and passive surveillance for cases of toxic shock associated with medical or spontaneous abortion. To identify the cause of toxic shock, immunohistochemical assays for multiple bacteria were performed on formalin-fixed surgical and autopsy tissues. We extracted DNA from tissues, performed Clostridium species-specific polymerase chain reaction assays, and sequenced amplified products for confirmation of Clostridium species. RESULTS: We report four patients with toxic shock associated with Clostridium species infection after medical or spontaneous abortion. Two women had fatal Clostridium perfringens infections after medically induced abortions: one with laminaria and misoprostol and one with the regimen of mifepristone and misoprostol. One woman had a nonfatal Clostridium sordellii infection after spontaneous abortion. Another woman had a fatal C sordellii infection after abortion with mifepristone and misoprostol. All four patients had a rapidly progressive illness with necrotizing endomyometritis. CONCLUSION: Toxic shock after abortion can be caused by C perfringens as well as C sordellii, can be nonfatal, and can occur after spontaneous abortion and abortion induced by medical regimens other than mifepristone and misoprostol. LEVEL OF EVIDENCE: III.