Antibiotic Treatments and Patient Outcomes in Necrotizing Enterocolitis.

OBJECTIVE: This study aimed to examine the impact of different antibiotic treatments on necrotizing enterocolitis (NEC) outcomes. STUDY DESIGN: Patient outcomes, including total parenteral nutrition and hospitalization durations, abdominal surgeries, intestinal strictures, and mortality data, were analyzed and compared by various antibiotic groups and treatment durations for 160 NEC patients managed at the Women and Children's Hospital of Buffalo between 2008 and 2016. RESULTS: Fourteen different antibiotics were used for NEC, most commonly ampicillin, gentamicin, and metronidazole (AGM). Medical (vs. surgical) NEC patients more likely received AGM (37 vs. 6%, p < 0.001). Surgical (vs. medical) NEC patients more likely received vancomycin (80 vs. 30%, p < 0.001) and antipseudomonal agents (69 vs. 15%, p < 0.001). For medical NEC there were no outcome differences between patients receiving only AGM versus those receiving other treatments; in patients receiving AGM, there were no outcome differences in durations of ≤10 days versus longer courses. CONCLUSION: Antibiotic use for NEC varies substantially without definite outcome differences. Particularly with medical NEC, AGM for ≤10 days had comparable outcomes to other treatments. In light of growing concern for short and longer term adverse effects with early-life antibiotic exposure, narrow-spectrum and shorter course NEC treatment may be preferred.

Kawasaki disease and vasculitis associated with immunization.

The etiology and pathogenesis of Kawasaki disease (KD) remain poorly understood. Among the diverse infectious and environmental factors examined to be triggers for, or be associated with, KD, are immunizations. In this report, we first describe the case of a Caucasian girl who presented with classic KD shortly after receiving her routine 4 months vaccination series. Prior published case reports and large epidemiological studies, which explore potential associations between immunization and KD and other vasculitides, are then comprehensively reviewed. The methodologic challenges that complicate analysis in this area are also considered.

Global antimicrobial resistance: a complex and dire threat with few definite answers.

Alors que divers organismes internationaux ont récemment proposé des plans pour la création de systèmes de surveillance de la résistance antimicrobienne (RAM), la plupart des PRMF ne disposent pas des infrastructures et des ressources pour le faire efficacement. La RAM est donc un problème majeur d'équité en matière de santé, mais aussi un exemple de la connexion dans notre monde unique: les populations les plus à risque disposent des mécanismes de surveillance et de confinement les plus médiocres; dans le même temps, la migration mondiale, les voyages et le commerce nous rendent tous vulnérables. Les mesures que nous utilisons actuellement ne capturent pas de manière significative l'impact potentiel de la RAM aux niveaux sanitaire, économique et sociétal plus large. La surveillance mondiale de la RAM devrait inclure une surveillance étroite de l'utilisation d'antibiotiques chez les animaux, ainsi que les concentrations de divers produits chimiques libérés dans l'environnement. En fin de compte, les efforts coordonnés de divers scientifiques et parties prenantes, dans diverses disciplines et dans le monde, sont essentiels pour relever les défis pressants de la RAM mondiale croissante.

Neonatal listeriosis: a rare but not-to-be forgotten infection.

Listeria monocytogenes is a foodborne pathogen, typically associated with contaminated dairy products and deli meats. L. monocytogenes can lead to severe infections in high-risk patient populations; in neonates, listeriosis is rare but carries a high rate of neurological morbidity and mortality. Here a case of neonatal listeriosis, in the newborn of a young Hispanic mother who frequently ate queso fresco (a fresh Mexican cheese), is presented. Pregnant women are commonly counselled to avoid unpasteurised dairy during the pregnancy, but many are unaware that soft cheeses, and other food products, may pose risks for perinatal infection. L. monocytogenes remains a cause of food-related outbreaks and maternal and neonatal sepsis around the world, and healthcare providers should ensure that expectant mothers are carefully counselled regarding potential sources.

Accuracy of Antibiotic Prescription Dosing for Urinary Tract Infections in a Regional Pediatric Ambulatory Care Setting.

OBJECTIVE: Antibiotics are the most common class of medication prescribed in pediatrics, with the majority of prescriptions occurring in the outpatient setting. Our objective was to evaluate the accuracy of antibiotic dose, frequency, and formulation prescribed for urinary tract infections (UTIs) in the pediatric ambulatory care setting. METHODS: This was a retrospective review of electronic medical records conducted at 2 suburban pediatric practices in a mid-sized metropolitan region. Encounter-related prescriptions were identified using UTI-associated International Classification of Diseases, 10th Revision codes. Patients aged 2 months through 18 years were included if they had been prescribed an oral antibiotic for the treatment of UTI. Antibiotic dose, frequency, and formulation were considered accurate if consistent with clinical guidelines and tertiary dosing references. RESULTS: Nearly 1 in 4 prescriptions had dosing inaccuracies. The proportion of errors was highest with amoxicillin-clavulanate (75%; 9/12) and amoxicillin (52%; 33/64). The most common reasons for dosing incorrectly were "low dose" or "unnecessarily high dose." Additionally, 55% of the included prescriptions were for oral suspensions, and 1 in 4 of these were dosed incorrectly. CONCLUSIONS: Inaccuracies in antibiotic prescribing for pediatric UTI are common, including for frequently prescribed agents and oral formulations. To address these missed opportunities for stewardship in the outpatient setting, key educational sessions with providers should include reviewing optimal antibiotic dosing for uropathogens and highlighting common errors when oral suspensions are prescribed.

The Role of a Spinning Top Urethra in the Development of Pyosalpinx in a Precoital Female.

Pelvic inflammatory disease (PID) is commonly related to sexual intercourse in postpubescent females. Inflammation of the fallopian tubes (pyosalpinx) is a common complication. We describe a case of anatomic spinning top-shaped urethra that led lead to complicated recurrent severe abdominal infections in an 11-year-old precoital female. This case highlights that prepubescent females can have pyosalpinx and pelvic inflammatory disease and anatomic contributions to these presentations should be considered.

Pediatric Antibiotic Prescribing and Utilization Practices for RTIs at Private Urgent Care Centers.

Data on pediatric antibiotic prescribing and utilization practices at urgent care centers (UCC) remain limited. In this study, an electronic medical record-based review of UCC encounters for respiratory tract infections (RTI) of patients belonging to one mid-sized pediatric practice was performed. Antibiotic prescribing and guideline adherence were compared between UCCs that were staffed exclusively by pediatric-trained providers to those staffed otherwise. Of a total of 457 RTI visits, 330 (72%) occurred at the pediatric UCC. Across all bacterial RTIs, 82% of encounters at the pediatric UCC were guideline-adherent versus 59% at nonpediatric UCCs (P < .001). At nonpediatric UCCs, pharyngitis was the most common RTI encounter diagnosis (40%), and full streptococcal management guideline adherence was 41%. While 93% of RTI-UCC encounters for <2 years were at pediatric UCCs, the majority of children >10 presented to nonpediatric UCCs. RTI guideline education to UCCs should be a focus of ambulatory stewardship efforts.

Infant with a rapidly progressing rash.

An infant presented to the emergency department with sudden onset of rapidly progressing erythematous macules and distal oedema. The rash was striking in appearance, covering most of the body, which raised concern for pressing infectious (eg, meningococcaemia) and other serious aetiologies. Nevertheless, the infant remained playful and was overall stable and posed a diagnostic and management dilemma. After an extensive workup and multispecialty consultations, the patient was eventually diagnosed with acute haemorrhagic oedema of infancy, a benign leucocytoclastic vasculitis. The patient received no treatment and resolution of the rash occurred within 7 days of onset. Recognition of this condition and its benign nature can spare patients from an extensive workup and reduce anxiety for both family members and healthcare providers.

Increasing incidence of post-kala-azar dermal leishmaniasis in a population-based study in Bangladesh.

Post-kala-azar dermal leishmaniasis (PKDL) occurs after kala-azar treatment and acts as a durable infection reservoir. On the basis of active case finding among 22,699 respondents, 813 (3.6%) had had kala-azar since 2002, of whom 79 (9.7%) developed PKDL. Eight additional patients with PKDL had no history of kala-azar. Annual kala-azar incidence peaked at 85 cases per 10,000 person-years in 2004 and fell to 46 cases per 10,000 person-years in 2007, but PKDL incidence rose from 1 case per 10,000 person-years in 2002-2004 to 21 cases per 10,000 person-years in 2007. The rising PKDL incidence threatens the regional visceral leishmaniasis elimination initiative and underscores the urgent need for more effective PKDL diagnosis and treatment.

Optimal Antibiotics at Hospital Discharge for Children With Urinary Tract Infection.

OBJECTIVES: Antibiotic stewardship at hospital discharge is an area of need. We assessed the rate of optimal antibiotic prescriptions at hospital discharge, on the basis of urine culture and susceptibility data, for children diagnosed with a urinary tract infection (UTI). METHODS: We conducted a retrospective study of patients ≤18 years of age who were admitted to a general pediatrics service at a freestanding children's hospital during 2017 with a diagnosis of UTI and received an antibiotic prescription at discharge. For the primary analysis, optimal antibiotic at hospital discharge was determined by evaluating if the cultured urinary pathogen was susceptible to the prescribed antibiotic and if the antibiotic was the narrowest-spectrum option available. Secondary objectives included assessment of antibiotic dosing accuracy and description of antibiotic treatment duration. RESULTS: A total of 78 cases were included. Sixty-eight (83%) cases were caused by cefazolin-susceptible Escherichia coli and Klebsiella species. Thirty-one (40%) cases had a discharge antibiotic prescription that was determined to be optimal. Of the 47 (60%) cases that were suboptimal, 44 (94%) were considered to be excessively broad spectrum. In 3 (6%) cases, the causative organism was nonsusceptible to the prescribed antibiotic. Ten (13%) discharge antibiotic prescriptions had inaccurate dosing and/or frequency. CONCLUSIONS: Missed opportunities for narrow-spectrum antibiotic selection at hospital discharge for pediatric UTIs frequently occurred. In particular, higher-generation cephalosporins and ciprofloxacin were often prescribed for cephalexin-susceptible cases. Antibiotic stewardship attention, specifically at hospital discharge for pediatric UTIs, is likely to have a high impact.

Coronavirus Disease 2019 in a Premature Infant: Vertical Transmission and Antibody Response or Lack Thereof.

With the global spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection, several reports highlight its effects on pregnant women. Based on scant available data, vertical transmission is considered unlikely. We present here a preterm neonate born to a critically ill mother with SARV-CoV-2 with early evidence of infection with a positive reverse transcription polymerase chain reaction on day 1. Lack of parental contact prior to testing and strict adherence to recommended airborne precautions perinatally suggest vertical transmission of infection. Critical maternal illness and medications may have contributed to the need for extensive resuscitation at birth and highlight the importance of close fetal monitoring. Infant lacked immunoglobulin G antibody response by 3 weeks, presumably secondary to mild clinical course and prematurity. Effects of SARS-CoV-2 in preterm infants, their antibody response and potential for asymptomatic carriage remain uncertain.

Guideline Adherence and Antibiotic Utilization by Community Pediatricians, Private Urgent Care Centers, and a Pediatric Emergency Department.

Pediatric antibiotic prescriptions originate from an increasingly broad range of ambulatory settings. In this retrospective study, pharyngitis, otitis media, sinusitis, pneumonia, and upper respiratory infection cases, at 11 primary care offices, 2 independent urgent care centers (UCCs), and a pediatric emergency department in Western New York, were analyzed relative to medical society practice guidelines and antibiotic utilization. Of 2358 eligible visits across all sites, 25% were for study diagnoses, with 38% at UCC (P < .01). Across all sites, 26% of pharyngitis cases given antibiotics did not have diagnostic evidence of bacterial infection. At primary care offices and UCCs, guideline recommended first-line agents for pharyngitis and otitis media were used in only 58% and 63% of treated cases, respectively. Overall, an estimated 9855 to 12 045 avoidable antibiotic and 8030 non-guideline antibiotic courses annually are represented by the 14 sites studied. These and other study findings highlight numerous opportunities for outpatient pediatric antibiotic stewardship.

Retrospective suspect screening reveals previously ignored antibiotics, antifungal compounds, and metabolites in Bangladesh surface waters.

Densely populated countries in Asia, such as Bangladesh, are considered to be major contributors to the increased occurrence of global antimicrobial resistance (AMR). Several factors make low-and middle-income countries vulnerable to increased emergence and spread of AMR in the environment including limited regulations on antimicrobial drug use, high volume of antimicrobials used in human medicine and agricultural production, and poor wastewater management. Previous monitoring campaigns to investigate the presence of antibiotics in the aquatic environment have employed targeted analysis in which selected antibiotics are measured using liquid chromatography with tandem mass spectrometry (LC/MS/MS). However, this approach can miss several important contaminants that can contribute to the selective pressure that promotes maintenance and dissemination of antibiotic resistance genes (ARGs) in the environment. Nontarget analysis by suspect screening and reanalysis of stored digital data of previously ran samples can provide information on analytes that were formerly uncharacterized and may be chemicals of emerging concern (CECs). In this study, surface waters in both urban and rural sites in Bangladesh were collected and analyzed for the presence of antibiotic residues and other pharmaceuticals. Utilizing targeted analysis, the antibiotics with the highest concentrations detected were ciprofloxacin (1407 ng/L) and clarithromycin (909 ng/L). In addition, using high-resolution LC/MS/MS in the first ever application of retrospective analysis in samples from Bangladesh, additional antibiotics clindamycin, lincomycin, linezolid, metronidazole, moxifloxacin, nalidixic acid, and sulfapyridine were detected. Prevalence of amoxicillin transformation products in surface waters was also confirmed. In addition, medicinal and agricultural antifungal compounds were frequently found in Bangladeshi surface waters. This later finding - the near ubiquity of antifungal agents in environmental samples - is of particular concern, as it may be contributing to the alarming rise of multi-drug resistant fungal (e.g. Candida auris) disease recently seen in humans throughout the world.

Lyme Arthritis in Children on the Uptick in Western New York Area.

OBJECTIVE: This study explores a suspected increasing incidence of Lyme arthritis in the Western New York pediatric population. In addition, we aim to describe a clinical picture of Lyme arthritis and the clinical features that distinguish it from other forms of arthritis. METHODS: Patients diagnosed with Lyme arthritis between January 2014 and September 2018 were identified using International Classification of Diseases-10th Revision (ICD 10) codes for Lyme disease and Lyme arthritis. Patients were included in the study if they (1) exhibited arthritis, (2) tested positive for Lyme antibodies, and (3) exhibited a positive Western blot. RESULTS: A total of 22 patients were included in the study. There was a general trend toward an increasing number of cases of Lyme arthritis over the 45-month observation period. We identified 1 case in each 2014 and 2015, 4 cases in 2016, 7 in 2017, and 9 in the first 9 months of 2018. In total, 17 patients had arthritis as their only symptom at the time of diagnosis and 10 patients had a rash or a history that prompted suspicion of Lyme disease. The knee was the most frequent joint (86.4% of patients), and patients typically had 2 or fewer joints affected (86.4% of patients). CONCLUSIONS: A significant increase (P = .02) in Lyme arthritis cases was observed at Oishei Children's Hospital of Buffalo. Lyme arthritis may clinically present similarly to other forms of arthritis, such as oligoarticular juvenile idiopathic arthritis, so health care providers should be aware of distinguishing clinical features, which include rapid onset of swelling and patient age. Because the geographic area of endemic Lyme disease is expanding, all health care providers need to be aware of Lyme arthritis as a possible diagnosis.

Rapidly progressing facial leishmaniasis: effective treatment with liposomal amphotericin B and a review of the management of Old World cutaneous leishmaniasis.

Cutaneous leishmaniasis (CL), a common condition in many parts of the world, is being increasingly encountered in non-endemic countries secondary to immigration. The clinical manifestations and course can vary substantially, with appropriate management ranging from observation for self-healing lesions to urgent treatment to prevent damaging anatomical and cosmetic sequelae. While there are now several effective medications, optimal therapy is not well defined, and decision-making can be challenged by the location of lesions and various drug issues, including availability, mode of delivery and adverse effects. A 7-year-old Afghani boy who presented shortly after arriving in the United States with a rapidly progressing crusting and ulcerative facial rash caused by Leishmania tropica is described. The various drugs currently available for CL and experience of using liposomal amphotericin B specifically are reviewed.

Recrudescing Plasmodium malariae infection despite appropriate treatment in an immigrant toddler.

Compared with other plasmodium species which cause human malaria, Plasmodium malariae is considered to be relatively infrequent and milder, although recent reports indicate that its prevalence and impact have been under-estimated. A 23-month-old boy, born and previously living in a refugee camp in Liberia who presented with P. malariae 6 weeks after arrival in the USA, is reported. Despite ostensibly effective anti-malarial treatment with artemether/lumefantrine and two courses of hydrochloroquine, he experienced recurrent parasitaemia, refractory anaemia and splenomegaly over a 6-month period; the symptoms resolved after he received atovaquone/proguanil. It is hypothesised that the recrudescing clinical malaria in this case was related to the long pre-erythrocytic phase unique to P. malariae, and potentially also to a proportion of the parasites being drug-resistant.