HIV in pregnancy: Identification of intrapartum and perinatal HIV exposures.

The benefits of human immunodeficiency virus (HIV) testing in pregnancy, when combined with appropriate maternal antiretroviral therapy and intrapartum and postnatal prophylaxis, are well established. The vertical rate of transmission of HIV in North America is now well below 2%. Efforts must continue to ensure that these benefits are sustained. Women who have received little or no prenatal care and those who present for delivery with unknown HIV status need immediate testing. As more infants are exposed to antiretroviral agents, strategies need to be implemented to ensure adequate follow-up of these infants. Issues relating to the identification of HIV-exposed infants are highlighted.

Invasive group A streptococcal disease: Management and chemoprophylaxis.

Reporting of severe invasive group A streptococcal disease (IGAS) has increased in Canada over the past decade, highlighting the importance of optimal chemoprophylaxis and management strategies. Canadian guidelines have had variable uptake across Canada. This practice point updates relevant aspects of these guidelines, with a focus on chemoprophylaxis of contacts of IGAS cases and clinical management of IGAS. The importance of penicillin in treating group A streptococcal disease is reaffirmed, and the role of clindamycin is discussed. In situations in which chemoprophylaxis may be considered, preferred agents are summarized.

The evolving epidemiology of Clostridium difficile infection in Canadian hospitals during a postepidemic period (2009-2015).

BACKGROUND: The clinical and molecular epidemiology of health care-associated Clostridium difficile infection in nonepidemic settings across Canada has evolved since the first report of the virulent North American pulsed-field gel electrophoresis type 1 (NAP1) strain more than 15 years ago. The objective of this national, multicentre study was to describe the evolving epidemiology and molecular characteristics of health care-associated C. difficile infection in Canada during a post-NAP1-epidemic period, particularly patient outcomes associated with the NAP1 strain. METHODS: Adult inpatients with C. difficile infection were prospectively identified, using a standard definition, between 2009 and 2015 through the Canadian Nosocomial Infection Surveillance Program (CNISP), a network of 64 acute care hospitals. Patient demographic characteristics, severity of infection and outcomes were reviewed. Molecular testing was performed on isolates, and strain types were analyzed against outcomes and epidemiologic trends. RESULTS: Over a 7-year period, 20 623 adult patients admitted to hospital with health care-associated C. difficile infection were reported to CNISP, and microbiological data were available for 2690 patients. From 2009 to 2015, the national rate of health care-associated C. difficile infection decreased from 5.9 to 4.3 per 10 000 patient-days. NAP1 remained the dominant strain type, but infection with this strain has significantly decreased over time, followed by an increasing trend of infection with NAP4 and NAP11 strains. The NAP1 strain was significantly associated with a higher rate of death attributable to C. difficile infection compared with non-NAP1 strains (odds ratio 1.91, 95% confidence interval [CI] 1.29-2.82). Isolates were universally susceptible to metronidazole; one was nonsusceptible to vancomycin. The proportion of NAP1 strains within individual centres predicted their rates of health care-associated C. difficile infection; for every 10% increase in the proportion of NAP1 strains, the rate of health care-associated C. difficile infection increased by 3.3% (95% CI 1.7%-4.9%). INTERPRETATION: Rates of health care-associated C. difficile infection have decreased across Canada. In nonepidemic settings, NAP4 has emerged as a common strain type, but NAP1, although decreasing, continues to be the predominant circulating strain and remains significantly associated with higher attributable mortality.

Needle stick injuries in the community.

When children sustain injuries from needles discarded in public places, concerns arise about possible exposure to blood-borne viruses. The risk of infection is low, but assessment, counselling, and follow-up of the injured child are needed. This statement reviews the literature concerning blood-borne viral infections after injuries from needles discarded in the community, and provides recommendations for the prevention and management of such incidents.

Infection prevention and control in paediatric office settings.

Transmission of infection in the paediatric office is an issue of increasing concern. This document discusses routes of transmission of infection and the principles of current infection control measures. Prevention includes appropriate office design and administrative policies, triage, routine practices for the care of all patients (e.g., hand hygiene; use of gloves, masks, eye protection, and gowns for specific procedures; adequate cleaning, disinfection, and sterilization of surfaces and equipment, including toys; and aseptic technique for invasive procedures), and additional precautions for specific infections. Personnel should be adequately immunized, and those infected should follow work-restriction policies.

Vaccine recommendations for children and youth for the 2017/2018 influenza season.

The Canadian Paediatric Society continues to encourage annual influenza vaccination for ALL children and youth ≥6 months of age. Recommendations from the National Advisory Committee on Immunization (NACI) for the 2017/2018 influenza season are not substantially changed from those of last season. NACI has conducted a review of all available vaccine effectiveness data concerning live attenuated influenza vaccine (LAIV) and concludes that current evidence supports the continued use of LAIV in Canada, although use is not currently recommended in the USA because of concern about efficacy.

Immunization of the immunocompromised child: Key principles.

The immunization of immunocompromised children requires vaccination strategies that provide maximum protection with minimal harm. Responsibility for immunization is shared by their primary care providers and their specialists. Detailed guidelines are published in the current version of the Canadian Immunization Guide and general principles are outlined here.

Vaccine recommendations for children and youth for the 2018/2019 influenza season.

The Canadian Paediatric Society continues to encourage annual influenza vaccination for all children and youth ≥6 months of age. Recommendations from the National Advisory Committee on Immunization (NACI) for the 2018/2019 influenza season are not substantially changed from those of last season. Quadrivalent vaccine, if available, is recommended for children 6 months to 17 years of age. Either inactivated influenza vaccine or live attenuated influenza vaccine may be used for children and youth 2 to 17 years of age who are not immunocompromised.

Vaccine recommendations for children and youth for the 2015/2016 influenza season.

The Canadian Paediatric Society continues to encourage annual influenza vaccination for ALL children and youth ≥6 months of age. Recommendations from the National Advisory Committee on Immunization for the 2015/2016 influenza season include some important changes: Children and adolescents with neurological or neurodevelopmental disorders were added to the list of individuals considered to be at high risk for severe influenza.Quadrivalent influenza vaccines are recommended preferentially over trivalent vaccines for use in children and youth.An adjuvanted trivalent inactivated influenza vaccine is now available for use in children six to 23 months of age.

La Société canadienne de pédiatrie continue d'encourager la vaccination antigrippale annuelle de TOUS les enfants et adolescents de six mois et plus. Les recommandations du Comité consultatif national de l'immunisation pour la saison grippale 2015­2016 comportent quelques changements importants : Les enfants et les adolescents atteints d'une affection neurologique ou neurodéveloppementale ont été ajoutés à la liste de personnes considérées comme à haut risque d'une grippe grave.Les vaccins antigrippaux quadrivalents inactivés sont recommandés de préférence aux vaccins trivalents inactivés chez les enfants et les adolescents.Un vaccin antigrippal trivalent inactivé contenant un adjuvant est désormais offert pour les enfants de six à 23 mois.

Preventing ophthalmia neonatorum.

The use of silver nitrate as prophylaxis for neonatal ophthalmia was instituted in the late 1800s to prevent the devastating effects of neonatal ocular infection with Neisseria gonorrhoeae. At that time - during the preantibiotic era - many countries made such prophylaxis mandatory by law. Today, neonatal gonococcal ophthalmia is rare in Canada, but ocular prophylaxis for this condition remains mandatory in some provinces/ territories. Silver nitrate drops are no longer available and erythromycin, the only ophthalmic antibiotic eye ointment currently available for use in newborns, is of questionable efficacy. Ocular prophylaxis is not effective in preventing chlamydial conjunctivitis. Applying medication to the eyes of newborns may result in mild eye irritation and has been perceived by some parents as interfering with mother-infant bonding. Physicians caring for newborns should advocate for rescinding mandatory ocular prophylaxis laws. More effective means of preventing ophthalmia neonatorum include screening all pregnant women for gonorrhea and chlamydia infection, and treatment and follow-up of those found to be infected. Mothers who were not screened should be tested at delivery. Infants of mothers with untreated gonococcal infection at delivery should receive ceftriaxone. Infants exposed to chlamydia at delivery should be followed closely for signs of infection.

Le nitrate d'argent a commencé à être utilisé en prophylaxie à la fin des années 1800 pour prévenir les effets dévastateurs de l'infection oculaire à Neisseria gonorrhoeae du nouveau-né. À cette époque où les antibiotiques n'existaient pas, cette prophylaxie avait force de loi dans de nombreux pays. De nos jours, la conjonctivite gonococcique du nouveau-né est rare au Canada, mais la prophylaxie oculaire demeure obligatoire dans certaines provinces et certains territoires. Les gouttes de nitrate d'argent ne sont plus en marché, tandis que l'efficacité de l'érythromycine, le seul onguent antibiotique actuellement offert pour les nouveau-nés, est douteuse. La prophylaxie oculaire ne prévient pas la conjonctivite à Chlamydia avec efficacité. L'application de médicaments dans les yeux des nouveau-nés peut provoquer une irritation oculaire bénigne. Pour certains parents, cette pratique nuit à l'attachement entre la mère et son nourrisson. Les médecins qui s'occupent de nouveau-nés devraient plaider pour la suppression des lois qui obligent la prophylaxie oculaire. Parmi les moyens plus efficaces de prévenir la conjonctivite néonatale, soulignons le dépistage de la gonorrhée et de la Chlamydia chez toutes les femmes enceintes et le traitement et le suivi de celles qui sont infectées. Les femmes qui n'ont pas été soumises au dépistage devraient l'être à l'accouchement. Les nourrissons de mères chez qui on décèle, à l'accouchement, une gonococcie non traitée devraient recevoir de la ceftriaxone. Ceux exposés à la Chlamydia lors de l'accouchement devraient faire l'objet d'un suivi étroit pour déceler tout signe d'infection.

Preventing ophthalmia neonatorum.

The use of silver nitrate as prophylaxis for neonatal ophthalmia was instituted in the late 1800s to prevent the devastating effects of neonatal ocular infection with Neisseria gonorrhoeae. At that time - during the preantibiotic era - many countries made such prophylaxis mandatory by law. Today, neonatal gonococcal ophthalmia is rare in Canada, but ocular prophylaxis for this condition remains mandatory in some provinces/ territories. Silver nitrate drops are no longer available and erythromycin, the only ophthalmic antibiotic eye ointment currently available for use in newborns, is of questionable efficacy. Ocular prophylaxis is not effective in preventing chlamydial conjunctivitis. Applying medication to the eyes of newborns may result in mild eye irritation and has been perceived by some parents as interfering with mother-infant bonding. Physicians caring for newborns should advocate for rescinding mandatory ocular prophylaxis laws. More effective means of preventing ophthalmia neonatorum include screening all pregnant women for gonorrhea and chlamydia infection, and treatment and follow-up of those found to be infected. Mothers who were not screened should be tested at delivery. Infants of mothers with untreated gonococcal infection at delivery should receive ceftriaxone. Infants exposed to chlamydia at delivery should be followed closely for signs of infection.

Le nitrate d'argent a commencé à être utilisé en prophylaxie à la fin des années 1800 pour prévenir les effets dévastateurs de l'infection oculaire à Neisseria gonorrhoeae du nouveau-né. À cette époque où les antibiotiques n'existaient pas, cette prophylaxie avait force de loi dans de nombreux pays. De nos jours, la conjonctivite gonococcique du nouveau-né est rare au Canada, mais la prophylaxie oculaire demeure obligatoire dans certaines provinces et certains territoires. Les gouttes de nitrate d'argent ne sont plus en marché, tandis que l'efficacité de l'érythromycine, le seul onguent antibiotique actuellement offert pour les nouveau-nés, est douteuse. La prophylaxie oculaire ne prévient pas la conjonctivite à Chlamydia avec efficacité. L'application de médicaments dans les yeux des nouveau-nés peut provoquer une irritation oculaire bénigne. Pour certains parents, cette pratique nuit à l'attachement entre la mère et son nourrisson. Les médecins qui s'occupent de nouveau-nés devraient plaider pour la suppression des lois qui obligent la prophylaxie oculaire. Parmi les moyens plus efficaces de prévenir la conjonctivite néonatale, soulignons le dépistage de la gonorrhée et de la Chlamydia chez toutes les femmes enceintes et le traitement et le suivi de celles qui sont infectées. Les femmes qui n'ont pas été soumises au dépistage devraient l'être à l'accouchement. Les nourrissons de mères chez qui on décèle, à l'accouchement, une gonococcie non traitée devraient recevoir de la ceftriaxone. Ceux exposés à la Chlamydia lors de l'accouchement devraient faire l'objet d'un suivi étroit pour déceler tout signe d'infection.

Vaccine recommendations for children and youth for the 2014/2015 influenza season.

The Canadian Paediatric Society continues to encourage annual influenza vaccination for ALL children and youth ≥6 months of age. Recommendations from the National Advisory Committee on Immunization for the 2014/2015 influenza season include some important changes: Influenza vaccination is recommended for ALL individuals ≥6 months of age, with particular focus on those at high risk of influenza-related complications and their close contacts. Definitions of high-risk conditions and close contacts have not changed from those of 2013/2014.The preference for intranasal, live attenuated influenza vaccine (LAIV) over trivalent inactivated influenza vaccines for healthy children is restricted to individuals two to six years of age. There is insufficient evidence to recommend LAIV over trivalent inactivated influenza vaccines in older children or in children with chronic health conditions; either vaccine may be used unless there are specific contraindications.Quadrivalent influenza vaccines are expected to be available for the 2014/2015 season and may be used interchangeably with trivalent vaccines. They may offer improved protection.Trivalent or quadrivalent inactivated vaccines may be used in individuals with egg allergy; LAIV has not yet been evaluated in this population and is not recommended at this time.

La Société canadienne de pédiatrie continue d'encourager la vaccination antigrippale annuelle de TOUS les enfants et adolescents de six mois et plus. Les recommandations du Comité consultatif national de l'immunisation pour la saison grippale 2014­2015 comportent quelques changements importants : La vaccination antigrippale est recommandée pour TOUTES les personnes de six mois et plus, notamment celles qui sont à haut risque de complications liées à la grippe et leurs contacts étroits. Les définitions d'affections à haut risque et de contacts étroits n'ont pas changé depuis 2013­2014.Chez les enfants en santé, la préférence pour le vaccin vivant atténué contre l'influenza (VVAI) administré par voie intranasale plutôt que pour les vaccins trivalents inactivés contre la grippe se limite aux enfants de deux à six ans. Les données ne sont pas suffisantes pour recommander le VVAI plutôt que les vaccins trivalents inactivés contre la grippe chez les enfants plus âgés ou atteints d'affections chroniques. Les deux vaccins peuvent être utilisés, à moins de contre-indications précises.Les vaccins antigrippaux quadrivalents devraient être homologués pour la saison 2014­2015 et sont interchangeables avec les vaccins trivalents. Il est possible qu'ils offrent une meilleure protection.Les vaccins trivalents ou quadrivalents inactivés peuvent être utilisés pour les personnes allergiques aux œufs. Le VVAI n'a pas encore été évalué au sein de cette population et n'est donc pas recommandé pour l'instant.

Influenza vaccine recommendations for children and youth for the 2013/2014 season.

Recommendations from the National Advisory Committee on Immunization concerning indications for the routine influenza vaccination of children and their close contacts have not changed from those of 2012/2013. Intranasal, live attenuated influenza vaccine (LAIV) is preferred over trivalent inactivated influenza vaccines (TIV) for healthy children and youth. There is insufficient evidence to recommend LAIV over TIV in children with chronic health conditions; either may be used unless there are specific contraindications. TIV may be used in persons with egg allergy; LAIV has not yet been evaluated in this population and is not recommended at this time.

Les recommandations du Comité consultatif national de l'immunisation à l'égard des indications relatives à l'administration systématique du vaccin contre l'influenza chez les enfants et leurs contacts étroits n'ont pas changé par rapport à celles de 2012­2013. Le vaccin vivant atténué contre l'influenza (VVAI) administré par voie intranasale est préférable au vaccin trivalent inactivé (VTI) pour les enfants et les adolescents en santé. Les données sont insuffisantes pour recommander le VVAI de préférence au VTI chez les enfants ayant une maladie chronique. Les deux vaccins peuvent être utilisés, à moins de contre-indications. Le VTI peut être utilisé chez les personnes allergiques aux œufs, tandis que le VVAI n'a pas encore été évalué au sein de cette population et n'est donc pas recommandé pour l'instant.

Burden of illness in infants and young children hospitalized for respiratory syncytial virus: A rapid review.

Respiratory syncytial virus (RSV) infections are common among young children and represent a significant burden to patients, their families and the Canadian health system. Here we conduct a rapid review of the burden of RSV illness in children 24 months of age or younger. Four databases (Medline, Embase, Cochrane Database of Clinical Trials, ClinicalTrials.gov from 2014 to 2018), grey literature and reference lists were reviewed for studies on the following: children with or without a risk factor, without prophylaxis and with lab-confirmed RSV infection. Of 29 studies identified, 10 provided within-study comparisons and few examined clinical conditions besides prematurity. For infants of 33-36 weeks gestation (wGA) versus term infants, there was low-to-moderate certainty evidence for an increase in RSV-hospitalizations (n=599,535 infants; RR 2.05 [95% CI 1.89-2.22]; 1.3 more per 100 [1.1-1.5 more]) and hospital length of stay (n=7,597 infants; mean difference 1.00 day [95% CI 0.88-1.12]). There was low-to-moderate certainty evidence of little-to-no difference for infants born at 29-32 versus 33-36 wGA for hospitalization (n=12,812 infants; RR 1.20 [95% CI 0.92-1.56]). There was low certainty evidence of increased mechanical ventilation for hospitalized infants born at 29-32 versus 33-35 wGA (n=212 infants; RR 1.58, 95% CI 0.94-2.65). Among infants born at 32-35 wGA, hospitalization for RSV in infancy may be associated with increased wheeze and asthma-medication use across six-year follow-up (RR range 1.3-1.7). Children with versus without Down syndrome may have increased hospital length of stay (n=7,206 children; mean difference 3.00 days, 95% CI 1.95-4.05; low certainty). Evidence for other within-study comparisons was of very low certainty. In summary, prematurity is associated with greater risk for RSV-hospitalization and longer hospital length of stay, and Down syndrome may be associated with longer hospital stay for RSV. Respiratory syncytial virus-hospitalization in infancy may be associated with greater wheeze and asthma-medication use in early childhood. Lack of a comparison group was a major limitation for many studies.

Risky business: failure to prevent and failure to communicate.

Healthcare-associated infections (HAIs), important threats to patient safety, are considered differently from other adverse events. Gardam and his colleagues discuss several reasons for this and outline approaches that may bring about changes in attitudes and enhance HAI prevention. We comment on the potential preventability of HAIs, the need for improved communication strategies and the different vision of the role of infection control personnel suggested by Gardam et al. Recent developments in infection control structure and management and patient safety in Quebec are summarized.

Paediatric abdominal tuberculosis in developed countries: case series and literature review.

OBJECTIVE: To provide an insight into the presentation, diagnosis and management of paediatric abdominal tuberculosis (TB) in developed countries. METHODS: The records of all children at the Montreal Children's Hospital (MCH) admitted with abdominal TB between 1990 and 2014 were reviewed. An automated and manual literature search from 1946 to 2014 was performed. RESULTS: (1) CASE SERIES: six cases were identified at the MCH. All were male between 5 and 17 years of age. All were from populations known to have high rates of TB (aboriginal, immigrant). Three underwent major surgical interventions and three underwent ultrasound (US) or CT aspiration or biopsy for diagnosis. (2) LITERATURE REVIEW: 29 male (64%) and 16 female subjects (36%) aged between 14 months and 18 years were identified, including the MCH patients. All patients except one were from populations with a high incidence of TB. Most presented with a positive tuberculin skin test (90%), abdominal pain (76%), fever (71%) and weight loss (68%). On imaging, 22 (49%) were classified with gastrointestinal TB with colonic wall irregularity (41%) and 19 (42%) with peritoneal TB with ascites (68%). A positive culture was obtained in 33 (73%) patients. Three cases used CT- or US-guided aspiration or biopsy to obtain tissue samples. A surgical intervention was performed in 34 (76%) children; 13 (38%) of these were for diagnosis. CONCLUSIONS: Diagnosis based on clinical features (abdominal pain, fever and weight loss) and CT- or US-guided aspiration or biopsy may encourage physicians to adopt a more conservative approach to abdominal TB.

Lack of evidence of encephalopathy related to pertussis vaccine: active surveillance by IMPACT, Canada, 1993-2002.

To assess whether pertussis-containing vaccines cause encephalitis or encephalopathy, the IMPACT network of Canadian pediatric centers screened more than 12,000 admissions for neurologic disorders between 1993 and 2002. Seven cases of encephalopathy began within 7 days after pertussis vaccination, but a more likely cause was found in each instance. No attributable case followed administration of >6.5 million doses of vaccine.

Surgical-site infection following spinal fusion: a case-control study in a children's hospital.

OBJECTIVES: To determine the rates of surgical-site infections (SSIs) after spinal surgery and to identify the risk factors associated with infection. DESIGN: SSIs had been identified by active prospective surveillance. A case-control study to identify risk factors was performed retrospectively. SETTING: University-associated, tertiary-care pediatric hospital. PATIENTS: All patients who underwent spinal surgery between 1994 and 1998. Cases were all patients who developed an SSI after spinal surgery. Controls were patients who did not develop an SSI, matched with the cases for the presence or absence of myelodysplasia and for the surgery date closest to that of the case. RESULTS: There were 10 infections following 125 posterior spinal fusions, 4 infections after 50 combined anterior-posterior fusions, and none after 95 other operations. The infection rate was higher in patients with myelodysplasia (32 per 100 operations) than in other patients (3.4 per 100 operations; relative risk = 9.45; P < .001). Gram-negative organisms were more common in early infections and Staphylococcus aureus in later infections. Most infections occurred in fusion involving sacral vertebrae (odds ratio [OR] = 12.0; P = .019). Antibiotic prophylaxis was more frequently suboptimal in cases than in controls (OR = 5.5; P = .034). Five patients required removal of instrumentation and 4 others required surgical debridement. CONCLUSIONS: Patients with myelodysplasia are at a higher risk for SSIs after spinal fusion. Optimal antibiotic prophylaxis may reduce the risk of infection, especially in high-risk patients such as those with myelodysplasia or those undergoing fusion involving the sacral area.