Instituting a New Central Line Policy to Decrease Central Line-associated Blood Stream Infection Rates During Induction Therapy in Pediatric Acute Lymphoblastic Leukemia Patients.

BACKGROUND: Children with acute lymphoblastic leukemia (ALL) require central lines to facilitate their care. Peripherally inserted central catheters (PICCs) may have lower rates of central line-associated bloodstream infections (CLABSIs) versus other central lines. OBJECTIVES: The objective of this study was to compare the CLABSI rate in the first month of therapy after initiating a policy to place PICCs in new patients with severe neutropenia (SN) and Mediports in those with moderate-to-no neutropenia. We also examined thrombosis rates. DESIGN/METHOD: We prospectively gathered data on new patients for 2.5 years following the policy change and retrospectively for the 2 years prior and compared rates of CLABSIs and thrombosis. RESULTS: CLABSIs decreased in SN patients from 7.52/1000 to 3.11/1000 line days (P=0.33). The CLABSI rate for all patients with SN who had a Mediport was 13.39/1000 versus 4.08/1000 line days for those that received PICCs (P=0.15). The thrombosis rate for Mediport patients was 3.13 clots/1000 versus 7.65/1000 line days for PICC patients, but the difference was not significant (P= 0.11). CONCLUSION: The differences observed suggest that placing PICCs versus Mediports in new ALL patients with SN may result in a lower incidence of CLABSIs in the first month of therapy without a significant increase in thrombosis.

Impact of the pneumococcal conjugate vaccine on serotype distribution and antimicrobial resistance of invasive Streptococcus pneumoniae isolates in Dallas, TX, children from 1999 through 2005.

BACKGROUND: Because the heptavalent pneumococcal conjugate vaccine has reduced vaccine-type invasive pneumococcal disease (IPD) in children, a greater proportion of IPD is now caused by nonvaccine (NVT) serotypes. We analyzed the serotypes, antimicrobial resistance profiles and genetic relatedness of Streptococcus pneumoniae responsible for IPD at Children's Medical Center of Dallas. METHODS: S. pneumoniae isolates were collected from January 1, 1999 through December 31, 2005. Incidence of IPD was calculated using inpatient and emergency center admissions to Children's Medical Center of Dallas as the denominator. Isolates were serotyped, and their penicillin and cefotaxime susceptibility determined. The 19A isolates were further characterized by pulsed-field gel electrophoresis, multilocus sequence typing and determination of penicillin-binding proteins and mef and erm genes. RESULTS: The incidence of IPD decreased from 93.6 cases/100,000 patients in 1999 to a nadir of 41 cases/100,000 patients in 2003 (P < 0.001). The number of IPD cases caused by serotype 19A increased, accounting for 40% of the cases of IPD in 2005. Penicillin and cefotaxime susceptibility of IPD isolates did not change from 1999 through 2005 (P = 0.687). There was a decrease in penicillin (P < 0.001) and cefotaxime (P = 0.034) susceptibility in NVT serotypes from 1999 to 2005. Molecular characterization of 19A isolates revealed a predominance of ST-199 (62%). Several highly penicillin-resistant and intermediately cefotaxime-resistant strains emerged in 2004 and 2005. CONCLUSIONS: In Dallas, heptavalent pneumococcal conjugate vaccine reduced the incidence of IPD from 1999 to 2005 by reducing the incidence of vaccine-type disease. NVT serotypes, particularly 19A, were prevalent and more resistant to antimicrobials in 2004 and 2005.

Clinical Experience with Daptomycin in Pediatrics.

INTRODUCTION: The management of gram-positive infections has been complicated in recent years by the emergence of antimicrobial resistance, leaving fewer options for therapy. Daptomycin is a lipopeptide antibiotic used for the systemic treatment of gram-positive infections. It has a distinct mechanism of action and a favorable side effect profile, and it requires once/day dosing. Unfortunately, there is a paucity of safety, efficacy, and pharmacokinetic data in neonatal and pediatric patients. The objective of this study was to review our experience with daptomycin use for the treatment of gram-positive infections in these patient populations. METHODS: We conducted a retrospective analysis of electronic medical records of hospitalized children who received daptomycin between October 2008 and June 2014 for the treatment of proven gram-positive infections. RESULTS: Of the 146 patients who received at least 3 days of daptomycin therapy, 109 patients had a proven gram-positive infection and were included for further analysis. Of the 109 patients, 71 were males (65%) and the median age was 12 years (range: 2.5 mo to 24 yrs). The median duration of therapy was 12 days (range: 3-121 days; mean = 16 days). Catheter-related bloodstream infections were the most common type of infections (n=81 patients) in those receiving daptomycin treatment. One hundred seven patients (98%) had documented improvement and resolution at the time of hospital discharge. One hundred four patients (95%) had a baseline creatine phosphokinase (CPK) level obtained. Of these 104 patients, 48 (46%) had at least one follow-up CPK level after the start of therapy. Three patients' charts showed laboratory evidence of elevated CPK values. CONCLUSIONS: The majority of patients demonstrated clinical improvement after receiving daptomycin as primary therapy for proven gram-positive infections. Larger randomized controlled trials focusing on safety and efficacy are necessary to assess these outcomes with daptomycin use in the pediatric population.

The management and outcome of spinal implant-related infections in pediatric patients: a retrospective review.

BACKGROUND: Infection after implantation of spinal rods is a significant complication of this procedure. Optimal treatment of surgical implants often involves device removal. This approach is problematic when treating spinal implant-related infections, because device removal may cause significant morbidity. Medical management of these infections is therefore necessary, but treatment regimens are not standardized. We conducted a retrospective review of pediatric patients with spinal implant-related infections at a regional spinal center for a 6-year period. We describe clinical course, duration of treatment and outcomes. METHODS: We reviewed records of patients with spinal implant-related infections from 2005 to 2010. Data collection included demographics, underlying diagnosis, surgical hardware, timing to infection after implantation, signs and symptoms of infection, duration of antimicrobials, adverse drug events and long-term outcomes. RESULTS: We enrolled 23 patients with spinal implant infections, aged 8-20 years. Wound drainage was the most common presenting symptom (82.6%). Median time from surgery to first infection was 16 days (range: 8-1052 days). Median length of antimicrobial therapy was 131 days (range: 42-597 days). Seventy eight percent were cured with antibiotics alone with implanted devices retained. Four patients failed medical therapy and required device removal. A wide range of antibiotic duration was used (42 to >597 days). Seven patients (30.4%) experienced at least 1 adverse drug event. CONCLUSIONS: Infection related to spinal instrumentation procedures can be managed medically with long-term antibiotic therapy. Careful monitoring for not only efficacy but also adverse drug events is advised. Further research is needed to determine the optimal duration of antibiotics for spinal implant-related infections.

Trimethoprim-sulfamethoxazole therapy for children with acute osteomyelitis.

BACKGROUND: The emergence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has complicated the conventional management of osteomyelitis. While oral clindamycin is commonly used to treat acute CA-MRSA osteomyelitis, the emergence of inducible clindamycin resistance among CA-MRSA isolates has made alternative therapy necessary. The excellent oral bioavailability, susceptibility profile, favorable palatability, and low cost of trimethoprim-sulfamethoxazole (TMP-SMX) make this drug an attractive option for treating osteomyelitis, yet its clinical efficacy for osteomyelitis has not been established. METHODS: Between October 1998 and September 2009, 20 children who received a TMP-SMX-containing regimen for acute osteomyelitis at All Children's Hospital were identified from hospital records, and their cases reviewed for clinical outcome and drug safety. RESULTS: Patients ranged in age from 9 months to 17 years. Twelve (60%) of the patients were male. Causative pathogens were found in 8 (40%) cases of which 5 were CA-MRSA and 3 were methicillin-susceptible Staphylococcus aureus. Eleven patients (55%) received TMP-SMX as their primary therapy. The median dose of TMP-SMX was 16.4 mg/kg/d. During TMP-SMX therapy, 8 patients (40%) experienced adverse events; all were considered mild. Duration of total therapy was 26 to 59 days, with a median of 40 days. All 20 patients were considered cured of their infection at the end of therapy. CONCLUSION: Orally administered TMP-SMX appears to be a useful and well-tolerated therapy for treatment of acute osteomyelitis in children. Further prospective comparative studies will be needed to confirm this observation.

Epidemiology and evolution of invasive pneumococcal disease caused by multidrug resistant serotypes of 19A in the 8 years after implementation of pneumococcal conjugate vaccine immunization in Dallas, Texas.

BACKGROUND: The heptavalent pneumococcal conjugate vaccine (PCV7) has significantly reduced vaccine-type invasive pneumococcal disease (IPD) in children. An increasing percentage of IPD cases are now caused by nonvaccine serotypes. The purpose of our observational study was to define the epidemiology of pneumococcal disease in Dallas, TX children for 8 years after implementation of PCV7 immunization. METHODS: Streptococcus pneumoniae isolates from normally sterile sites were collected at Children's Medical Center of Dallas from January 1, 1999 to December 31, 2008. Incidence of IPD was calculated using inpatient and emergency center admissions to Children's Medical Center of Dallas as the denominator. Isolates were serotyped and penicillin and cefotaxime susceptibilities were determined. Serotype 19A isolates were further characterized by multilocus sequence typing. RESULTS: Compared with the prevaccine period of 1999-2000, there was a significant reduction in the incidence of IPD from 2002 to 2008 (P < 0.05), although a significant increase in IPD incidence was observed from 2006 to 2008 (P = 0.038). The number of IPD cases caused by serotype 19A increased from 1999 to 2008 (P < 0.001). There were significant increases in penicillin and cefotaxime nonsusceptible 19A isolates during this 10-year period (P < 0.001 and P = 0.004, respectively). The most common sequence type (ST) of the 19A isolates was ST-199 (42.7%). Clonal complex (cc-156) and cc-320 emerged in the period of 2005-2008 as penicillin and cefotaxime resistant 19A strains. CONCLUSIONS: In Dallas, PCV7 immunization reduced significantly the incidence of IPD caused by vaccine-type strains. A significant increase in IPD caused by serotype 19A was observed. The penicillin and cefotaxime nonsusceptible STs, not previously identified in Dallas, have recently become an important cause of IPD.

Healthcare worker knowledge of measurement and documentation of tuberculin skin test reaction.

A cross-sectional survey of 210 healthcare workers at a pediatric teaching hospital was performed to assess knowledge of published guidelines for proper measurement and documentation of tuberculin skin test results. We conclude that many healthcare workers have inadequate knowledge for optimal measurement and documentation of tuberculin skin test results.

Herpes simplex virus encephalitis during suppressive therapy with acyclovir in a premature infant.

Cutaneous herpes simplex virus type 2 (HSV-2) infection was recognized at 19 days of age in a 1415-g female infant born at 31 weeks of gestation. Cerebrospinal fluid (CSF) HSV polymerase chain reaction (PCR) was negative, and MRI of the brain was normal. After a 14-day course of high-dose intravenous acyclovir, the infant developed a cutaneous recurrence at 38 days of age. CSF HSV PCR again was negative. She was subsequently begun on oral acyclovir to prevent cutaneous reactivation of HSV. At 3 months of age, the infant developed HSV encephalitis as manifested by fever, seizures, abnormal CSF indices, abnormal brain MRI, and positive CSF HSV PCR. No cutaneous disease was present. It is not known whether the HSV encephalitis in our patient represented reactivation of previously unrecognized central nervous system infection or new onset of central nervous system disease as a result of spread from other tissue or site to the brain. The failure of oral acyclovir to prevent such an occurrence, however, highlights gaps in our understanding of the pathogenesis of neonatal HSV disease and questions the use of acyclovir suppression to prevent neurologic sequelae.