Comparison of a Point-of-Care FilmArray Test to Standard-of-Care Microbiology Test in Diagnosis of Healthcare Associated Infections in a Tertiary Care Pediatric Intensive Care Unit.

BACKGROUND: Rapid and accurate identification of healthcare associated pathogens is crucial for early diagnosis and treatment of infections. This study aimed to assess the performance of a point-of-care multiplex polymerase chain reaction (PCR) in diagnosis of pathogens and their antibiotic resistance genes in bloodstream infections, pneumonia and meningitis/encephalitis in a pediatric intensive care unit (PICU). METHODS: A retrospective cross-sectional study was conducted on pediatric patients diagnosed with healthcare associated infections at Alexandria University PICU, Egypt. A total of 111 samples from 98 patients were subjected simultaneously to standard-of-care microbiology testing (SOCMT) and molecular testing by BioFire multiplex PCR. RESULTS: In comparison to SOCMT, the BioFire FilmArray® had a better diagnostic yield with broncho-alveolar lavage (BAL) (45 vs. 21) and cerebrospinal fluid (CSF) samples (five vs. none) (p ≤ 0.0001). Klebsiella pneumoniae was the most common pathogen in BAL (n = 19 by BioFire, n = 9 by SOCMT) and blood (n = 7, by SOCMT and BioFire) samples, while Streptococcus pneumoniae was the most common in CSF samples. BioFire showed 95.8% overall percent agreement, 100% positive percent agreement and 95.6% negative percent agreement with SOCMT. All phenotypically confirmed resistant isolates had resistance genes by the BioFire FilmArray® (100%). The turnaround time (TAT) of positive results by the FilmArray panels was 1-1.5 h in comparison to 48-72 h by SOCMT (p ≤ 0.001). CONCLUSIONS: The results of the current study confirm the utility of the BioFire FilmArray® in making early decisions regarding patients' diagnosis and management of infection in the PICU, in terms of rapid TAT and appropriate antimicrobial use.

Outcome of Early Hemostatic Intervention in Children With Sepsis and Nonovert Disseminated Intravascular Coagulation Admitted to PICU: A Randomized Controlled Trial.

OBJECTIVES: Evaluation of the outcome of early hemostatic management of disseminated intravascular coagulopathy in patients with severe sepsis/septic shock admitted to PICU, before the development of clinically overt disseminated intravascular coagulopathy. DESIGN: Prospective interventional, open label randomized controlled clinical trial. SETTING: PICU at Alexandria University Children's Hospital. PATIENTS: The study included 80 patients with proven severe sepsis/septic shock in nonovert disseminated intravascular coagulopathy stage. They were randomly assigned into two groups (group 1 and group 2). INTERVENTIONS: Specific intervention was applied for group 1 (plasma transfusion, low-dose unfractionated heparin, and tranexamic acid). MEASUREMENTS: All patients had assessment of Pediatric Index of Mortality 2 score, Pediatric Logistic Organ Dysfunction score, inotropic score, routine laboratory, and hemostatic tests including fibrin degradation products and d-dimers. Disseminated intravascular coagulopathy risk assessment scores were calculated on daily basis. RESULTS: Mortality rate was significantly higher in group 2. Progression to overt disseminated intravascular coagulopathy was significantly more common among group 2 patients than group 1 (45% and 10%, respectively) (p < 0.0001). Disseminated intravascular coagulopathyRisk Assessment Scores were significantly higher on the second and fifth days among group 2 patients. The initial specific hemostatic intervention was the only significant predictor of survival and prevention of progression to overt disseminated intravascular coagulopathy. CONCLUSIONS: Our results suggest that early use of a combination of fresh frozen plasma transfusion, low-dose heparin, and tranexamic acid in children with severe sepsis/septic shock in the "window of opportunity" before the development of overt disseminated intravascular coagulopathy stage was associated with better outcome for survival and prevention of progression to overt disseminated intravascular coagulopathy, with no increase in bleeding risk. Larger multicenter studies are needed to further prove this practice.

Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children.

AIM: To assess the accuracy of the passive leg raising (PLR) test to anticipate fluid responsiveness in critically ill children under age of 5 years. MATERIALS AND METHODS: A prospective observational study was conducted, in a university hospital pediatric intensive care unit from June 1, 2017, to January 30, 2018. Hemodynamic parameters including stroke volume using bedside transthoracic echocardiography were assessed at baseline I (45° semi-recumbent position), after PLR, at baseline II, and following fluid challenge. Changes in the stroke volume (delta SV) and in the cardiac index (CI) were recorded after PLR and fluid challenge. FINDINGS: Delta SV of 10% after PLR was an excellent discriminator of the fluid responsiveness with an area under ROC (AUC) of 0.81 (95% CI 0.68-0.9) with a sensitivity of 65.38% and a specificity of 100%. The change in CI of 8.7% after PLR was a significant discriminator of fluid responsiveness with an AUC of 0.7 (95% CI 0.56-0.81) with 57.78% sensitivity and 91.67% specificity. CONCLUSION: Passive leg raising can identify nonresponders among seriously ill children under the age of 5 years but it cannot identify all responders with certainty. CLINICAL SIGNIFICANCE: Passive leg raising is reliable test in under 5 year-old-children if performed appropriately using bedside echocardiography for the measurement of its transient effect. HOW TO CITE THIS ARTICLE: El-Nawawy AA, Farghaly PM, Hassouna HM, Accuracy of Passive Leg Raising Test in Prediction of Fluid Responsiveness in Children. Int J Clin Pediatr Dent 2020;24(5):344-349.

Reply to "Using Transthoracic Echocardiography to Predict Fluid Responsiveness after Passive Leg Raising Test: Caution Needed".

How to cite this article: El Nawawy AA, Farghaly PM, Hassouna HM. Reply to "Using Transthoracic Echocardiography to Predict Fluid Responsiveness after Passive Leg Raising Test: Caution Needed". Indian J Crit Care Med 2020;24(11):1149.

Intraosseous Versus Intravenous Access in Pediatric Septic Shock Patients Admitted to Alexandria University Pediatric Intensive Care Unit.

The cornerstone of emergency management of sepsis is early, goal-directed therapy. The purpose of this study was to evaluate the effect of intraosseous (IO) vs. intravenous (IV) access for resuscitation of patients with septic shock admitted to pediatric intensive care unit. This prospective interventional randomized clinical trial study was conducted on 60 patients with septic shock who need rapid administration of fluids and drugs; 30 cases were randomly chosen for IO vascular access, while the other 30 were selected for IV access. The IO route was successfully secured in all cases with a significant shorter time of vascular access insertion, shorter length of stay and reduction in mortality in IO group vs. IV group (p = 0.001, 0.045, 0.002, respectively). In pediatric emergencies, as in case of shock, the use of IO route is recommended to get rapid vascular access as soon as possible, as it revealed better outcome.

Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial / Papel da ecocardiografia na redução do tempo de reversão do choque no choque séptico pediátrico: ensaio controlado randomizado

Abstract Objective: To evaluate the role of echocardiography in reducing shock reversal time in pediatric septic shock. Methods: A prospective study conducted in the pediatric intensive care unit of a tertiary care teaching hospital from September 2013 to May 2016. Ninety septic shock patients were randomized in a 1:1 ratio for comparing the serial echocardiography-guided therapy in the study group with the standard therapy in the control group regarding clinical course, timely treatment, and outcomes. Results: Shock reversal was significantly higher in the study group (89% vs. 67%), with significantly reduced shock reversal time (3.3 vs. 4.5 days). Pediatric intensive care unit stay in the study group was significantly shorter (8 ± 3 vs. 14 ± 10 days). Mortality due to unresolved shock was significantly lower in the study group. Fluid overload was significantly lower in the study group (11% vs. 44%). In the study group, inotropes were used more frequently (89% vs. 67%) and initiated earlier (12[0.5-24] vs. 24[6-72] h) with lower maximum vasopressor inotrope score (120[30-325] vs. 170[80-395]), revealing predominant use of milrinone (62% vs. 22%). Conclusion: Serial echocardiography provided crucial data for early recognition of septic myocardial dysfunction and hypovolemia that was not apparent on clinical assessment, allowing a timely management and resulting in shock reversal time reduction among children with septic shock.

Resumo Objetivo: Avaliar o papel da ecocardiografia na redução do tempo de reversão do choque no choque séptico pediátrico. Métodos: Estudo prospectivo conduzido em uma UTIP de um hospital universitário de cuidados terciários de setembro de 2013 a maio de 2016. Foram randomizados 90 pacientes com choque séptico na proporção 1:1 para comparar a terapia guiada por ecocardiografia em série com a terapia padrão no grupo de controle com relação ao curso clínico, tratamento oportuno e resultados. Resultados: A reversão do choque foi significativamente maior no grupo de estudo (89% em comparação com 67%) com redução significativa do tempo de reversão do choque (3,3 em comparação com 4,5 dias). A permanência na UTIP no grupo de estudo foi significativamente mais curta (8 ± 3 em comparação com 14 ± 10 dias). A mortalidade devido ao choque não resolvido foi significativamente menor no grupo de estudo. A sobrecarga de fluidos foi significativamente menor no grupo de estudo (11% em comparação com 44%). No grupo de estudo, os inotrópicos foram usados com mais frequência (89% em comparação com 67%) e foram administrados antecipadamente (12 [0,5-24] em comparação com 24 [6-72] horas) e o menor escore inotrópico máximo dos vasopressores (120 [30-325] em comparação com 170 [80-395]) revela o uso predominante de milrinona (62% em comparação com 22%). Conclusão: A ecocardiografia em série forneceu dados fundamentais para o reconhecimento precoce da disfunção miocárdica séptica e hipovolemia não evidente na avaliação clínica, possibilitou o manejo tempestivamente adequado e resultou na redução do tempo de reversão do choque entre crianças com choque séptico.

Role of echocardiography in reducing shock reversal time in pediatric septic shock: a randomized controlled trial.

OBJECTIVE: To evaluate the role of echocardiography in reducing shock reversal time in pediatric septic shock. METHODS: A prospective study conducted in the pediatric intensive care unit of a tertiary care teaching hospital from September 2013 to May 2016. Ninety septic shock patients were randomized in a 1:1 ratio for comparing the serial echocardiography-guided therapy in the study group with the standard therapy in the control group regarding clinical course, timely treatment, and outcomes. RESULTS: Shock reversal was significantly higher in the study group (89% vs. 67%), with significantly reduced shock reversal time (3.3 vs. 4.5 days). Pediatric intensive care unit stay in the study group was significantly shorter (8±3 vs. 14±10 days). Mortality due to unresolved shock was significantly lower in the study group. Fluid overload was significantly lower in the study group (11% vs. 44%). In the study group, inotropes were used more frequently (89% vs. 67%) and initiated earlier (12[0.5-24] vs. 24[6-72]h) with lower maximum vasopressor inotrope score (120[30-325] vs. 170[80-395]), revealing predominant use of milrinone (62% vs. 22%). CONCLUSION: Serial echocardiography provided crucial data for early recognition of septic myocardial dysfunction and hypovolemia that was not apparent on clinical assessment, allowing a timely management and resulting in shock reversal time reduction among children with septic shock.

Nasopharyngeal Carriage, Capsular and Molecular Serotyping and Antimicrobial Susceptibility of Streptococcus pneumoniae among Asymptomatic Healthy Children in Egypt.

Streptococcus pneumoniae is a major cause of childhood morbidity and mortality worldwide with increasing antimicrobial resistance. 600 randomly chosen asymptomatic healthy children aged 2-60 months attending Alexandria University Children's Hospital were evaluated for prevalence of nasopharyngeal (NP) carriage of S. pneumoniae. Prevalence of NP carriage was 29.2% (n = 175/600) Capsular serotyping was done using Quellung reaction. Vaccine covered serotypes (VST) represented 67.4% while non-vaccine serotypes (NVST) were 32.6%. The most common VST isolated were 19F (24.6%), 6B (14.3%) and 6A (10.9%). Confirmation of serotyping was performed by multiplex PCR which showed 100% concordance with the Quellung reaction. Antimicrobial susceptibility testing showed penicillin non-susceptibility of 15% (using non-meningitis penicillin MIC breakpoints) and 55% (using meningitis penicillin MIC breakpoints). Highest resistance was found in sulphamethoxazole-trimethoprim (55%), tetracyclins (49%), erythromycin (40%) and clindamycin (25%). This study revealed the epidemiological importance to evaluate regularly the prevalence, serotypes and the increasing antimicrobial resistance of S. pneumoniae in the community.