The Impact of Rapid Species Identification on Management of Bloodstream Infections: What's in a Name?

Bloodstream infections are a leading cause of morbidity and mortality. Molecular rapid diagnostic tests (mRDTs) are transforming care for patients with bloodstream infection by providing the opportunity to dramatically shorten times to effective therapy and speeding de-escalation of overly broad empiric therapy. However, because of the novelty of these tests which provide information regarding microbial identification and whether specific antibiotic-resistance mutations were detected, many front-line providers still delay final decisions until complete phenotypic susceptibility results are available several days later. Thus the benefits of mRDTs have been largely limited to circumstances where antimicrobial stewardship programs closely monitor these tests and intervene as soon as the results are available. We searched PubMed and Google Scholar for articles published from 1980 to 2019 using the terms antibiotic, antifungal, bacteremia, bloodstream infection, candidemia, candidiasis, children, coagulase negative staphylococcus, consultation, contamination, costs, echocardiogram, endocarditis, enterobacteriaceae, enterococcus, Gram-negative, guidelines, IDSA, immunocompromised, infectious disease or ID, lumbar puncture, meningitis, mortality, MRSA, MSSA, neonatal, outcomes, pediatric, pneumococcal, polymicrobial, Pseudomonas, rapid diagnostic testing, resistance, risk factors, sepsis, Staphylococcus aureus, stewardship, streptococcus, and treatment. With the data from this search, we aim to provide guidance to front-line providers regarding the interpretation and immediate actions to be taken in response to the identification of common bloodstream pathogens by mRDTs. In addition to antimicrobial therapy, additional diagnostic or therapeutic interventions are recommended for particular organisms and clinical settings to either determine the extent of infection or control its source. Pediatric perspectives are offered for those bloodstream pathogens for which management differs from that in adults.

Vaccine health beliefs and educational influences among pediatric residents.

OBJECTIVE: A pilot study of pediatric residents to describe perceived benefits and effects of vaccines and educational influences on vaccine practice among pediatric residents. STUDY DESIGN: Eighty-seven residents, from two institutions in a region with relatively high vaccine hesitancy, responded to a survey conducted in 2014-2015. RESULTS: Residents identified professional experiences with vaccine preventable diseases (VPDs) and observing pediatricians as most impactful to their vaccine beliefs. Residents who had observed pediatric faculty agreeing to alternative or delayed vaccinations were more likely to believe this to be acceptable vaccine practice (70.1% vs. 21.1%, χ2 = 17.778, p < 0.001). Most residents (68 [79.1%]) reported feeling confident in their ability to discuss vaccines. CONCLUSIONS: Pediatricians must be equipped with accurate vaccine health beliefs to impact parental vaccine hesitancy. This study identifies important gaps in medical education, with pediatric residents reporting limitations in their professional experience with VPDs and high rates of observing alternative vaccination practice.

An Observational Study of Severe Pertussis in 100 Infants ≤120 Days of Age.

BACKGROUND: Pertussis in young infants is a unique, severe, afebrile, cough illness that is frequently fatal. METHODS: All pertussis cases ≤120 days of age admitted to a pediatric intensive care unit in California between October 1, 2013, and April 25, 2015, were evaluated. RESULTS: Of 100 pertussis patients ≤120 days of age admitted to pediatric intensive care unit, there were 5 deaths. The white blood cell counts in the fatal cases were significantly higher than in the nonfatal cases. Thirty-four percent of patients were intubated, 18% received inotropic and/or vasoactive support, 22% received steroid, 4% received extracorporal membrane oxygenation, and 3% underwent exchange blood transfusion. The median age at the time of illness onset in the patients who died was 23 days. CONCLUSIONS: These data, as well as data from previous California studies, suggest updated strategies for the management of severe pertussis. These include perform serial white blood cell counts, treat all presumptive cases with azithromycin, evaluate for pulmonary hypertension, intubate and administer oxygen for apneic episodes and administer inotropic/vasoactive agents for cardiogenic shock. Do not administer steroids or nitric oxide. Criteria for exchange blood transfusion therapy for leukocytosis with lymphocytosis are suggested.

A Flipped Classroom and Case-Based Curriculum to Prepare Medical Students for Vaccine-Related Conversations with Parents.

INTRODUCTION: Immunizations, one of the most significant public health successes in the last century, have recently been met with a resistance that has resulted in populations with falling immunity and outbreaks of vaccine-preventable diseases. In response to this, we conducted a needs assessment of medical students at the University of California, Los Angeles David Geffen School of Medicine to assess attitudes towards vaccines, knowledge of vaccines and vaccine-preventable diseases, and confidence in discussing vaccines. The results informed the development of this interactive, flipped-classroom and case-based curriculum for third-year pediatric clerkship students. METHODS: In our two-part curriculum, students independently view a short podcast with an overview of vaccines and vaccine-preventable diseases, then participate in a case-based workshop. For the workshop, students divide into small groups and are presented with a case-based scenario surrounding a child with a parent who has concerns about recommended vaccines. Students discuss the case in small groups, find answers to directed questions, and present the case and findings to the larger group, with specific focus on their approach to the vaccine hesitant parent. RESULTS: Anonymous student evaluations revealed that 93% of students enjoyed learning from this flipped classroom and case-based format. Likewise, 98% of students felt more confident in their approach to vaccine discussions. DISCUSSION: Vaccine hesitancy is becoming an increasingly common and worrisome problem. Our curriculum provides students with knowledge about the importance of childhood immunizations as well as an opportunity to practice addressing common concerns and misconceptions they will encounter in clinical settings.

Leishmaniasis Gone Viral: Social Media and an Outbreak of Cutaneous Leishmaniasis.

This report details how social media communication was used in a group of teens to diagnose cutaneous leishmaniasis that they acquired during a trip to Israel. Their posts quickly brought the cluster to the attention of the teens and their parents, leading to prompt recognition of the true etiology of their lesions and appropriate treatment.

Exchange blood transfusion in the management of severe pertussis in young infants.

We analyzed data from 10 young infants who received exchange blood transfusions for management of severe pertussis. Our data are insufficient to address efficacy of the procedure, but our data, as well as previous reports in the literature, indicate that if the procedure is to be successful, it should be done before organ failure has occurred and immediately if shock/hypotension occur.

Characteristics of Severe Bordetella pertussis Infection Among Infants ≤90 Days of Age Admitted to Pediatric Intensive Care Units - Southern California, September 2009-June 2011.

BACKGROUND: Bordetella pertussis infection can cause severe illness and death among young infants. METHODS: We collected demographic and clinical information from the medical records of infants who were ≤90 days of age and hospitalized for pertussis in 5 Southern California pediatric intensive care units (PICUs) from September 1, 2009 to June 30, 2011. Infants who died or were diagnosed with pulmonary hypertension were considered to have more severe pertussis. RESULTS: Thirty-one infants were admitted to a participating PICU. Eight infants had more severe infections, 6 infants had pulmonary hypertension, and 4 infants died. The 8 infants with more severe infections had white blood cell counts that exceeded 30 000, heart rates that exceeded 170, and respiratory rates that exceeded 70 more rapidly after cough onset than the 23 infants with less severe illness. CONCLUSIONS: Identifying higher-risk infants earlier might allow for more rapid implementation of interventions.

Cerebral abscess complicating Proteus mirabilis meningitis in a newborn infant.

Neonatal bacterial meningitis is associated with high morbidity and mortality, especially when complicated by intracranial abscesses. The authors report the case of an 11-day-old female with Proteus mirabilis meningitis complicated by an asymptomatic brain abscess. With this report, the authors illustrate the importance of surveillance neuroradiologic imaging in patients with Proteus meningitis.

Successful surgical drainage and aggressive medical therapy in a preterm neonate with Bacillus cereus meningitis.

Bacillus cereus meningitis is a rare disease with a very high mortality rate in neonates. The authors present the rare case of a premature infant with B. cereus bacteremia and subsequent intracranial abscesses. In addition to aggressive medical therapy, surgical drainage was performed via a left frontal mini-craniotomy. At 15 months of age, the patient had mild developmental delay, cortical blindness, and sensorineural hearing loss. The clinical case is described and difficulties in the management of B. cereus meningoencephalitis in infants are discussed.

Staphylococcus aureus Panton-Valentine leukocidin targets muscle tissues in a child with myositis and necrotizing fasciitis.

The incidence of myositis has been increasing since the advent of the epidemic of community-associated methicillin-resistant Staphylococcus aureus infection, and Panton-Valentine leukocidin has been implicated as a factor contributing to more-severe muscle injury. We report a case of severe myositis accompanying septic osteomyelitis and necrotizing fasciitis caused by a Panton-Valentine leukocidin-positive S. aureus strain. Immunostaining showed strong binding of the Panton-Valentine leukocidin toxin to necrotic muscle tissues.

Development and validation of the eating stimulus index in low-income, minority women in early postpartum.

Dietary modification to achieve weight loss during the postpartum period may be critical for prevention of obesity, particularly in low-income, minority women. The aim of this cross-sectional study was to develop and validate a measure to examine motivations to eat in low-income, minority women during early postpartum. A convenience sample of 179 triethnic women was recruited from the Special Supplemental Program for Women, Infants, and Children clinics from June 2004 to April 2007. Subjects made one visit to a study center where they completed the Eating Stimulus Index and questions regarding individual demographic characteristics including ethnicity, age, income, education, marital status, breastfeeding, and employment status. Weight and height were also measured during this visit and used to calculate body mass index (BMI; calculated as kg/m(2)). An additional sample of 31 women completed the Eating Stimulus Index on two occasions with 2 weeks between to establish test-retest reliability. The factor structure of the scale was examined with principal components analysis. Total scale scores and subscale scores were calculated and Pearson's correlation and multiple regression analysis examined relationships to BMI. Principal component analysis produced an eight-factor structure with loadings >0.40. Cronbach's alpha coefficients for each subscale ranged from .54 to .89. Subscales of Convenience Eating, Emotional Eating, and Dietary Restraint were related to BMI in mothers. African-American, exclusively formula-feeding, and older women were most vulnerable to convenience eating. White women and those with the highest level of education were most vulnerable to emotional eating. The Eating Stimulus Index is a valid and reliable instrument with the ability to discriminate by weight. It can be used to assess motivations to eat in order to facilitate development of tailored weight-loss messages during early postpartum.

A nutrition and physical activity intervention promotes weight loss and enhances diet attitudes in low-income mothers of young children.

The purpose of this study was to evaluate a nutrition and physical activity program for reducing body weight and improving nutrition attitudes in mothers of young children. A convenience sample of 114 intervention mothers and 33 comparison mothers was recruited from public health clinics and community centers. Eligibility criteria included Hispanic, African American, or white ethnicity; body mass index of at least 25 kg/m(2); low income (< 200% of the federal poverty index); and youngest child aged 1 to 4 years. For intervention participants, height, weight, percentage of body fat, waist circumference, demographics, nutrition attitudes, and dietary intake were measured at weeks 0 and 8; height, weight, percentage of body fat, and waist circumference were reassessed at 6 months. Overweight mothers in the comparison group provided anthropometric and demographic data at weeks 0 and 8. Changes in anthropometrics, attitudes, and dietary intake were evaluated in intervention mothers. Anthropometric data of intervention vs comparison group mothers were examined. Differences in anthropometrics and attitude scores between weight loss responders (> or = 2.27 kg) and nonresponders (< 2.27 kg) were assessed at week 8. Intervention participants lost weight (x = -2.7 kg; P < .001), whereas comparison mothers gained a slight amount of weight (x = 0.1 kg) by week 8. Weight loss responders had healthier eating attitudes (5.6 vs 5.2; P < .01) and fewer perceived barriers (2.4 vs 2.9; P < .05) than nonresponders postintervention. In conclusion, this dietary and physical activity curriculum is a valuable resource for weight management programs serving low-income women.

Greater nutrition knowledge is associated with lower 1-year postpartum weight retention in low-income women.

The purpose of this study was to assess nutrition knowledge during early and late postpartum in a sample of low-income and minority women, and to determine if that knowledge had any relationship to weight retention at 1-year postpartum. A questionnaire was developed and validated in a sample of 151 low-income new mothers. This instrument was then administered to a separate sample of mothers (n=140) of similar demographics to assess nutrition knowledge at 0 to 1 days and 12 months postpartum. In addition, a survey of nutrition information sources was administered at both time points. Nutrition knowledge was compared with 12-month postpartum weight retention and demographic variables. Women who retained less than 5% of weight gained during pregnancy had greater knowledge of nutrition at 0 months (53% vs 49%, P<0.05) and 12 months (55% vs 51%, P<0.05) than those who retained 5% or more of weight gained during pregnancy. Whites had higher nutrition knowledge scores than non-Hispanic blacks and Hispanics. Women who lactated 6 months or more had more knowledge than those who lactated less than 6 months. Higher knowledge test scores were observed among women who used the Internet and books/magazines as their source for information. These results indicate that assessment of nutrition knowledge in early postpartum can identify women at risk for significant weight retention.

Predictors of weight loss in low-income mothers of young children.

OBJECTIVE: To identify predictors of weight loss in a tri-ethnic population of low-income mothers. DESIGN: An 8-week dietary and physical activity program was tested. Demographic data were collected at baseline; anthropometric, dietary, physical activity, and psychosocial data were measured at baseline and week 8. SUBJECTS/SETTING: A convenience sample of 114 Hispanic, African-American, and white, low-income mothers with a body mass index > or = 25 (calculated as kg/m2) participated in the intervention. INTERVENTION: Weight-loss classes that incorporated nutrition, physical activity, and behavior modification were administered for 8 weeks. MAIN OUTCOME MEASURES: Anthropometry (body weight, weight loss). STATISTICAL ANALYSES PERFORMED: Analysis of variance, chi2 tests, and Spearman and Pearson correlations were used to test for associations between baseline and change data and total weight loss. Hierarchical regression was employed to assess the marginal importance of factors beyond socioeconomic influences. RESULTS: Correlates of weight loss included less satisfaction with appearance (r=0.24), greater percentage of energy from protein (r=-0.22), enhanced nutrition knowledge (r=-0.23), and higher scores for benefits of weight loss (r =-0.20) at baseline; and the change in healthful eating attitudes (r=-0.28) and social support (r=-0.21) at 8 weeks. The predictive models of baseline and change variables represented 11.4% and 13.8% of the variance, respectively. CONCLUSIONS: Weight-management programs serving low-income mothers should provide techniques to enhance social support, attitudes toward healthful eating, benefits of weight loss, and nutrition knowledge.

Low-income, overweight and obese mothers as agents of change to improve food choices, fat habits, and physical activity in their 1-to-3-year-old children.

OBJECTIVE: To examine the effects of a weight loss program for mothers on the diet and activity of mothers and their 1-3 year old children. DESIGN: Overweight and obese mothers participated in an 8-week weight loss intervention encompassing diet, physical activity, and behavioral modification. Anthropometrics, demographic, dietary, and physical activity questionnaires were administered at weeks 0 and 8; anthropometrics were re-evaluated at week 24. SUBJECTS: Mothers (N=91) of a 1-3 year old child; body mass index (BMI) >or= 25 kg/m2; non-breastfeeding; age 18-45 years; income < 200% of federal poverty index; Hispanic, African American, or white; and English-speaking were recruited from Special Supplemental Program for Women Infants and Children (WIC) and public health clinics. INTERVENTION MEASURES OF OUTCOME: Weight loss in mothers and improvements in diet (reduction in calories, fat, snacks/desserts, sweetened beverages, and increases in fruit, vegetables) and activity in mothers and children. RESULTS: Weight loss in mothers was modest (-2.7 kg, p < 0.001) and sustained at week 24 (-2.8 kg, p < 0.001), and children gained in height and weight as expected for normal growth (p < 0.001). Initial energy intakes of children exceeded Estimated Energy Requirements (123%) and were reduced to acceptable levels post-intervention (102%, p < 0.001); additional beneficial changes in children's diets were decreased total (47.7 to 39.9 g/day) and saturated fat (19.2 to 16.6 g/day), high-fat snacks/desserts (1.6 to 0.9 servings/day), added fats (81.8 to 40.9% using), sweetened beverages (0.8 to 0.4 servings/day), and fast food consumption (11.6 to 6.6% of meals), and increased home-prepared meals (63.2 to 71.6% of meals) (p < 0.01 for all). Physical activity scores improved by 7% in children (p < 0.05). Comparable changes in food choices and activity also were seen in mothers. CONCLUSION: Offering weight loss classes was a successful method of enticing low-income women to participate in an educational intervention that benefited their children. Overweight and obese mothers who modified their food choices and fat habits made comparable changes for their child.

Promotion of physical activity in low-income mothers using pedometers.

OBJECTIVE: This study tested the effectiveness of a pedometer program for increasing physical activity levels and reducing body weight in overweight and obese mothers of young children. DESIGN: Participants' motivational readiness to exercise, exercise self-efficacy, pedometer steps, pedometer kilocalories, and anthropometrics were evaluated at week 0 and week 8; anthropometrics were reassessed at week 24. Healthful-weight mothers provided comparison data at baseline. SUBJECTS/SETTING: A convenience sample of 93 intervention women (body mass index [calculated as kg/m(2)] >or=25) and 31 comparison women (body mass index <25) were recruited from public health clinics, community centers, and churches. Eligibility criteria included Hispanic, African-American, or white ethnicity and low income (<200% of the federal poverty index). INTERVENTION: An 8-week physical activity and dietary program was conducted. MAIN OUTCOME MEASURES: Motivational readiness to exercise, exercise self-efficacy, pedometer steps, and weight loss. STATISTICAL ANALYSES PERFORMED: Independent sample t tests, chi(2) tests, paired t tests, Wilcoxon signed-ranks tests, repeated measures analysis of variance, and Pearson and Spearman correlations. RESULTS: Mothers enhanced their motivational readiness to exercise, exercise self-efficacy, pedometer steps, and pedometer kilocalories. Reductions in body weight, percent body fat, and waist circumference also were observed. Significant correlations were found between exercise self-efficacy and exercise readiness (r=0.28, P<0.01), pedometer steps (r=0.30, P<0.01), and pedometer kilocalories (r=0.28, P<0.05). CONCLUSIONS: This intervention successfully increased the physical activity levels and promoted weight loss in low-income mothers. Public health clinics may wish to incorporate elements of this intervention into their programs to improve the physical fitness of recipients.

Influence of nutrition attitudes and motivators for eating on postpartum weight status in low-income new mothers.

OBJECTIVE: The purpose of this study was to identify attitudes about nutrition and their influence on weight status in low-income mothers in the first year postpartum. DESIGN: Nutrition attitudes were assessed at 1.5, 6, and 12 months postpartum. Body weight was measured at each time point and height at 1.5 months to calculate body mass index. Nutrition attitudes at each time were compared with demographic variables and weight status. SUBJECTS: Subjects were 340 non-Hispanic white (31.3%), non-Hispanic black (25.1%), and Hispanic (43.7%) new mothers (mean age=22.4 years) located in central Texas. Criteria for participation included good health at delivery and low income (

Congenital lymphocytic choriomeningitis virus: an underdiagnosed cause of neonatal hydrocephalus.

We report a case of congenital hydrocephalus caused by lymphocytic choriomeningitis virus with severe neurologic sequelae, including hydrocephalus, chorioretinitis, blindness and developmental delay. This is the first report of lymphocytic choriomeningitis virus isolation in the cerebrospinal fluid of a congenitally infected infant.