Association of Radiology Findings with Etiology of Community Acquired Pneumonia among Children.

OBJECTIVE: To evaluate the association between consolidation on chest radiograph and typical bacterial etiology of childhood community acquired pneumonia (CAP) in the Etiology of Pneumonia in the Community study. STUDY DESIGN: Hospitalized children <18 years of age with CAP enrolled in the Etiology of Pneumonia in the Community study at 3 children's hospitals between January 2010 and June 2012 were included. Testing of blood and respiratory specimens used multiple modalities to identify typical and atypical bacterial, or viral infection. Study radiologists classified chest radiographs (consolidation, other infiltrates [interstitial and/or alveolar], pleural effusion) using modified World Health Organization pneumonia criteria. Infiltrate patterns were compared according to etiology of CAP. RESULTS: Among 2212 children, there were 1302 (59%) with consolidation with or without other infiltrates, 910 (41%) with other infiltrates, and 296 (13%) with pleural effusion. In 1795 children, at least 1 pathogen was detected. Among these patients, consolidation (74%) was the most frequently observed pattern (74% in typical bacterial CAP, 58% in atypical bacterial CAP, and 54% in viral CAP). Positive and negative predictive values of consolidation for typical bacterial CAP were 12% (95% CI 10%-15%) and 96% (95% CI 95%-97%) respectively. In a multivariable model, typical bacterial CAP was associated with pleural effusion (OR 7.3, 95% CI 4.7-11.2) and white blood cell ≥15 000/mL (OR 3.2, 95% CI 2.2-4.9), and absence of wheeze (OR 0.5, 95% CI 0.3-0.8) or viral detection (OR 0.2, 95% CI 0.1-0.4). CONCLUSIONS: Consolidation predicted typical bacterial CAP poorly, but its absence made typical bacterial CAP unlikely. Pleural effusion was the best predictor of typical bacterial infection, but too uncommon to aid etiology prediction.

Implementation and Evaluation of a Nurse Practitioner Onboarding Program at a Large Healthcare Facility.

A comprehensive, evidence-based onboarding program benefits healthcare workers and institutions. Many institutions do not have onboarding programs for new nurse practitioners (NPs). In this quality improvement initiative, a standardized onboarding program was developed. The impact on NP satisfaction and retention was evaluated. Lead NPs were identified as program managers. Program components included role introduction, competency validation, review of administrative essentials, ongoing progress logs, and program evaluations. The program resulted in increased NP satisfaction and retention.

Early Intravenous Magnesium Sulfate Administration in the Emergency Department for Severe Asthma Exacerbations.

BACKGROUND: Severe asthma exacerbations in pediatric patients occur frequently and can require pediatric intensive care unit (PICU) admission. OBJECTIVE: To determine if early administration of intravenous magnesium sulfate (IVMg) to pediatric patients experiencing severe asthma exacerbations, defined as a respiratory clinical score (RCS) of 9 to 12, resulted in fewer PICU admissions. METHODS: Retrospective chart review of pediatric patients aged from 2 to 17 years presenting with a severe asthma exacerbation to a single tertiary care pediatric emergency department. Univariable and multivariable logistic regression analyses were used to determine if admission to the PICU was associated with early IVMg treatment, within 60 minutes of registration. RESULTS: A total of 1911 patients were included in the study, of which 1541 received IVMg. The average time to IVMg was 79 minutes, with 35% of the patients receiving it within 60 minutes of arrival. Two hundred forty-eight (13%) were admitted to the PICU, 641 (34%) were admitted to the general inpatient floor, and 1022 (53%) were discharged home. Factors associated with increased odds ratio (OR) of PICU admission were: early IVMg (OR, 1.63; 95% CI: 1.16-2.28), arrival mode to the emergency department via ambulance (OR, 2.23; 95% CI: 1.45-3.43), history of PICU admission for asthma (OR, 1.73; 95% CI: 1.22-2.44), and diagnosis of status asthmaticus (OR, 8.88; 95% CI: 3.49-30.07). Calculated OR of PICU admission subcategorized by RCS for early IVMg patients, after controlling for PICU risk factors, are as follows: RCS 9 (reference), RCS 10 (OR, 2.52; 95% CI: 0.89-2.23), RCS 11 (OR, 2.19; 95% CI: 1.3-3.70), and RCS 12 (OR, 4.12; 95% CI: 2.13-7.95). CONCLUSIONS: Early administration of IVMg to pediatric patients experiencing severe asthma exacerbations does not result in fewer PICU admissions.

How Broad Should Gram-Negative Coverage Be for Febrile Parenteral Nutrition Dependent Short Bowel Syndrome Patients?

ABSTRACT: Broader spectrum Gram-negative antibiotics are commonly utilized empirically for central line-associated bloodstream infections (CLABSI) in febrile short bowel syndrome (SBS) patients receiving home parenteral nutrition compared to those used empirically for inpatient-acquired CLABSI. This analysis reports 57 CLABSI in 22 patients with SBS admitted from the community and 78 inpatient-acquired CLABSI in 76 patients over a 5-year period. Proportional Gram-negative CLABSI was similar between the SBS and inpatient-acquired cohorts (43.8% vs42.3%, respectively, P  = 0.78). 1.8% and 10.3% (P = 0.125) of Gram-negative CLABSI were non-susceptible to ceftriaxone and 0% and 3.8% (P = 0.52) were non-susceptible to ceftazidime in the SBS and inpatient-acquired cohorts, respectively. In the SBS cohort, home ethanol lock therapy and prior culture results impacted Gramnegative pathogen distribution. Broader empiric Gram-negative coverage for CLABSI among SBS patients compared to inpatients is unnecessary. Third-generation cephalosporins represent appropriate empiric Gramnegative agents for febrile SBS patients presenting from the community to our institution.

Establishing a COVID-positive mental health ward: an Australian-first case study.

OBJECTIVE: Managing mental health patients during the COVID-19 pandemic has been a global challenge. Current workforce arrangements tend to separate those skilled in caring for highly infectious medical patients from those whose specialism is in managing co-morbid mental health, substance misuse and/or behaviours of concern, including potential non-compliance with community or health care directives. This paper reports an innovative service development through the emergency establishment of a temporary COVID-positive mental health ward in response to a local outbreak in Melbourne. METHOD: A case study of service reorientation is presented, examining barriers and enablers to effective care of co-morbid mental illness, addiction and COVID-19. RESULTS: Establishing a skilled multidisciplinary workforce across mental health and infectious disease is the most important consideration in optimising care. Other issues included suitable physical space, security arrangements and inter-disciplinary communication. CONCLUSIONS: The paper holds insights for managing mental health care during potential future infectious disease outbreaks across the country.

Parainfluenza Virus Types 1-3 Infections Among Children and Adults Hospitalized With Community-acquired Pneumonia.

BACKGROUND: Parainfluenza virus (PIV) is a leading cause of lower respiratory tract infections. Although there are several distinct PIV serotypes, few studies have compared the clinical characteristics and severity of infection among the individual PIV serotypes and between PIV and other pathogens in patients with community-acquired pneumonia. METHODS: We conducted active population-based surveillance for radiographically confirmed community-acquired pneumonia hospitalizations among children and adults in 8 US hospitals with systematic collection of clinical data and respiratory, blood, and serological specimens for pathogen detection. We compared clinical features of PIV-associated pneumonia among individual serotypes 1, 2, and 3 and among all PIV infections with other viral, atypical, and bacterial pneumonias. We also compared in-hospital disease severity among groups employing an ordinal scale (mild, moderate, severe) using multivariable proportional odds regression. RESULTS: PIV was more commonly detected in children (155/2354; 6.6%) than in adults (66/2297; 2.9%) (P < .001). Other pathogens were commonly co-detected among PIV cases (110/221; 50%). Clinical features of PIV-1, PIV-2, and PIV-3 infections were similar to one another in both children and adults with pneumonia. In multivariable analysis, children with PIV-associated pneumonia exhibited similar severity to children with other nonbacterial pneumonia, whereas children with bacterial pneumonia exhibited increased severity (odds ratio, 8.42; 95% confidence interval, 1.88-37.80). In adults, PIV-associated pneumonia exhibited similar severity to other pneumonia pathogens. CONCLUSIONS: Clinical features did not distinguish among infection with individual PIV serotypes in patients hospitalized with community-acquired pneumonia. However, in children, PIV pneumonia was less severe than bacterial pneumonia.

Clinical Features of Human Metapneumovirus-Associated Community-acquired Pneumonia Hospitalizations.

BACKGROUND: Human metapneumovirus (HMPV) is a leading cause of respiratory tract infections. Few studies have compared the clinical characteristics and severity of HMPV-associated pneumonia with other pathogens. METHODS: Active, population-based surveillance was previously conducted for radiographically confirmed, community-acquired pneumonia hospitalizations among children and adults in 8 United States hospitals. Clinical data and specimens for pathogen detection were systematically collected. We described clinical features of all HMPV-associated pneumonia and, after excluding codetections with other pathogen types, we compared features of HMPV-associated pneumonia with other viral, atypical, and bacterial pneumonia and modeled the severity (mild, moderate, and severe) and length of stay using multivariable proportional odds regression. RESULTS: HMPV was detected in 298/2358 (12.6%) children and 88/2320 (3.8%) adults hospitalized with pneumonia and was commonly codetected with other pathogens (125/298 [42%] children and 21/88 [24%] adults). Fever and cough were the most common presenting symptoms of HMPV-associated pneumonia and were also common symptoms of other pathogens. After excluding codetections in children (n = 1778), compared to HMPV (reference), bacterial pneumonia exhibited increased severity (odds ratio [OR], 3.66; 95% confidence interval [CI], 1.43-9.40), respiratory syncytial virus (RSV; OR, 0.76; 95% CI, .59-.99) and atypical (OR, 0.39; 95% CI, .19-.81) infections exhibited decreased severity, and other viral pneumonia exhibited similar severity (OR, 0.88; 95% CI, .55-1.39). In adults (n = 2145), bacterial (OR, 3.74; 95% CI, 1.87-7.47) and RSV pneumonia (OR, 1.82; 95% CI, 1.32-2.50) were more severe than HMPV (reference), but all other pathogens had similar severity. CONCLUSIONS: Clinical features did not reliably distinguish HMPV-associated pneumonia from other pathogens. HMPV-associated pneumonia was less severe than bacterial and adult RSV pneumonia, but was otherwise as or more severe than other common pathogens.

Disaster preparedness and cultural factors: a comparative study in Romania and Malta.

This exploratory study investigates the relationships between the disaster preparedness of citizens and cultural factors in Romania and Malta. With regard to methodology, quantitative and qualitative data were collected during two Citizen Summits, which consisted of a real-time survey and focus group discussions. The results point to two specific cultural factors that may bridge this 'gap' and be operationalised to enhance people's readiness for a disaster event. In Malta, the findings reveal how community cohesion is altered from a personal to a cultural value, which has the potential to encourage the transformation of preparedness intentions into actual preparedness behaviour. In Romania, meanwhile, the findings highlight the ambivalent aspects of trusting behaviour as a cultural norm on the one hand, and distrust in authorities based on experience and unmet expectations on the other hand. Social media use may reduce this tension between trust and distrust, and thus foster successful disaster risk-related communication.

How Do Mental Health Nurses Define Success? A Comparative Study of Bed-Based and Community-Based Services.

Nursing is the single largest professional group within both hospital and community mental health care services, however the role of mental health nurses in under-defined. The nursing workforce is also coming under increasing pressure from internal and external requirements, and nurses themselves are on the frontline of providing patient care in what can be a risky and unpredictable workplace environment. This project explored via interview the ways in which mental health nurses experience and reflect on their personal and professional feelings of nursing success. Participants were 19 nurses who were employed in a range of bed-based and community mental health services in inner south eastern Melbourne. This study complies with the Consolidated Criteria for Reporting Qualitative Research (COREQ). The findings of the project align with existing evidence from the literature. Factors which helped mental health nurses feel successful included: therapeutic success; good teamwork; targeted education; and feedback. Barriers to success included: patients/clients do not engage or recover; poor communication amongst staff; lack of psychological safety in the workplace; and lack of respect from management. Nurses in community settings were more able than nurses in bed-based settings to: make effective use of clinical supervision; make use of targeted training and educational offerings; and practice therapeutically and holistically. Project results offer an opportunity to understand nurses' motivations and reward systems. Better understanding of these issues can improve the way mental health care services manage their workforce planning, maintain staff personal wellbeing, increase staff retention and ultimately improve patient/client care.

Analysis of Community-Acquired Urinary Tract Infection Treatment in Pediatric Patients Requiring Hospitalization: Opportunity for Use of Narrower Spectrum Antibiotics.

Background: The most narrow-spectrum antibiotic possible should be used for empiric and definitive treatment of pediatric urinary tract infections (UTIs). Objectives: The objectives of this study were to determine an appropriate narrow-spectrum antibiotic for empiric UTI treatment, factors differentiating empiric first-generation cephalosporin (FGC) versus third-generation cephalosporin (TGC) coverage, and factors associated with unnecessarily broad-spectrum definitive antibiotic treatment. Methods: This was a retrospective chart review of children admitted from 2013 to 2015 who were diagnosed with a UTI and received treatment. Multivariable logistic regression assessed independent factors associated with our outcomes. Results: Of 568 diagnosed UTIs, 88.6% received empiric TGC treatment. Empiric coverage among cultured organisms was only 5.4% lower in FGC versus TGC. Adolescent age group (odds ratio [OR] = 8.83, 95% confidence interval [CI] = 1.47-53.11), uncircumcised males (OR = 4.52, 95% CI = 1.27-16.08), Hispanic ethnicity (OR = 4.37, 95% CI = 1.14-16.82), and hospitalization within the preceding 3 months (OR = 4.73, 95% CI = 1.38-16.23) were associated with FGC nonsusceptibility among TGC susceptible Enterobacteriaceae pathogens. De-escalation occurred in 55.8% of diagnosed UTIs eligible for de-escalation at discharge. Urine white blood cell (WBC) count >5 (OR = 2.89, 95% CI = 1.14-7.21), serum WBC count (OR = 1.04, 95% CI = 1.01-1.07), and having only one narrow-spectrum treatment option (OR = 5.1, 95% CI = 2.43-10.66) were associated with unnecessarily broad-spectrum definitive treatment. Conclusion and Relevance: FGC would be an appropriate narrow-spectrum empiric agent for UTIs at our institution. The factors associated with FGC nonsusceptibility can further stratify empiric treatment decisions. The factors associated with unnecessarily broad-spectrum definitive treatment illustrate areas for educational efforts and future research regarding UTI treatment.

School-Based Physical Therapy Services: Predicting the Gap Between Ideal and Actual Embedded Services.

PURPOSE: To ascertain the variables predicting the gap between ideal and actual practice in embedding school-based physical therapy services. METHODS: School-based physical therapists completed an online survey estimating ideal and actual practice of embedding physical therapy services. Predictive modeling was used to determine whether disability, interventions, goals, families, teachers, workload, billing, and/or contracts predicted the gap between estimated ideal and actual practice. RESULTS: Data from 410 participants revealed that severity of students' disability, billing, written contracts, and families' preferences predicted the gap between estimated ideal and actual services. Actual practice varied based on region, APTA membership, and Academy of Pediatric Physical Therapy membership. CONCLUSIONS: Our model predicts the gap between estimates of ideally and actually embedding school-based physical therapy services. While 4 variables predicted the gap, further research is needed to develop a predictive model of actual practice to inform school-based physical therapy practice.

Concurrent Validity of the School Outcomes Measure and the School Function Assessment in Elementary Students.

PURPOSE: Examine the concurrent validity of the School Outcomes Measure (SOM) and the School Function Assessment (SFA) in students kindergarten through sixth grade. METHODS: Twenty-four school-based therapists completed the SOM and the SFA for 42 students, representing Gross Motor Function Classification System (GMFCS) levels I to V. RESULTS: Correlation coefficients between SOM Self-Care, Mobility, and Assuming Student's Role median total scores and the 21 SFA Activity Performance scale median criterion scores were statistically significant. There were significant correlation coefficients between SOM Expressing Learning and Behavior and SFA median criterion scores. The SOM differentiated between GMFCS groups for all physical tasks but not cognitive/behavioral tasks, and the SFA for half of the physical tasks. CONCLUSIONS: Overall, student performance on the SOM was consistent with participation on the SFA, which lends support to the preliminary validity of the SOM. The GMFCS analysis suggests that the SOM differentiates between the GMFCS levels for physical tasks.

Developing a model of perceptions of security and insecurity in the context of crime.

The current study was carried out as part of the CITYCOP project exploring fear of crime, risk perception and feelings of security and insecurity. Participants (n = 272) from 11 European countries answered a questionnaire exploring measures of risk perception, fear of crime, anxiety, trust in police and related behaviours. A seven-factor structure is proposed incorporating 'Signs of Social and Physical Disorder', 'Trust in Police', 'Trait Anxiety', 'Collective Efficacy', 'Perceived Risk of Victimisation', 'Fear of Personal Harm' and 'Fear of Property Theft'. Overall findings suggest that the measures associated with feelings of insecurity are negatively related to the measures associated with feelings of security. Efforts should be made to reduce feelings of insecurity through encouraging trust in law enforcement and community interaction and reducing signs of social and physical disorder.

Mycoplasma pneumoniae Among Children Hospitalized With Community-acquired Pneumonia.

Background: The epidemiology of Mycoplasma pneumoniae (Mp) among US children (<18 years) hospitalized with community-acquired pneumonia (CAP) is poorly understood. Methods: In the Etiology of Pneumonia in the Community study, we prospectively enrolled 2254 children hospitalized with radiographically confirmed pneumonia from January 2010-June 2012 and tested nasopharyngeal/oropharyngeal swabs for Mp using real-time polymerase chain reaction (PCR). Clinical and epidemiological features of Mp PCR-positive and -negative children were compared using logistic regression. Macrolide susceptibility was assessed by genotyping isolates. Results: One hundred and eighty two (8%) children were Mp PCR-positive (median age, 7 years); 12% required intensive care and 26% had pleural effusion. No in-hospital deaths occurred. Macrolide resistance was found in 4% (6/169) isolates. Of 178 (98%) Mp PCR-positive children tested for copathogens, 50 (28%) had ≥1 copathogen detected. Variables significantly associated with higher odds of Mp detection included age (10-17 years: adjusted odds ratio [aOR], 10.7 [95% confidence interval {CI}, 5.4-21.1] and 5-9 years: aOR, 6.4 [95% CI, 3.4-12.1] vs 2-4 years), outpatient antibiotics ≤5 days preadmission (aOR, 2.3 [95% CI, 1.5-3.5]), and copathogen detection (aOR, 2.1 [95% CI, 1.3-3.3]). Clinical characteristics were non-specific. Conclusions: Usually considered as a mild respiratory infection, Mp was the most commonly detected bacteria among children aged ≥5 years hospitalized with CAP, one-quarter of whom had codetections. Although associated with clinically nonspecific symptoms, there was a need for intensive care in some cases. Mycoplasma pneumoniae should be included in the differential diagnosis for school-aged children hospitalized with CAP.

Mediastinal Lymphadenopathy in Children With Histoplasmosis.

BACKGROUND: Mediastinal lymphadenopathy (ML) in children can arise from malignancy, infection, or rheumatic illness among others, and may be found incidentally on imaging or during workup for a variety of symptoms. Our aim was to describe the clinical presentation and natural history of histoplasmosis in children who present to a tertiary care center with ML in an endemic area of the country. METHODS: After institutional review board approval, a retrospective study of all children (aged < 21 y) presenting with proven (positive serologies) or suspected histoplasmosis (negative serologies, negative tuberculosis testing, and benign outcomes in follow-up) over a 5-y period was done. Seventy-four patients were tested; those with another diagnosis (n = 6) or without ML (n = 26) were excluded, for a total cohort of 44 patients. Demographics, clinical presentation, symptoms, laboratory data, treatment course, radiography studies, and inpatient and outpatient visits were examined. RESULTS: Of the 44 patients with ML, 27 had proven histoplasmosis, and 19 had suspected histoplasmosis. The median follow-up by imaging or clinical examination was 6.9 mo (0.3-73.2 mo). Sixteen patients received antifungal therapy with itraconazole, and 15 patients received at least one course of steroids, nearly all for respiratory symptoms; 11 patients (24%) received both. There was no difference in readmission rate (n = 5 versus 2, P = 0.7) or recurrence of symptoms (n = 2 versus 5, P = 0.4) between patients who received an antifungal and those that did not. Receiving steroid therapy was associated with airway narrowing and a higher readmission rate (n =6 versus 2 who were not treated with steroids, P = 0.04), but not with symptom recurrence. Nine lymph node or mass biopsies were performed; however, the pathology only confirmed nonspecific infection in three and was nondiagnostic in the remaining six patients. Twenty-seven patients had at least one confirmatory laboratory test positive for histoplasmosis. Thirty-nine of the 44 patients (84%) with a diagnosis of histoplasmosis (proven or suspected) were asymptomatic by 1-2 mo follow up, with the remainder having intermittent chest pain or reactive airway disease. CONCLUSIONS: ML because of proven or suspected histoplasmosis is usually a self-limiting disease that can be managed with treatment of the child's symptoms. Antifungals and steroids are of unclear benefit and may not alter the natural course of the disease. Biopsies are rarely diagnostic in the setting of ML, and invasive procedures should be avoided.

Difference in Objectively Measured Physical Activity and Obesity in Children With and Without Siblings.

Background/Context: Children without siblings (singletons) have higher rates of obesity than do children with siblings (nonsingletons). Higher moderate to vigorous physical activity (PA) and less sedentary behavior (SB) are associated with lower childhood obesity. PURPOSE: To examine the difference in PA and SB between singleton and nonsingleton children. METHODS: Mothers of children ages 5.0-7.9 years old who were singletons or nonsingletons with a sibling between the ages of 2.0 and 4.9 years old were recruited. Height, weight, and waist circumference of the 5.0- to 7.9-year-old children were measured, and age and sex percentiles were calculated. Accelerometry measured SB and PA, including light PA, moderate to vigorous PA, and counts per minute. RESULTS: Fifty-six mother-child dyads (23 singletons and 33 nonsingletons) with an average child age of 5.7 (0.7) years participated. More singletons were classified as overweight or obese than were nonsingletons (49% vs 17%, P = .04). In adjusted linear models, singletons had less light PA per day (ß = -38.1, SE = 19.2, P = .001) and more SB (ß = 38.0, SE = 16.5, P = .02) than did nonsingletons, with no difference in moderate to vigorous PA or counts per minute. CONCLUSION: In this sample, singletons had higher obesity and lower light PA than did nonsingleton children. Investigation into differences in singleton/nonsingleton families, including family health behaviors, may help assess sibling influence in early behavior development.

Etiology and Impact of Coinfections in Children Hospitalized With Community-Acquired Pneumonia.

Background: Recognition that coinfections are common in children with community-acquired pneumonia (CAP) is increasing, but gaps remain in our understanding of their frequency and importance. Methods: We analyzed data from 2219 children hospitalized with CAP and compared demographic and clinical characteristics and outcomes between groups with viruses alone, bacteria alone, or coinfections. We also assessed the frequency of selected pairings of codetected pathogens and their clinical characteristics. Results: A total of 576 children (26%) had a coinfection. Children with only virus detected were younger, more likely to be black, and more likely to have comorbidities such as asthma, compared with children infected with typical bacteria alone. Children with virus-bacterium coinfections had a higher frequency of leukocytosis, consolidation on chest radiography, parapneumonic effusions, intensive care unit admission, and need for mechanical ventilation and an increased length of stay, compared with children infected with viruses alone. Virus-virus coinfections were generally comparable to single-virus infections, with the exception of the need for oxygen supplementation, which was higher during the first 24 hours of hospitalization in some virus-virus pairings. Conclusions: Coinfections occurred in 26% of children hospitalized for CAP. Children with typical bacterial infections, alone or complicated by a viral infection, have worse outcomes than children infected with a virus alone.

Community-Acquired Pneumonia Requiring Hospitalization among U.S. Adults.

BACKGROUND: Community-acquired pneumonia is a leading infectious cause of hospitalization and death among U.S. adults. Incidence estimates of pneumonia confirmed radiographically and with the use of current laboratory diagnostic tests are needed. METHODS: We conducted active population-based surveillance for community-acquired pneumonia requiring hospitalization among adults 18 years of age or older in five hospitals in Chicago and Nashville. Patients with recent hospitalization or severe immunosuppression were excluded. Blood, urine, and respiratory specimens were systematically collected for culture, serologic testing, antigen detection, and molecular diagnostic testing. Study radiologists independently reviewed chest radiographs. We calculated population-based incidence rates of community-acquired pneumonia requiring hospitalization according to age and pathogen. RESULTS: From January 2010 through June 2012, we enrolled 2488 of 3634 eligible adults (68%). Among 2320 adults with radiographic evidence of pneumonia (93%), the median age of the patients was 57 years (interquartile range, 46 to 71); 498 patients (21%) required intensive care, and 52 (2%) died. Among 2259 patients who had radiographic evidence of pneumonia and specimens available for both bacterial and viral testing, a pathogen was detected in 853 (38%): one or more viruses in 530 (23%), bacteria in 247 (11%), bacterial and viral pathogens in 59 (3%), and a fungal or mycobacterial pathogen in 17 (1%). The most common pathogens were human rhinovirus (in 9% of patients), influenza virus (in 6%), and Streptococcus pneumoniae (in 5%). The annual incidence of pneumonia was 24.8 cases (95% confidence interval, 23.5 to 26.1) per 10,000 adults, with the highest rates among adults 65 to 79 years of age (63.0 cases per 10,000 adults) and those 80 years of age or older (164.3 cases per 10,000 adults). For each pathogen, the incidence increased with age. CONCLUSIONS: The incidence of community-acquired pneumonia requiring hospitalization was highest among the oldest adults. Despite current diagnostic tests, no pathogen was detected in the majority of patients. Respiratory viruses were detected more frequently than bacteria. (Funded by the Influenza Division of the National Center for Immunizations and Respiratory Diseases.).

Community-acquired pneumonia requiring hospitalization among U.S. children.

BACKGROUND: Incidence estimates of hospitalizations for community-acquired pneumonia among children in the United States that are based on prospective data collection are limited. Updated estimates of pneumonia that has been confirmed radiographically and with the use of current laboratory diagnostic tests are needed. METHODS: We conducted active population-based surveillance for community-acquired pneumonia requiring hospitalization among children younger than 18 years of age in three hospitals in Memphis, Nashville, and Salt Lake City. We excluded children with recent hospitalization or severe immunosuppression. Blood and respiratory specimens were systematically collected for pathogen detection with the use of multiple methods. Chest radiographs were reviewed independently by study radiologists. RESULTS: From January 2010 through June 2012, we enrolled 2638 of 3803 eligible children (69%), 2358 of whom (89%) had radiographic evidence of pneumonia. The median age of the children was 2 years (interquartile range, 1 to 6); 497 of 2358 children (21%) required intensive care, and 3 (<1%) died. Among 2222 children with radiographic evidence of pneumonia and with specimens available for bacterial and viral testing, a viral or bacterial pathogen was detected in 1802 (81%), one or more viruses in 1472 (66%), bacteria in 175 (8%), and both bacterial and viral pathogens in 155 (7%). The annual incidence of pneumonia was 15.7 cases per 10,000 children (95% confidence interval [CI], 14.9 to 16.5), with the highest rate among children younger than 2 years of age (62.2 cases per 10,000 children; 95% CI, 57.6 to 67.1). Respiratory syncytial virus was more common among children younger than 5 years of age than among older children (37% vs. 8%), as were adenovirus (15% vs. 3%) and human metapneumovirus (15% vs. 8%). Mycoplasma pneumoniae was more common among children 5 years of age or older than among younger children (19% vs. 3%). CONCLUSIONS: The burden of hospitalization for children with community-acquired pneumonia was highest among the very young, with respiratory viruses the most commonly detected causes of pneumonia. (Funded by the Influenza Division of the National Center for Immunization and Respiratory Diseases.).

Disseminated histoplasmosis in pediatric kidney transplant recipients-A report of six cases and review of the literature.

BACKGROUND: We report a case series of histoplasmosis in KTx patients in a children's hospital in an endemic area. METHODS: All KTx cases from January 1, 2002, to August 31, 2016, were reviewed to identify those with disseminated histoplasmosis. RESULTS: The attack rate of histoplasmosis among our KTx patients was 6.9 per 100 cases. The median age at the time of diagnosis was 16 years (11-18). Comorbidities included glomerulosclerosis (3), medullary cystic disease (1), and obstructive uropathy (2) and HIV (1). There were 5 deceased and 1 living-related donor transplants, and no patient had a history of rejection prior to histoplasmosis. Median time from transplant to histoplasmosis was 14.8 months (IQR 2.2-38.3) and 33% occurred in the first year after transplant. Urine and/or serum antigens were positive in all patients. They were either treated with amphotericin B and transitioned to an azole or received azole monotherapy. Most (83%) received chronic suppression with itraconazole. No patients died and relapse occurred in 1 patient after repeat transplant. CONCLUSIONS: KTx patients in endemic areas are at risk for disseminated histoplasmosis. Further study is needed to determine which factors portend the need for fungal prophylaxis in this subset of patients.