Planned Out-of-Hospital Birth as a Risk Factor for Nonreceipt of Hepatitis B Immunization.

BACKGROUND: The hepatitis B vaccine (HBV) is recommended at birth to prevent perinatal hepatitis B transmission; however, many newborns still do not receive HBV. The extent to which planned out-of-hospital births, which have increased over the past decade, are associated with nonreceipt of the HBV birth dose is unknown. The purpose of this study was to determine whether a planned out-of-hospital birth location is associated with the nonreceipt of the HBV birth dose. METHODS: We performed a retrospective cohort study of all births from 2007 to 2019 recorded in the Colorado birth registry. χ2 analyses were used to compare maternal demographics by birth location. Univariate and multiple logistic regression were used to evaluate the association of birth location with nonreceipt of the HBV birth dose. RESULTS: In total 1.5% of neonates born in freestanding birth centers and 0.1% of neonates born at a planned home birth received HBV compared to 76.3% of neonates born in a hospital location. After adjusting for confounders, this translated to a large increase in the odds of not receiving HBV compared to in-hospital births [freestanding birth center (aodds ratio (aOR): 172.98, 95% confidence interval (CI): 136.98-219.88); planned home birth (aOR: 502.05, 95% CI: 363.04-694.29)]. Additionally, older maternal age, White/non-Hispanic race and ethnicity, higher income, and private or no insurance were associated with nonreceipt of the HBV birth dose. CONCLUSIONS: Planned out-of-hospital birth is a risk factor for nonreceipt of the HBV birth dose. As births in these locations become more common, targeted policies and education are warranted.

A Tool to Distinguish Viral From Bacterial Pneumonia.

BACKGROUND: Establishing the etiology of community-acquired pneumonia (CAP) in children at admission is challenging. Most of the admitted children with CAP receive antibiotics. We aimed to build and validate a diagnostic tool combining clinical, analytical and radiographic features to differentiate viral from bacterial CAP, and among bacterial CAP, typical from atypical bacteria. METHODS: Design-observational, multi-center, prospective cohort study was conducted in 2 phases. Settings: 24 secondary and tertiary hospitals in Spain. Patients-A total of 495 consecutive hospitalized children between 1 month and 16 years of age with CAP were enrolled. Interventions-A score with 2 sequential steps was built (training set, 70% patients, and validation set 30%). Step 1 differentiates between viral and bacterial CAP and step 2 between typical and atypical bacterial CAP. Optimal cutoff points were selected to maximize specificity setting a high sensitivity (80%). Weights of each variable were calculated with a multivariable logistic regression. Main outcome measures-Viral or bacterial etiology. RESULTS: In total, 262 (53%) children (median age: 2 years, 52.3% male) had an etiologic diagnosis. In step 1, bacterial CAPs were classified with a sensitivity = 97%, a specificity = 48%, and a ROC's area under the curve = 0.81. If a patient with CAP was classified as bacterial, he/she was assessed with step 2. Typical bacteria were classified with a sensitivity = 100%, a specificity = 64% and area under the curve = 0.90. We implemented the score into a mobile app named Pneumonia Etiology Predictor, freely available at usual app stores, that provides the probability of each etiology. CONCLUSIONS: This 2-steps tool can facilitate the physician's decision to prescribe antibiotics without compromising patient safety.

Viruses and Mycoplasma pneumoniae are the main etiological agents of community-acquired pneumonia in hospitalized pediatric patients in Spain.

OBJECTIVES: To describe the etiology of community-acquired pneumonia (CAP) in hospitalized children in Spain and analyze the predictors of the etiology. HYPOTHESIS: The different etiological groups of pediatric CAP are associated with different clinical, radiographic, and analytical data. DESIGN: Observational, multicenter, and prospective study. PATIENT SELECTION: This study included children aged 1 month to 17 years with CAP, who were hospitalized between April 2012 and May 2019. METHODS: An extensive microbiological workup was performed. The clinical, radiographic, and analytical parameters were analyzed for three etiological groups. RESULTS: Among the 495 children included, at least one causative pathogen was identified in 262 (52.9%): pathogenic viruses in 155/262 (59.2%); atypical bacteria (AB), mainly Mycoplasma pneumonia, in 84/262 (32.1%); and typical bacteria (TyB) in 40/262 (15.3%). Consolidation was observed in 89/138 (64.5%) patients with viral CAP, 74/84 (88.1%) with CAP caused by AB, and 40/40 (100%) with CAP caused by TyB. Para-pneumonic pleural effusion (PPE) was observed in 112/495 (22.6%) patients, of which 61/112 (54.5%) presented a likely causative pathogen: viruses in 12/61 (19.7%); AB in 23/61 (37.7%); and TyB in 26/61 (42.6%). Viral etiology was significantly frequent in young patients and in those with low oxygen saturation, wheezing, no consolidation, and high lymphocyte counts. CAP patients with AB as the etiological agent had a significantly longer and less serious course as compared to those with other causative pathogens. CONCLUSIONS: Viruses and M. pneumoniae are the main causes of pediatric CAP in Spain. Wheezing, young age, and no consolidation on radiographs are indicative of viral etiology. Viruses and AB can also cause PPE. Since only a few cases can be directly attributed to TyB, the indications for antibiotics must be carefully considered in each patient.

Occurrence of Amblyomma americanum (Acari: Ixodidae) and Human Infection With Ehrlichia chaffeensis in Wisconsin, 2008-2015.

Because of the increasing incidence of human ehrlichiosis in Wisconsin, we assessed reports of human infections by Ehrlichia chaffeensis and the distribution of its vector, the lone star tick (Amblyomma americanum (L.)). From 2008 through 2015, 158 probable and confirmed human cases of E. chaffeensis infections were reported to the Wisconsin Department of Health Services. Five cases without travel history outside of Wisconsin were confirmed as E. chaffeensis by polymerase chain reaction. Surveillance for the vector occurred from 2008 through 2015 and was based on active and passive methods, including examination of white-tailed deer, collections from live-trapped small mammals, submissions of ticks removed from wild and domestic animals through the Wisconsin Surveillance of Animals for Ticks (SWAT) program, digital or physical submissions by the public to the University of Wisconsin Insect Diagnostic or Medical Entomology laboratories, and active tick dragging. More than 50 lone star ticks (46 adults, 6 nymphs, and 1 larva) were identified. Lone star ticks were more commonly found in south central Wisconsin, particularly in Dane County, where discovery of more than one life stage in a single year indicates possible establishment.

Rate of candidiasis among HIV-infected children in Spain in the era of highly active antiretroviral therapy (1997-2008).

BACKGROUND: Candidiasis is the most common opportunistic infection seen in human immunodeficiency virus (HIV)-infected individuals. The aim of our study was to estimate the candidiasis rate and evaluate its trend in HIV-infected children in Spain during the era of highly active antiretroviral therapy (HAART) compared to HIV-uninfected children. METHODS: We carried out a retrospective study. Data were obtained from the records of the Minimum Basic Data Set from hospitals in Spain. All HIV-infected children were under 17 years of age, and a group of HIV-uninfected children with hospital admissions matching the study group by gender and age were randomly selected. The follow-up period (1997-2008) was divided into three calendar periods: a) From 1997 to 1999 for early-period HAART; b) from 2000 to 2002 for mid-period HAART; and c) from 2003 to 2008 for late-period HAART. RESULTS: Among children with hospital admissions, HIV-infected children had much higher values than HIV-uninfected children during each of the three calendar periods for overall candidiasis rates (150.0 versus 6.1 events per 1,000 child hospital admissions/year (p < 0.001), 90.3 versus 3.1 (p < 0.001), and 79.3 versus 10.7 (p < 0.001), respectively) and for non-invasive Candida mycosis (ICM) rates (118.5 versus 3.8 (p < 0.001), 85.3 versus 2.3 (p < 0.001), and 80.6 versus 6.0 (p < 0.001), respectively). In addition, HIV-infected children also had higher values of ICM rates than HIV-uninfected children, except during the last calendar period when no significant difference was found (32.4 versus 1.2 (p < 0.001), 11.6 versus 0.4 (p < 0.001), and 4.6 versus 2.3 (p = 0.387), respectively). For all children living with HIV/AIDS, the overall candidiasis rate (events per 1,000 HIV-infected children/year) decreased from 1997-1999 to 2000-2002 (18.8 to 10.6; p < 0.001) and from 2000-2002 to 2003-2008 (10.6 to 5.7; p = 0.060). Within each category of candidiasis, both non-ICM and ICM rates experienced significant decreases from 1997-1999 to 2003-2008 (15.9 to 5.7 (p < 0.001) and 4.1 to 0.3 (p < 0.001), respectively). CONCLUSIONS: Although the candidiasis rate still remains higher than in the general population (from 1997 to 2008), candidiasis diagnoses have decreased among HIV-infected children throughout the HAART era, and it has ceased to be a major health problem among children with HIV infection.

Trend of pneumonia incidence among children infected with HIV in the era of highly active antiretroviral therapy.

We performed a retrospective study using a cross-sectional design for each year from 1997 to 2008 to evaluate the trend in pneumonia rates among HIV-infected children in the highly active antiretroviral therapy (HAART) era in Spain. We found that rate of pneumonia decreased among HIV-Infected children in the highly active antiretroviral therapy era but still remained higher than in the general population. Non-AIDS-defining pneumonia remains a significant health problem for HIV-infected children.

Reduction in mycobacterial disease among HIV-infected children in the highly active antiretroviral therapy era (1997-2008).

BACKGROUND: HIV-infected children are at increased risk of developing mycobacterial disease. The aim of this study was to estimate the change in mycobacterial disease rate in HIV-infected children and adolescents in the highly active antiretroviral therapy (HAART) era. METHODS: We carried out a retrospective study. Data were obtained from the records of the minimum basic data set of hospitals in Spain from 1997 to 2008. The epidemiologic trends of mycobacterial diseases were evaluated through the following 3 calendar periods: early-period HAART (1997-1999), midperiod HAART (2000-2002), and late-period HAART (2003-2008). RESULTS: We analyzed 1307 HIV-infected children and 5228 HIV-uninfected children. HIV-infected children had similar rate of tuberculosis (TB) and nontuberculous mycobacteria (NTM) disease, and they had an overall rate of mycobacterial disease higher than that of HIV-uninfected children (P < 0.001). In HIV-infected children, the highest rates were for pulmonary TB (15/42 [35.7%]) in the TB category and disseminated mycobacterium (9/42 [21.4%]) in the NTM category. The overall rate of mycobacterial disease (events per 1000 HIV-infected children-year) decreased from 1997-1999 to 2003-2008 (5.88-1.63, P = 0.007) and from 2000-2002 to 2003-2008 (4.20-1.63, P = 0.021). Furthermore, the rate of TB decreased from 1997-1999 to 2000-2002 (3.53-0.84, P = 0.016) and from 1997-1999 to 2003-2008 (3.53-1.31, P = 0.030), and the rate of NTM disease decreased from 2000-2002 to 2003-2008 (3.36-0.32, P = 0.002). CONCLUSIONS: The rate of mycobacterial disease decreased among HIV-infected children in the HAART era, but the incidence of mycobacterial disease still remains higher than in the general population.

Epidemiologic trends of cancer diagnoses among HIV-infected children in Spain from 1997 to 2008.

BACKGROUND: The introduction of highly active antiretroviral therapy (HAART) has influenced the incidence of cancer in people with human immunodeficiency virus (HIV) infection. The aim of this study was to evaluate changes in the pattern of cancer rates in HIV-infected children on HAART during over a decade of follow-up. PATIENTS AND METHODS: We carried out a case-control study. Data were obtained from the records of the minimum basic data set of hospitals in Spain from 1999 to 2008. The epidemiologic trends of cancer diagnoses were evaluated through 3 calendar periods: early-period HAART: 1997-1999, midperiod HAART: 2000-2002, and late-period HAART: 2003-2008). RESULTS: HIV-infected children had higher rates of cancer diagnosis than HIV-negative children (P < 0.001) for both acquired immunodeficiency disease syndrome (AIDS)-defining malignancies (ADM) and non-AIDS-defining malignancies (non-ADM). The highest rates of cancer diagnosis in HIV-positive children were for non-Hodgkin lymphoma, malignant neoplasm of bone and articular cartilage, and Hodgkin lymphoma. When we compared the 3 calendar periods, we found that the rate of ADM diagnoses decreased (from 9.1 to 3.6 to 1.0 cancers per 1000 HIV-children/yr; P < 0.05) and that the rate of non-ADM diagnoses increased (from 0.6 to 5.0 to 8.7 cancers per 1000 HIV-children/yr; P < 0.05). Moreover, the overall rate of cancer diagnoses (ADM plus non-ADM) did not change during the study period (9.7, 8.7, and 9.7 cancers per 1000 HIV-children/yr). CONCLUSIONS: HIV-infected children had a dramatic decrease in the rate of ADM diagnoses and an increase in the rate of non-ADM diagnoses. The overall cancer diagnosis rate has not decreased during the past decade and the incidence of cancer still remains high in HIV-infected children in Spain.

Post-surgical invasive aspergillosis: an uncommon and under-appreciated entity.

OBJECTIVE: Post-surgical invasive aspergillosis (PSIA) is an unusual and underestimated complication of surgery. It may occur after colonization of surgical sites by airborne Aspergillus conidia during surgery, or in the immediate postoperative. METHODS: We reviewed 7 cases of PSIA (1997-2006) and checked the air levels of Aspergillus conidia in the operating rooms and/or areas surrounding 5/7 patients. RESULTS: PSIA accounted for 8.4% (n = 83) of all cases of invasive aspergillosis. Patients had no classic predisposing conditions (wound infection (n = 4), mediastinitis (n = 2), and endotipsitis with endocarditis (n = 1)). PSIA occurred sporadically after heart, thoracic, and vascular prosthetic surgery. Aspergillus fumigatus was involved in all cases. Median time from surgery to diagnosis was 25 days. Galactomannan was only positive (> or =1 ng/mL) in 2 patients (endotipsitis with endocarditis and mediastinitis). Mortality was 100% in cases of organ/space post-surgical infections. Although the air of operating rooms taken before surgery was free of Aspergillus, airborne Aspergillus conidia levels were high (>95 CFU/m(3)) in the rooms of 2 patients. CONCLUSIONS: PSIA represented almost 10% of all cases of invasive aspergillosis. Our cases were not linked to high levels of Aspergillus conidia in the operating rooms but to postoperative contamination by environmental isolates present in high counts.

Value of a single galactomannan determination (Platelia) for the diagnosis of invasive aspergillosis in non-hematological patients with clinical isolation of Aspergillus spp.

We studied 75 patients with non-hematological conditions from whom Aspergillus spp. were recovered from clinical specimens during the period March 2003 to August 2006. The patients were classified according to EORTC criteria and the presence of galactomannan (Platelia Aspergillus) in their sera was evaluated. Ten of these patients (13.3%) had proven or probable invasive aspergillosis, i.e., chronic obstructive pulmonary disease in five (50%), HIV infection in one (10%), lymphoma in one (10%), liver transplant in one (10%), solid malignancies in one (10%), and corticosteroid treatment in one (10%). The sensitivity, specificity, and positive and negative predictive values for the detection of galactomannan, using cut-offs of > or =0.5 ng/ml and > or =1 ng/ml were 60%/50%, 89.23%/100%, 46.15%/100%, and 93.55%/92.86% (p=0.001 and p<0.001), respectively. The determination of galactomannan in the sera of non-neutropenic patients could prove to be a useful microbiological finding when diagnosing invasive aspergillosis.

Long-term response to highly active antiretroviral therapy in human immunodeficiency virus and hepatitis C virus coinfected children: 6 years of follow-up.

We carried out a retrospective study to analyze the long-term response to highly active antiretroviral therapy of 19 vertically human immunodeficiency virus type 1/hepatitis C virus (HCV-1/HIV) coinfected children. The clinical, immunologic, viral, and biochemical variables were assayed at 0, 1, 2, 3, 4, 5, and 6 years of follow-up. Our data suggest that CD4 T-cell recovery and viral load control during long-term highly active antiretroviral therapy among HIV-1/HCV children were similar to those described in HIV-1 monoinfected children, but hepatic function was significantly altered in HIV-1/HCV children.

Slow progression of human immunodeficiency virus and hepatitis C virus disease in a cohort of coinfected children.

We carried out a retrospective study to determine the evolution of 23 vertically HIV-1/HCV coinfected children and 30 vertically HIV-1 infected children (control group). Six out of 23 HIV-1/HCV coinfected children developed AIDS versus 20 out of 30 HIV-1 children (P < 0.05). HIV-1/HCV children had a good evolution in relation to CD4 and HIV-RNA viral load. They presented higher CD8 counts than HIV-1 children during long periods, and slower progression of HCV liver disease.

[Chronic angioedema and blastocystis hominis infection]. / Angioedema crónico e infección por blastocystis hominis.

The presence of urticaria associated with Blastocystic Hominis infection has been described in very few studies. To the best of our knowledge, no cases of chronic angioedema associated with Blastocystic hominis have been published. The clinical and immunological data of a patient with said association is presented. In the last 5 years, a 21 year old woman suffered episodic spells of angioedema which affected her lips, face and upper limbs accompanied by recurring urticaria. The patient continually used antihistamines and corticoids. Laboratory and immunological tests were normal. Blastocystic hominis in faeces was identified on three occasions. The angioedema and urticaria, as well as the intestinal infection, were successfully treated with paramomycin sulphate. The angiodema and urticaria continue in remission after 24 months of followup care. This case helps to encourage studies to establish an association between the infection by Blastocystis hominis and the presence of chronic angioedema which does not respond to standard treatment, as this condition can seriously affect the quality of life of sufferers.

Mixed fungemia: incidence, risk factors, and mortality in a general hospital.

BACKGROUND: Fungemia has been historically considered to be a disease caused by a single Candida species; the detection of >1 species of yeast in circulating blood was distinctly uncommon using traditional microbiological procedures. We describe episodes of mixed fungemia (MF), detected between 1985 and 2006, in a large teaching hospital. METHODS: The study was divided into 2 periods that were separated by the introduction, in January 2005, of the CHROmagar Candida medium (CHROMagar) for the routine subculturing of blood cultures in which yeast has been identified. Overall, we documented 747 cases of fungemia. During the first period (1985-1994), we identified 217 episodes of fungemia and no single episode of MF; during the second period (1995-2006), 15 episodes of MF were detected among 530 episodes of fungemia (2.8%). Candida albicans was isolated in 13 patients, non-albicans species of Candida in 16 patients, and Saccharomyces cerevisiae in 1 patient. Each episode of MF was compared with 2 control episodes of monomicrobial fungemia. RESULTS: Patients with MF had more frequently experienced organ transplantation (13% vs. 0%) and surgery (60% vs. 27%), had less frequently received parenteral nutrition (40% vs. 70%) or had intravenous lines (80% vs. 100%), and had a lower incidence of shock (6% vs. 37%) and a lower mortality (20% vs. 53%). CONCLUSIONS: Despite the introduction of chromogenic agar, MF is still an uncommon disease and has a less severe outcome than does monomicrobial candidemia.