Evaluating a neonatal intensive care unit MRSA surveillance programme using agent-based network modelling.

BACKGROUND: Surveillance for meticillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs) is a commonplace infection prevention strategy, yet the optimal frequency with which to monitor the unit is unknown. AIM: To compare various surveillance frequencies using simulation modelling. METHODS: One hundred NICU networks of 52 infants were simulated over a six-month period to assess MRSA transmission. Unit-wide surveillance occurred every N weeks where N={1,2,3,4}, and was compared with the current NICU policy of dynamic surveillance (i.e. weekly when at least one positive screen, otherwise every three weeks). For each surveillance period, colonized infants received a decolonization regimen (56% effective) and were moved to isolation rooms, if available. FINDINGS: As the surveillance frequency increased, the mean number of MRSA-colonized infants decreased, from a high of 2.9 (four-weekly monitoring) to a low of 0.6 (weekly monitoring) detected per episode. The mean duration of colonization decreased from 307 h (four-weekly monitoring) to 61 h (weekly monitoring). Meanwhile, the availability of isolation rooms followed an inverse relationship: as surveillance frequency increased, the availability of isolation rooms decreased (61% isolation success rate for four-weekly monitoring vs 49% success rate for weekly monitoring). The dynamic policy performed similar to a biweekly programme. CONCLUSIONS: An effective MRSA surveillance programme needs to balance resource availability with potential for harm due to longer colonization periods and opportunity for development of invasive disease. While more frequent monitoring led to greater use of a decolonization regimen, it also reduced the likelihood of isolation rooms being available.

Characteristics of late-onset sepsis in the NICU: does occupancy impact risk of infection?

OBJECTIVE: Infants in neonatal intensive care units (NICUs) are vulnerable to a variety of infections, and occupancy in the unit may correlate with risk of infection. STUDY DESIGN: A retrospective cohort of infants admitted to the NICUs between 1997 and 2014. Survival analysis was used to model the relative hazard of sepsis infection in relation to two measures of occupancy: 1) the average census and 2) proportion of infants <32 weeks gestation in the unit. RESULT: There were 446 (2.3%) lab-confirmed cases of bacterial or fungal sepsis, which steadily declined over time. For each additional percentage of infants <32 weeks gestation, there was an increased hazard of 2% (hazard ratio 1.02, 95% confidence interval: 1.00, 1.03) over their NICU hospitalization. Census was not associated with risk for infection. CONCLUSION: During times of a greater proportion of infants <32 weeks gestation in the NICU, enhanced infection-control interventions may be beneficial to further reduce the incidence of infections.

Teratogen update: Lyme disease.

We reviewed the world literature concerning the reproductive effects of Lyme disease (LD). Borrelia burgdorferi, which is the etiology of LD, is a spirochete and, as such, may share the potential for causing fetal infection, which may occur in the setting of maternal spirochetemia. Information concerning the effects of gestational LD derives from case reports and series, epidemiologic studies, and experimental animal models. Although provocative, these studies fail to define a characteristic teratogenic effect. However, skin and cardiac involvement have predominated in some reports. Pregnancy wastage has been suggested primarily by animal studies. Gestational LD appears to be associated with a low risk of adverse pregnancy outcome, particularly with appropriated antibiotic therapy. Suggestions for management of clinical situations are presented.

Cat-scratch disease presenting as multifocal osteomyelitis with thoracic abscess.

The case of a 4-year-old girl who presented with fever and back pain after being scratched by a kitten is presented. The diagnosis of cat scratch disease osteomyelitis was made by the detection of Bartonella henselae DNA by PCR analysis of a rib abscess aspirate.

Long-term cognitive effects of Lyme disease in children.

Most studies of adults infected with Lyme disease (LD) have found adverse cognitive effects from the disease. In contrast, the only controlled study investigating cognitive effects of LD in a pediatric population found no effects after a 2-year follow-up. However, it was questioned whether the negative effects might take longer than 2 years to emerge. Therefore, this investigation reports a 4-year follow-up of the original sample. Twenty-five children with strictly defined LD were compared with 17 sibling control children. A neuropsychological battery was utilized, including assessment of the cognitive areas of IQ, information processing speed, fine-motor dexterity, novel problem solving and executive functioning, short-term and intermediate memory, and acquisition of new learning. In addition, parents' subjective ratings were obtained on the disease's impact on their child's participation in everyday activities. No between-group differences were found for 17 of the 18 neuropsychological test measures, nor were there differences in parents' subjective ratings. Therefore, in contrast with studies of adults with LD, the results of long-term follow-up of the pediatric population continue to strongly support the finding that children treated appropriately for LD have an excellent prognosis for normal cognitive functioning.

Cognitive effects of Lyme disease in children: a 4 year followup study.

OBJECTIVE: To measure cognitive effects of Lyme disease (LD) in a pediatric population 4 years after disease onset. METHODS: Prospective, blinded, multivariable controlled study of cognitive skills in children who have been treated for LD. The setting was a children's hospital in an area endemic for LD. Twenty-five children with strictly defined LD were compared with 17 control children (6 disease-control and 11 sibling-control). OUTCOME MEASURES: An extensive set of neuropsychological measures was administered. These included assessment of the cognitive areas of IQ, information processing speed, fine-motor dexterity, novel problem solving and executive functioning, short term and intermediate memory, and acquisition of new learning. Parents' ratings were also obtained concerning disease impact upon everyday activities. RESULTS: Seventeen of the 18 neuropsychological test measures showed the LD and control groups similar at time of 4 year followup. There were no differences between the groups regarding parents' impressions of disease impact. CONCLUSION: In contrast to studies of adults with LD, the results of longterm followup of the pediatric population continue to strongly support the finding that children treated appropriately for LD have an excellent prognosis for normal cognitive functioning.

Characterization of Lyme meningitis and comparison with viral meningitis in children.

OBJECTIVES: The objectives of this study were to characterize Lyme meningitis (LM) in the pediatric population; to compare LM with viral meningitis (VM) with respect to epidemiology, history and physical examination, and laboratory data; and to provide means of early distinction of Lyme neuroborreliosis from other forms of aseptic meningitis. METHODS: This retrospective analysis involved children admitted to Alfred I. duPont Hospital for Children between 1990 and 1996 whose discharge diagnoses indicated viral or aseptic meningitis or Lyme disease. LM was defined as the presence of cerebrospinal fluid (CSF) pleocytosis with positive Lyme serology and/or erythema migrans. Patients were considered to have VM if they exhibited CSF pleocytosis and had a positive viral culture. Demographic, clinical, and laboratory data were collected for each patient, and patients with LM were compared with age-matched patients with VM. RESULTS: Of 179 patient records, 12 patients with LM and 10 patients with VM (all, >2 years old) were identified by using the above criteria. In comparing LM patients with VM patients, we noted no differences among demographic variables. Children with LM had significantly lower temperatures at the time of presentation. The presence of headache, neck pain, and malaise was similar for the two groups, but the duration of these symptoms was significantly longer among LM patients. Five children with LM had cranial neuropathies. All but 1 LM patient exhibited either papilledema, erythema migrans, or cranial neuropathy. These three findings were absent in the VM group. On CSF analysis, LM patients had fewer white blood cells (mean, 80/mm3 versus 301/mm3) and a significantly greater percentage of mononuclear cells than the VM patients. CONCLUSIONS: In this study, in a Lyme-endemic area, LM was about as common as VM in older children who were hospitalized with aseptic meningitis. Attention to pertinent epidemiologic and historical data, along with physical and CSF findings, allows early differentiation of LM from VM.

Multivariate predictive models for group A beta-hemolytic streptococcal pharyngitis in children.

OBJECTIVES: To create predictive models for the clinical diagnosis of group A beta-hemolytic streptococcal (GABHS) pharyngitis in children. METHODS: Patients aged 6 months to 18 years presenting to a pediatric ED with suspected GABHS pharyngitis were prospectively enrolled in the study. Clinicians recorded pertinent clinical information using a standardized form and obtained a throat swab to culture GABHS using a reference standard method. Twelve demographic and clinical features of patients with positive throat cultures were compared with the features of patients with negative throat cultures. Significantly different features were entered in a stepwise logistic regression analysis to create predictive models for the diagnosis. RESULTS: Eighty-five patients (29%) were culture-positive and 212 (71%) were culture-negative for GABHS. Respective mean ages were 6.2 years and 6.1 years in the two groups. Univariate chi-square analysis of the 12 features identified six variables that were significantly associated with GABHS. All significant features were initially included in a stepwise logistic regression analysis. In model I, four independent variables were identified: moderate to severe presentation of tonsillar swelling, moderate to severe tenderness and enlargement of cervical lymph nodes, the presence of scarlatiniform rash, and the absence of moderate to severe coryza, yielding a 95% probability for GABHS. Excluding the rare scarlatiniform rash, the remaining variables were used in the second regression analysis. In model II, three independent variables were identified: moderate to severe tonsillar swelling, moderate to severe tenderness and enlargement of cervical lymph nodes, and absence of moderate to severe coryza, yielding a probability of 65% for the diagnosis. A probability of <15% was observed in the absence of scarlatiniform rash, the absence of moderate to severe tenderness and enlargement of cervical lymph nodes, and the presence of moderate to severe coryza. CONCLUSIONS: In children with moderate to severe presentation of tonsillar swelling, tenderness and enlargement of cervical lymph nodes, and the absence of coryza, the probability of a positive throat culture is >65%. Conversely, in the absence of a moderate to severe presentation of tonsillar swelling, enlargement of cervical nodes, and the presence of coryza, the probability of a positive throat culture is <15%. If prospectively validated, these models could be integrated into a consistent treat, test, and no treatment/no testing approach to the clinical management of childhood pharyngitis.

Infective endocarditis in the premature neonate.

We describe a series of 11 high-risk neonates with infective endocarditis (IE) in this retrospective review. Previously IE has rarely been diagnosed in newborns and is usually fatal. The frequency was 4.3 cases per 100 patients. Five patients survived. Microorganisms included gram positives such as S. aureus and coagulase-negative Staphylococcus, gram negatives such as Klebsiella pneumoniae, Enterobacter cloacae, Enterococcus faecalis, Serratia marcescens, and Acinetobacter calcoaceticus. Echocardiographic location of the lesions showed four left sided, five right sided, and two bilateral. We conclude that IE may be more common than previously described. Prompt diagnosis and treatment led to survival in 45% of our patients. Prospective studies are needed to identify patients at risk and to establish the true incidence of IE in high-risk neonates.

Cat scratch disease presenting with peripheral facial nerve paralysis.

Acquired peripheral facial nerve paralysis is a relatively common disorder that affects both children and adults. The most frequent nontrauma-related etiologies in otherwise neurologically intact patients are idiopathic (Bell's palsy) and infectious, which includes otitis media, herpes zoster, Lyme disease, herpes simplex virus, Epstein-Barr virus, and Mycoplasma pneumoniae. Cat scratch disease (CSD) is typically a subacute, regional lymphadenitis caused by Bartonella henselae that is seen in children and young adults. CSD most often has a benign, self-limited course. However, 11% of CSD patients may present atypically, most commonly with Perinaud's oculoglandular syndrome or acute encephalopathy. We present a child with the first reported case of acute facial nerve paralysis in serologically proven CSD with typical lymphadenitis.

Lyme disease and seventh nerve paralysis in children.

PURPOSE: This study was undertaken to determine the frequency of Lyme disease (LD) as a cause of transient facial nerve palsy (FNP) in children. Acute onset FNP in children has been primarily associated with acute otitis media (AOM). Recently, LD has emerged in regions where the deer-tick vector is present and has been associated with multiple cranial neuropathies. PATIENTS AND METHODS: Fifty children with transient FNP were evaluated and treated at our institution over a 5.5-year period. RESULTS: The rank of etiologies confirmed LD to now be the most common (50%), followed by AOM (12%), varicella (6%), Herpes zoster (4%), and coxsackievirus (2%). Thirteen children (26%) had idiopathic FNP consistent with Bell's palsy. CONCLUSION: We conclude that transient FNP in children is most commonly caused by LD for regions with endemic infections caused by Borrelia burgdorferi.

Infection-related arthritis.

Postinfection arthritis represents a significant portion of the referrals to pediatric rheumatology centers, particularly in the United States. Many viral and common bacterial infections can be associated with arthritis, and their recognition can sometimes be difficult on a clinical basis. In patients with acute onset of arthritis, the clinician should actively seek epidemiologic, clinical, or laboratory evidence of infection. Diagnostic tests should be used rationally and results interpreted carefully. Some infections, once recognized, require antibiotic treatment, but in most cases anti-inflammatory therapy is successful in treating articular symptoms.

Morganella morganii: a newly reported, rare cause of neonatal sepsis.

This case report reviews the clinical course of an 11-day-old boy who developed late-onset neonatal sepsis secondary to a rare neonatal pathogen, Morganella morganii. This gram-negative enteric bacterium, within the Enterobacteriaceae family, has most commonly been a nosocomial pathogen in debilitated, postsurgical patients. Like many other Enterobacteriaceae, M. morganii has an inducible beta-lactamase and is resistant to multiple antibiotics. When caring for neonates with culture-proven M. morganii sepsis, the authors recommend administering both a third-generation cephalosporin and an aminoglycoside to ensure that both antibiotics are bactericidal and to reduce the induction of resistance.

Vibrio fluvialis: an underrecognized enteric pathogen in infants?

We report a case of Vibrio fluvialis gastroenteritis in an infants 3 1/2 weeks old. The case was unusual because no likely epidemiologic risk factors were involved. Since several other such cases in young infants have been reported, V fluvialis should be considered in the differential diagnosis of infantile gastroenteritis.

Environmental and life-style risk factors for Lyme disease in children.

Risk factors for Lyme disease and/or infection with Borrelia burgdorferi in children are not defined. A case-control study was performed using Lyme disease patients from our Lyme Clinic population. Age- and sex-matched controls from the same neighborhood were identified by the Lyme patients' families. A site visit was made to each case/control neighborhood. Twenty-four environmental variables, especially the ecologic characteristics of the home environment were examined. Forty-five items were surveyed by parent questionnaire, including certain "high-risk" activities and behaviors, whether ticks or certain animals were present on the property, and whether antitick measures were used. Control subjects had serologic assays for antibodies to B. burgdorferi. Forty-four Lyme disease patients and 44 well-matched control subjects participated; 2 controls were seropositive. Significant associations with Lyme disease were found for deer ticks in the home environment, ground cover containing moist humus, and leaf litter in the yard. Among the 45 items related to life-style, there was no correlation with Lyme disease for the use of any antitick measures or for any childhood activities; in fact, an inverse correlation was observed for camping and fishing. We conclude that conditions in the immediate home environment, including certain ecologic factors that favor the presence of Ixodes ticks, are associated with an increased risk for Lyme disease in children.

Tuboovarian abscess and peritonitis caused by Streptococcus pneumoniae serotype 1 in young girls.

Streptococcus pneumoniae is a frequent bacterial cause of pneumonia, bacteremia, meningitis, and otitis media in infants and children. Primary pneumococcal peritonitis, however, is rare in children and is usually associated with an underlying medical condition (such as nephrotic syndrome) or with upper genital tract disease in females, Pneumococcal upper genital tract infections in the premenarchal child are extremely unusual. Epidemiologic reviews of pneumococcal serotypes causing infection in children have indicated that serotype 1 is an uncommon pathogen of pelvic disease in children. We describe three children who presented with abdominal pain and a toxic appearance; appendicitis was initially suspected in all three children, but peritonitis due to S pneumoniae serotype 1 was subsequently diagnosed in all three. Each child had a tuboovarian abscess that was demonstrated radiographically. Two children had complicated courses, but all ultimately recovered. The epidemiology and possible tropism of serotype 1 isolates for the female upper genital tract are discussed.

Health care of children and adults with acquired immunodeficiency syndrome. A population-based analysis.

OBJECTIVES: To compare the use of medical services by pediatric and adult patients with acquired immunodeficiency syndrome (AIDS) in the 6 months before and after the diagnosis of AIDS when demand for care is often high and to study the influence of human immunodeficiency virus specialty care on survival of pediatric patients. DESIGN: Retrospective analysis of Medicaid files. SETTING: New York State Medicaid Program. PATIENTS: A cohort identified as having AIDS from 1985 through 1990 and enrolled on Medicaid from birth or 1 year or more before diagnosis. Because of differing prognoses, 3 groups were studied by age at the time that AIDS was diagnosed: infants younger than 6 months, children aged 6 months to 12 years, and adults aged 13 to 60 years. MAIN OUTCOME MEASURES: Frequencies of any service use and, among users, monthly rates of services. From Cox proportional hazards models, the adjusted hazard of death for human immunodeficiency virus specialty ambulatory care. RESULTS: Nearly all infants (n = 122) were hospitalized before and after the diagnosis of AIDS was made--the most of all groups. After diagnosis, only 81% of older children (n = 612) were hospitalized vs 93% of infants and 90% of adults (n = 5602). Hospitalized children had a median of only 3.3 inpatient days per month vs 12.3 and 7.8 inpatient days for infants and adults, respectively. Of older children, 45% used the emergency department vs 33% of adults. Human immunodeficiency virus specialty care for infants and children was associated with a 40% lower risk of death after the diagnosis of AIDS. CONCLUSIONS: In this AIDS cohort, infants had the greatest use of inpatient care, and older children used the emergency department more than adults. The finding of improved survival for infants and children with human immunodeficiency virus specialty care warrants further study in more recent years.