Sexually Transmitted Infections in Pregnant Women: Integrating Screening and Treatment into Prenatal Care.

Chlamydia, gonorrhea, and syphilis continue to be significant burdens to the health of pregnant women and their children despite easy and effective guidance for screening and treatment. Specific guidelines exist for screening for these infections as well as treatment and follow-up. In this article, we review the epidemiology of chlamydia, gonorrhea, and syphilis. Testing methodology is also reviewed as molecular-based techniques have replaced culture as the current gold standard tests of choice for chlamydia and gonorrhea. The nontreponemal and treponemal serologic diagnostic and screening approach to syphilis has undergone less change. Treatment for gonorrhea includes a one-time dose of parenteral ceftriaxone and oral azithromycin. This treatment regimen not only addresses the possible gonococcal resistance seen in recent years but also treats chlamydia, which may present similarly or co-infect the same patient. Syphilis treatment in both pregnant women and their infected neonates remains with penicillin G formulations. It is crucial to establish close follow-up evaluation for the pregnant woman infected with these sexually transmitted infections to ensure adequate treatment and help prevent perinatal spread of the infection.

Genomic Epidemiology of Methicillin-Resistant Staphylococcus aureus in a Neonatal Intensive Care Unit.

Despite infection prevention efforts, neonatal intensive care unit (NICU) patients remain at risk of Methicillin-resistant Staphylococcus aureus (MRSA) infection. Modes of transmission for healthcare-associated (HA) and community-associated (CA) MRSA remain poorly understood and may vary by genotype, hindering the development of effective prevention and control strategies. From 2008-2010, all patients admitted to a level III NICU were screened for MRSA colonization, and all available isolates were spa-typed. Spa-type t008, the most prevalent CA- genotype in the United States, spa-type t045, a HA- related genotype, and a convenience sample of strains isolated from 2003-2011, underwent whole-genome sequencing and phylodynamic analysis. Patient risk factors were compared between colonized and noncolonized infants, and virulence and resistance genes compared between spa-type t008 and non-t008 strains. Epidemiological and genomic data were used to estimate MRSA importations and acquisitions through transmission reconstruction. MRSA colonization was identified in 9.1% (177/1940) of hospitalized infants and associated with low gestational age and birth weight. Among colonized infants, low gestational age was more common among those colonized with t008 strains. Our data suggest that approximately 70% of colonizations were the result of transmission events within the NICU, with the remainder likely to reflect importations of "outside" strains. While risk of transmission within the NICU was not affected by spa-type, patterns of acquisition and importation differed between t008 and t045 strains. Phylodynamic analysis showed the effective population size of spa-type t008 has been exponentially increasing in both community and hospital, with spa-type t008 strains possessed virulence genes not found among t045 strains; t045 strains, in contrast, appeared to be of more recent origin, with a possible hospital source. Our data highlight the importance of both intra-NICU transmission and recurrent introductions in maintenance of MRSA colonization within the NICU environment, as well as spa-type-specific differences in epidemiology.

Salmonella Infections in Childhood.

Salmonella are gram-negative bacilli within the family Enterobacteriaceae. They are the cause of significant morbidity and mortality worldwide. Animals (pets) are an important reservoir for nontyphoidal Salmonella, whereas humans are the only natural host and reservoir for Salmonella Typhi. Salmonella infections are a major cause of gastroenteritis worldwide. They account for an estimated 2.8 billion cases of diarrheal disease each year. The transmission of Salmonella is frequently associated with the consumption of contaminated water and food of animal origin, and it is facilitated by conditions of poor hygiene. Nontyphoidal Salmonella infections have a worldwide distribution, whereas most typhoidal Salmonella infections in the United States are acquired abroad. In the United States, Salmonella is a common agent for food-borne­associated infections. Several outbreaks have been identified and are most commonly associated with agricultural products. Nontyphoidal Salmonella infection is usually characterized by a self-limited gastroenteritis in immunocompetent hosts in industrialized countries, but it may also cause invasive disease in vulnerable individuals (eg, children less than 1 year of age, immunocompromised). Antibiotic treatment is not recommended for treatment of mild to moderate gastroenteritis by nontyphoidal Salmonella in immunocompetent adults or children more than 1 year of age. Antibiotic treatment is recommended for nontyphoidal Salmonella infections in infants less than 3 months of age, because they are at higher risk for bacteremia and extraintestinal complications. Typhoid (enteric) fever and its potential complications have a significant impact on children, especially those who live in developing countries. Antibiotic treatment of typhoid fever has become challenging because of the emergence of Salmonella Typhi strains that are resistant to classically used first-line agents: ampicillin, trimethoprim-sulfamethoxazole, and chloramphenicol. The choice of antibiotics for the management of typhoid fever should be guided by the local resistance pattern. Recommendations include using an extended spectrum cephalosporin, azithromycin, or a fluoroquinolone. Fecal carriage of Salmonella is an important factor in the spread of the organism to healthy individuals. The most important measures to prevent the spread and outbreaks of Salmonella infections and typhoid fever are adequate sanitation protocols for food processing and handling as well as hand hygiene. In the United States, 2 vaccines are commercially available against Salmonella Typhi. The WHO recommends the use of these vaccines in endemic areas and for outbreak control.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Pneumococcal infections.

Overwhelmingly consistent evidence from observational studies has demonstrated that the pneumococcal conjugate vaccine has reduced the burden of pneumococcal disease but continues to affect the epidemiology of pneumococcal infections caused by nonvaccine serotypes and antibiotic-resistant pneumococci. On the basis of strong evidence, susceptible pneumococci causing uncomplicated, noninvasive childhood infections (eg, otitis or pneumonia) should be treated with a narrow-spectrum antimicrobial (eg, amoxicillin). Severely ill patients and those with infections caused by resistant pneumococci may be treated with parenteral antibiotic agents based on the isolate's susceptibility and the site of the infection.

Prevalence of and risk factors for methicillin-resistant Staphylococcus aureus colonization and infection among infants at a level III neonatal intensive care unit.

BACKGROUND: Methicillin-resistant Staphylococcus aureus (MRSA) is a well-known nosocomial pathogen of neonatal intensive care unit (NICU) patients and can cause both serious infections in preterm neonates and prolonged MRSA outbreaks in NICUs. OBJECTIVES: Our objectives were to determine the prevalence of and identify risk factors for MRSA colonization and infection in the NICU and the impact of an active surveillance program on MRSA in the NICU. METHODS: We collected weekly nasal MRSA surveillance cultures on 2,048 infants admitted to NICU over 3 years. Data on these infants were collected retrospectively. Characteristics of MRSA colonized and infected infants were analyzed and compared. RESULTS: MRSA colonization was detected in 6.74% of infants, and MRSA infection occurred in 22% of those colonized. Using clinical cultures alone, only 41 (27.5%) of 149 MRSA affected infants were identified. The majority (75%) developed MRSA infection within 17 days of colonization. For every 10-day increment in NICU stay, the odds ratio of being infected and colonized with MRSA increased by 1.32 and 1.29, respectively. Colonization was significantly associated with longer NICU stay, low birth weight, low gestational age, and multiple gestation status. CONCLUSION: Colonization is a risk factor for infection with MRSA in NICUs. Clinical cultures underestimate MRSA affected infants in NICUs, whereas active surveillance cultures could detect MRSA affected infants earlier and limit nosocomial spread.

Propionic acidemia mimicking diabetic ketoacidosis.

Propionic acidemia manifesting with hyperglycemia is rare. Few cases have been reported mainly of the neonatal-onset form associated with high mortality. We report a 9-month-old Palestinian boy who manifested with coma, severe hyperglycemia and ketoacidosis mimicking diabetic ketoacidosis. Family history of unexplained infant deaths was helpful in reaching the correct diagnosis. In response to therapy, the patient regained consciousness without neurologic deficits and had normal examination. This is, to our knowledge, the first case report of late-onset propionic acidemia that had this presentation and survived.

Outpatient parenteral antimicrobial therapy in osteoarticular infections in children.

There are few data on the use of outpatient parenteral antimicrobial therapy (OPAT) in the management of osteoarticular infections (OAIs) in childhood. The objective of this study was to determine if OPAT is safe and effective in the management of OAIs. Using their OPAT database, the authors evaluated the use of OPAT in children younger than 18 years old treated for OAIs between January 1, 1995, and December 31, 1999. One hundred eighty-four OAIs were treated in 179 patients over 5 years. OPAT involved central venous lines (CVLs) in 110 (59.8%), peripherally inserted central catheters (PICCs) in 71 (38.6%), and peripheral cannulas in 3 (1.6%). One hundred eighteen (64%) OPAT courses were completed without interruption. Rehospitalization occurred in 48 (26.1%) courses and occurred earlier with PICC. OPAT complications were catheter-related in 58 (30%) courses, not catheter-related in 60 (32%), and unknown in 10 (5.3%). The mechanical complication rate was 6.3 per 1,000 catheter-days (CVL 4.2, PICC 10.6), and the rate of infectious complications was 2.7 per 1,000 catheter-days (CVL 2.8, PICC 2.4). One hundred sixty-eight (98%) of 172 evaluable OAIs were cured. Four (2.2%) patients failed treatment: one had recurrence and three had persistent infection. The authors conclude that OPAT can be safely used to manage OAIs in children without compromising outcome. Mechanical complications are more common with PICCs.

Higher occurrence of hepatotoxicity and rash in patients treated with oxacillin, compared with those treated with nafcillin and other commonly used antimicrobials.

This study compared adverse drug reactions (ADRs) to oxacillin with those to nafcillin and other antibiotics. We reviewed the medical records of 222 children receiving outpatient parenteral antimicrobial therapy (OPAT) from February 1995 through June 1999. The diagnosis, antibiotics used, ADRs, action taken, and patient demographics were recorded. The most common ADRs were neutropenia (9.8%), rash (8.5%), and hepatotoxicity (3.8%). ADRs occurred more frequently in the oxacillin group (58.5%) than in the nafcillin group (29.3%; P=.004), the clindamycin group (12.5%; P<.001) and the "other" antibiotics group (14.4%; P<.001). Hepatotoxicity and rash occurred more frequently in the oxacillin group (22% and 31.7%, respectively) than in the nafcillin group (0% [P<.001] and 10.3% [P=.008]), the clindamycin group (1.4% [P<.001] and 8.3% [P=.001]), and the other antibiotics group (1.4% [P<.001] and 1.4% [P<.001]). On the basis of this retrospective analysis, oxacillin use in children was associated with a higher incidence of hepatotoxicity and rash, compared with the use of nafcillin and other intravenous antimicrobials.