Trends in Use of Postdischarge Intravenous Antibiotic Therapy for Children.

Children with complicated appendicitis, osteomyelitis, and complicated pneumonia have historically been treated with postdischarge intravenous antibiotics (PD-IV) using peripherally inserted central catheters (PICCs). Recent studies have shown no advantage and increased complications of PD-IV, compared with oral therapy, and the extent to which use of PD-IV has since changed for these conditions is not known. We used a national children's hospital database to evaluate trends in PD-IV during 2000-2018 for each of these three conditions. PD-IV decreased from 13% to 2% (risk ratio [RR], 0.15; 95% CI, 0.14-0.16) for complicated appendicitis, 61% to 22% (RR, 0.41; 95% CI, 0.39-0.43) for osteomyelitis, and 29% to 19% (RR, 0.63; 95% CI, 0.58-0.69) for complicated pneumonia. Despite these overall reductions, substantial variation in PD-IV use by hospital remains in 2018.

Heart murmurs and echocardiography findings in the normal newborn nursery.

OBJECTIVE: To determine the clinical findings and management implications of echocardiograms performed on infants with murmurs in the nursery. DESIGN: Retrospective cohort study conducted from January 2008 through December 2015. Patients in the study were followed by chart review for up to 5 years. In addition, a survey of nursery providers was conducted in February 2016. SETTING: A single community hospital associated with a university. PATIENTS: All 26 573 infants who received care in the normal newborn nursery were eligible for inclusion in the study. Infants with echocardiograms were analyzed. The survey was sent by e-mail to all 135 physicians who work in the nursery. OUTCOME MEASURES: The primary outcomes include the specific findings on echocardiogram and whether the findings required an acute change in management, outpatient follow up, or were incidental findings. The primary survey question was how physicians would manage an otherwise asymptomatic newborn with a heart murmur. RESULTS: Four hundred ninety-nine infants had echocardiograms, and over the study period the utilization of echocardiography increased from 1.02% to 2.56% (P < .001) of all infants. Three hundred fifty-four babies had echocardiography performed because of a heart murmur. One hundred sixty-three (46.0%) of these echocardiograms were normal and 160 (45.2%) had findings that did not require additional care. Twenty-three neonates (6.5%) had echocardiographic findings that necessitated outpatient follow-up and 8 neonates (2.3%) required neonatal intensive care due to the findings on their echocardiogram. In total, 14 infants (4%) would go on to require heart surgery or interventional cardiac catheterization. 63/135 (47%) physicians completed the survey, with wide variations in the management of newborns with heart murmurs. CONCLUSIONS: The use of echocardiography in the normal newborn nursery has increased with time despite improved prenatal detection of heart disease and the use of pulse oximetry screening, and identifies significant heart disease in a small but important number of infants.

Innate immunity against Granulibacter bethesdensis, an emerging gram-negative bacterial pathogen.

Acetic acid bacteria were previously considered nonpathogenic in humans. However, over the past decade, five genera of Acetobacteraceae have been isolated from patients with inborn or iatrogenic immunodeficiencies. Here, we describe the first studies of the interactions of the human innate immune system with a member of this bacterial family, Granulibacter bethesdensis, an emerging pathogen in patients with chronic granulomatous disease (CGD). Efficient phagocytosis of G. bethesdensis by normal and CGD polymorphonuclear leukocytes (CGD PMN) required heat-labile serum components (e.g., C3), and binding of C3 and C9 to G. bethesdensis was detected by immunoblotting. However, this organism survived in human serum concentrations of ≥90%, indicating a high degree of serum resistance. Consistent with the clinical host tropism of G. bethesdensis, CGD PMN were unable to kill this organism, while normal PMN, in the presence of serum, reduced the number of CFU by about 50% after a 24-h coculture. This finding, together with the observations that G. bethesdensis was sensitive to H(2)O(2) but resistant to LL-37, a human cationic antimicrobial peptide, suggests an inherent resistance to O(2)-independent killing. Interestingly, 10 to 100 times greater numbers of G. bethesdensis were required to achieve the same level of reactive oxygen species (ROS) production induced by Escherichia coli in normal PMN. In addition to the relative inability of the organism to elicit production of PMN ROS, G. bethesdensis inhibited both constitutive and FAS-induced PMN apoptosis. These properties of reduced PMN activation and resistance to nonoxidative killing mechanisms likely play an important role in G. bethesdensis pathogenesis.

Recurrent Granulibacter bethesdensis infections and chronic granulomatous disease.

Chronic granulomatous disease (CGD) is characterized by frequent infections, most of which are curable. Granulibacter bethesdensis is an emerging pathogen in patients with CGD that causes fever and necrotizing lymphadenitis. However, unlike typical CGD organisms, this organism can cause relapse after clinical quiescence. To better define whether infections were newly acquired or recrudesced, we use comparative bacterial genomic hybridization to characterize 11 isolates obtained from 5 patients with CGD from North and Central America. Genomic typing showed that 3 patients had recurrent infection months to years after apparent clinical cure. Two patients were infected with the same strain as previously isolated, and 1 was infected with a genetically distinct strain. This organism is multidrug resistant, and therapy required surgery and combination antimicrobial drugs, including long-term ceftriaxone. G. bethesdensis causes necrotizing lymphadenitis in CGD, which may recur or relapse.