The prevalence of vesicoureteral reflux in infants with first urinary tract infection following circumcision is similar to infants with UTI not following circumcision

PURPOSE

Urinary tract infections (UTIs) are common serious bacterial infections in early infancy. Ritual circumcision in neonates may increase the risk of UTI within 2 weeks of the procedure. The aims of this study were to assess the prevalence and risk factors for vesicoureteral reflux (VUR) among young infants with first UTI following circumcision, and compare it with the prevalence of VUR among young infants with first UTI not related to circumcision.

METHODS

In this retrospective cohort study, the medical records of all children aged 0-100 days who were diagnosed with UTI at Shaare Zedek Medical Center between 2005 and 2012 were reviewed for demographic, clinical and laboratory data and for the presence of VUR in voiding cystourethrography (VCUG).

RESULTS

Four hundred and sixty eight cases of UTI were included. Infants with post-circumcision UTI in our study were more likely to have associated bacteremia and abnormal renal function tests. VCUG was done for 166 infants (35%). There was no statistically significant difference in the prevalence of abnormal VCUG between infants with UTI following circumcision, in comparison to infants with UTI not following circumcision (30% vs. 36%, p = NS).

CONCLUSIONS

The decision regarding the need for radiographic evaluation and prophylactic antibiotic treatment following UTI should be made regardless if infection was related to circumcision.

Impact of pneumococcal conjugate vaccines introduction on antibiotic resistance of Streptococcus pneumoniae meningitis in children aged 5 years or younger, Israel, 2004 to 2016

Background

Empiric treatment of pneumococcal meningitis includes ceftriaxone with vancomycin to overcome ceftriaxone resistant disease. The addition of vancomycin bears a risk of adverse events, including increased antibiotic resistance. We assessed antibiotic resistance rates in pneumococcal meningitis before and after pneumococcal conjugate vaccine (PCV) implementation.

Methods

All pneumococcal meningitis episodes in children aged 5 years and younger, from 2004 to 2016, were extracted from the nationwide bacteremia and meningitis surveillance database. For comparison purposes, we defined pre-PCV period as 2004–2008 and PCV13 period as 2014–2016. Minimal inhibitory concentration (MIC) > 0.06 and > 0.5 μg/mL were defined as penicillin and ceftriaxone resistance, respectively.

Results

Overall, 325 episodes were identified. Pneumococcal meningitis incidence rates declined non-significantly by 17%, comparing PCV13 and pre-PCV periods. Throughout the study, 90% of isolates were tested for antibiotic susceptibility, with 26.6%, 2.1% and 0% of isolates resistant to penicillin, ceftriaxone and vancomycin, respectively. Mean proportions (± SD) of meningitis caused by penicillin-resistant pneumococci were 40.5% ± 8.0% and 9.6% ± 7.4% in the pre-PCV and the PCV13 periods, respectively, resulting in an overall 83.9% reduction (odd ratio:0.161; 95% confidence interval: 0.059–0.441) in penicillin resistance rates. The proportions of meningitis caused by ceftriaxone resistant pneumococci were 5.0% ± 0.8% in the pre-PCV period, but no ceftriaxone resistant isolates were identified since 2010.

Conclusions

PCV7/PCV13 sequential introduction resulted in > 80% reduction of penicillin- resistant pneumococcal meningitis and complete disappearance of ceftriaxone resistant disease. These trends should be considered by the treating physician when choosing an empiric treatment for pneumococcal meningitis.

Does Acute Otitis Media in the First Month of Life Increase the Risk for Recurrent Otitis?

Acute otitis media (AOM) is a common childhood illness. The aim of this study was to assess whether AOM in the first month of life predicts recurrent AOM (rAOM) in early childhood. The medical records of all neonates with AOM and isolation of bacterial pathogen from middle-ear fluid during 2005-2010 were reviewed. Neonates without AOM admitted during the same period for neonatal fever workup were included as controls. Information regarding rAOM and possible risk factors were collected through a phone interview with the parents. A total of 84 neonates with AOM were enrolled; 25 (30%) had rAOM compared with 8/79 (10%) in the control group. Neonatal AOM increases 4-fold the odds of rAOM later in childhood (odds ratio = 4; 95% CI = 1.44-11.42; P = .008), independent of smoke exposure, numbers of siblings, AOM in siblings, breastfeeding, day care attendance, or use of pacifier. Neonatal AOM is a significant risk factor for rAOM during infancy.

Comparative incidence dynamics and serotypes of meningitis, bacteremic pneumonia and other-IPD in young children in the PCV era: Insights from Israeli surveillance studies

INTRODUCTION

Widespread introduction of pneumococcal conjugated vaccines (PCVs) impacted on invasive pneumococcal disease (IPD). However, IPD reduction may not be similar in all outcomes within IPD. We assessed PCV7/PCV13 impact on pneumococcal meningitis, bacteremic pneumonia (BP) and other (non-meningitis, non-pneumonia) IPD episodes in children <5years in Israel.

METHODS

A prospective, population-based, active nationwide surveillance. All pneumococcal invasive episodes with positive blood/CSF cultures, July 2000 through June 2016, were included. Three sub-periods were defined: pre-PCV (2000-2008), PCV7 (2009-2011) and PCV13 (2014-2016). Incidence rate ratios (IRRs) were calculated.

RESULTS

Overall, 4321 episodes were recorded; 456 (10.6%) meningitis, 1478 (34.2%) pneumonia and 2387 (55.2%) other-IPD. In the pre-PCV period, proportion of serotypes in PCV13, but not in PCV7 (mainly serotypes 1, 5 and 19A) was higher in BP (43.3%) compared with other-IPD episodes (32.8%, p<0.001) and similar to that of meningitis (37.6%, p=0.1). The proportion of episodes in children <12months was higher in meningitis (52.1%) compared with pneumonia (23.2%) and other-IPD episodes (39.5%; p<0.001 for both). The declines of the 3 entities were not similar; Meningitis rate non-significantly declined by 24% (IRR=0.76; 95% CI 0.57-1.01), while BP and other-IPD rates significantly declined by 57% and 70%, respectively. In contrast to other entities, BP did not decline significantly after PCV7 introduction but started to decline only after PCV13 introduction. Rates of meningitis, pneumonia and other-IPD caused by PCV13-serotypes (VT13) substantially declined by 88%, 95% and 97%, respectively, comparing PCV13 and the pre-PCV periods. However, diseases caused by non-VT13 increased by 256%, 302% in meningitis and pneumonia, respectively, but only 116% in other-IPD.

CONCLUSIONS

Following PCV7/PCV13 introduction, rates of episodes caused by VT13 were substantially reduced in all 3 groups. However, differences in age distribution, serotype replacement and specific serotype decrease suggest different pathogenesis and host susceptibility between the 3 entities.

Occult Bacteremia: Should We Look for the Needle in the Haystack?

BACKGROUND

Once a well-recognized entity, occult bacteremia (OB) is no longer a significant or serious bacterial infection. First following the introduction of the Haemophilus influenzae type B vaccine and now with the implementation of the conjugate pneumococcal vaccine (PCV), the number of cases has declined significantly. This has led to a change in many published guidelines to avoid taking blood cultures in fully vaccinated children presenting with fever. In Israel, the introduction of the PCV13 is now widespread.

OBJECTIVES

To assess the incidence and outcome of OB, specifically by Streptococcus pneumoniae, in a single large pediatric medical center.

METHODS

We conducted a retrospective review of all cases of pneumococcal bacteremias in the years 2008-2013 and specifically those considered occult.

RESULTS

Of 355 cases of bacteremia diagnosed during the study period, 164 were caused by S. pneumoniae and 20 (12.8%) were considered occult. None of the OB cases had any complications. OB was not found in children over the age of 36 months. There was a change in the serotypes involving pneumococcal OB.

CONCLUSIONS

OB is uncommon in the PCV-vaccinated population and the serotypes involved have changed.

Brucellosis Outbreak in Children and Adults in Two Areas in Israel

Two parallel outbreaks of Brucella melitensis infection occurred in 2014 in two geographical areas in Israel. In two medical centers in northern Israel and one medical center in Jerusalem, 102 patients (58 children, 47 adults) were diagnosed with brucellosis. Most patients (N = 76, 72%) were Muslim Arabs, 28 (27%) were Druze, and one was Jewish. The source of infection was often traced to cheese from the Palestinian Authority. Biovar-1 was evident in 98% in northern Israel but only in 42% in Jerusalem. Most common manifestations were fever (82%) and osteoarticular symptoms (49%). The major differences between the geographic areas were ethnicity and duration until diagnosis. Compared with adults, children had higher rates of hospitalization (93% versus 64%, P = 0.001), osteoarticular symptoms (60% versus 36%, P = 0.05), elevated alanine aminotransferase (12% versus 0%, P = 0.01), and lower C-reactive protein (2.28 ± 2.08 versus 5.57 ± 6.3l mg/dL, P = 0.001). Two unrelated brucellosis outbreaks occurred in 2014 in two different geographic areas of Israel and were limited to sections of the Arab and Druze populations. Most of the demographic and clinical aspects of patients were not affected by geographic variability. Clinical and laboratory differences were found between children and adults emphasizing the nonuniformity of the disease in different age groups. Effective control of unpasteurized dairy foods, health education programs, and improved regional cooperation are required to control brucellosis in Israel.

Glucose-6-Phosphate Dehydrogenase Screening in Israel-Arab and Palestinian-Arab Neonates

OBJECTIVE

To evaluate the frequency of glucose-6-phosphate dehydrogenase (G-6-PD) deficiency, the incidence of clinically significant jaundice (any serum total bilirubin value >75th percentile on the hour-specific bilirubin nomogram), and the need for phototherapy in the pooled male Israeli-Arab and Palestinian-Arab population born at the Shaare Zedek Medical Center in Jerusalem, Israel.

STUDY DESIGN

Quantitative G-6-PD enzyme testing of umbilical cord blood was performed during birth hospitalization. G-6-PD deficiency was defined as any G-6-PD value <7.0 U/gHb. Transcutaneous bilirubin was performed daily during birth hospitalization, with serum total bilirubin testing in those with a transcutaneous bilirubin value >75th percentile.

RESULTS

Ten of 286 (3.5%) consecutively delivered male Arab newborns had G-6-PD deficiency. Clinically significant jaundice was higher in the population with G-6-PD deficiency compared with normal controls (relative risk, 3.45; 95% CI, 1.24-9.58). Thirty percent of the newborns with G-6-PD deficiency met American Academy of Pediatrics indications for phototherapy according to the high-risk (middle) curve on the phototherapy graph.

CONCLUSION

The frequency of G-6-PD deficiency in the Arab neonatal population delivering at this medical center meets World Health Organization criteria for neonatal G-6-PD screening (3%-5%). As in other ethnic groups, clinically significant jaundice is more frequent in newborns of this ethnic group with G-6-PD deficiency compared with G-6-PD-normal controls. Neonatal G-6-PD screening for both males and females of this population subgroup, in conjunction with parental education regarding the dangers of the condition and its prophylaxis, has now been incorporated into our institution's routine G-6-PD screening program.

Mycobacterium simiae infection in two unrelated patients with different forms of inherited IFN-γR2 deficiency

Interferon-γ receptor 2 (IFN-γR2) deficiency is a rare primary immunodeficiency characterized by predisposition to infections with weakly virulent mycobacteria, such as environmental mycobacteria and BCG vaccines. We describe here two children with IFN-γR2 deficiency, from unrelated, consanguineous kindreds of Arab and Israeli descent. The first patient was a boy who died at the age of 4.5 years, from recurrent, disseminated disease caused by Mycobacterium simiae. His IFN-γR2 defect was autosomal recessive and complete. The second patient was a girl with multiple disseminated mycobacterial infections, including infection with M. simiae. She died at the age of 5 years, a short time after the transplantation of umbilical cord blood cells from an unrelated donor. Her IFN-γR2 defect was autosomal recessive and partial. Autosomal recessive IFN-γR2 deficiency is life-threatening, even in its partial form, and genetic diagnosis and familial counseling are therefore particularly important for this condition. These two cases are the first of IFN-γR2 deficiency associated with M. simiae infection to be described.

Extended-spectrum β-lactamase-producing bacteria causing community-acquired urinary tract infections in children

BACKGROUND

Extended-spectrum β-lactamase (ESBL)-producing bacteria are infrequent pathogens of community-acquired (CA) urinary tract infections (UTIs) in children. The aim of this study was to assess the frequency of and identify risk factors for CA-UTIs due to ESBL-producing microorganisms (CA-ESBL-UTI).

METHODS

The medical records of all children diagnosed with CA-ESBL-UTI at our medical center between 2003 and 2013 were reviewed. Patients with non-ESBL-UTIs during the same period were included as controls.

RESULTS

Eighty cases of CA-ESBL-UTI were identified. The incidence of ESBL-UTI increased from 2 to 3.8% during the study period. Compared to children with non-ESBL-UTI, those with ESBL were more likely to be of Arab descent, to have underlying medical conditions, to have received antibiotics in the month prior to the UTI and to have been previously hospitalized. The mean duration of hospitalization for patients with an ESBL-UTI was significantly longer than that for patients with a non-ESBL UTI (3.6 vs. 2 days; P = 0.01). In multivariate analysis, Arab ethnicity [odds ratio (OR) 6.1; 95 % confidence interval (CI) 2.7-13.6] and recent antibiotic treatment (OR 4.0; 95 % CI 1.6-10.4) were risk factors for CA-ESBL-UTI.

CONCLUSIONS

The incidence of CA-ESBL-UTI is rising. The empiric treatment for suspected UTI in children who had been previously hospitalized and who had received antibiotics in the last month should cover ESBL-producing bacteria.

Neurologic manifestations of Fusobacterium infections in children

Fusobacterium necrophorum causes various clinical syndromes, ranging from otitis media to life-threatening Lemierre's syndrome. The purpose of this study was to review our experience with pediatric Fusobacterium infections. The medical records of all children aged 0 to 18 years who were diagnosed between 1999 and 2011 with Fusobacterium infection were reviewed. Fusobacterium was isolated from clinical samples of 27 children: blood cultures (n = 16), abscesses (n = 8), joint fluids (n = 2), and cerebrospinal fluid (n = 1). The median age at admission was 3.5 years (range, 7 months to 17 years). Eight children (30 %) had seizures at presentation. Ten children (37 %) underwent lumbar puncture. Fifteen children (56 %) underwent brain imaging, and in seven of these children, a thrombus was identified either in a sinus vein or in an internal jugular vein. The most common source of infection was otogenic in 19 (70 %) of the children. Six of the children presented in 2011. All patients recovered.

CONCLUSIONS

Neurologic manifestations are common at presentation of children with Fusobacterium infections. In young children, the most common source of infection is otogenic. Thrombotic complications are common, and imaging should be considered in all children with Fusobacterium infections arising from the head or neck region. There was a recent increase in the isolation of this bacterium, either because of better culturing techniques and increased awareness to this entity or a true increase in infections due to this organism.

Inducible clindamycin resistance in β-hemolytic streptococci and Streptococcus pneumoniae

BACKGROUND

Resistance to macrolides in beta-hemolytic streptococci and Streptococcus pneumoniae arises primarily due to Erm(B) or Mef(A). Erm(B) typically confers high level resistance to macrolides, lincosamides and streptogramin B (MLSB phenotype), whereas Mef(A) confers low level resistance to macrolides only (M phenotype).

OBJECTIVES

To investigate the incidence of macrolide resistance mechanisms in isolates of beta-hemolytic streptococci and pneumococci in Israel, with particular emphasis on inducible MLSB phenotype.

METHODS

We collected 316 clinical isolates of streptococci during May-August 2010. Erythromycin resistance mechanism was determined by the erythromycin-clindamycin double disk diffusion method.

RESULTS

Erythromycin and clindamycin resistance rates were 19.4% and 13.4% for S. pneumoniae, 4.7% and 1.6% for group A Streptococcus (GAS), 17% and 17% for group B Streptococcus (GBS), and 38.8% and 27.8% for group G Streptococcus (GGS) respectively. The most common resistance mechanism for all streptococci was constitutive MLSB (cMLSB). Inducible MLSs (iMLSB) mechanism was found in 3% of all strains and represented 25% of resistance mechanisms.

CONCLUSIONS

The prevalence of macrolide resistance and the distribution of resistance mechanisms differ among beta-hemolytic streptococci and S. pneumoniae, with GBS, GGS and S. pneumoniae showing the highest resistance rate. Macrolide or lincosamide cannot be empirically used for severe streptococcal infections before strains are proved to be susceptible. Continuous surveillance of erythromycin and clindamycin resistance patterns among streptococci is needed.

[Congenital skull base defect causing recurrent bacterial meningitis]

Bacterial meningitis is a life threatening disease. Most patients will experience only one episode throughout life. Children who experience bacterial meningitis more than once, require further immunologic or anatomic evaluation. We report a 9 year old child with five episodes of bacterial meningitis due to a congenital defect of the skull base. A two and a half year old boy first presented to our medical center with pneumococcal meningitis. He was treated with antibiotics and fully recovered. Two months later he presented again with a similar clinical picture. Streptococcus pneumoniae grew in cerebrospinal fluid (CSF) culture. CT scan and later MRI of the brain revealed a defect in the anterior middle fossa floor, with protrusion of brain tissue into the sphenoidal sinus. Corrective surgery was recommended but the parents refused. Three months later, a third episode of pneumococcal meningitis occurred. The child again recovered with antibiotics and this time corrective surgery was performed. Five years later, the boy presented once again with clinical signs and symptoms consistent with bacterial meningitis. CSF culture was positive, but the final identification of the bacteria was conducted by broad spectrum 16S ribosomal RNA PCR (16S rRNA PCR) which revealed a sequence of Neisseria lactamica. CT and MRI showed recurrence of the skull base defect with encephalocele in the sphenoid sinus. The parents again refused neurosurgical intervention. A year later the patient presented with bacterial meningitis. CSF culture obtained after initiation of antibiotics was negative, but actinobacillus was identified in the CSF by 16S rRNA PCR. The patient is scheduled for neurosurgical intervention. In patients with recurrent bacterial meningitis caused by organisms colonizing the oropharynx or nasopharynx, an anatomical defect should be carefully sought and surgically repaired.

Haemophilus influenzae activity in a single medical center in Israel in the post-vaccine era

BACKGROUND

The incidence of invasive disease due to Haemophilus influenzae has decreased since the implementation of vaccination against serotype B.

OBJECTIVES

To describe the epidemiological, clinical and microbiological characteristics of patients with H. influenzae meningitis or bacteremia in the vaccine era in Israel.

METHODS

We reviewed the medical records of all patients admitted to Shaare Zedek Medical Center between 1997 and 2010 who had blood or cerebrospinal fluid culture positive for H. influenzae.

RESULTS

The study group comprised 104 patients - 57 children and 47 adults. Overall, 21 (20%) of the infections were due to serotype b. The children had shorter hospitalizations (6vs. 12 days, P = 0.005) and lower mortality rate (5% vs. 28%, P = 0.003) as compared to the adults. Bacteremic pneumonia was the most common diagnosis in adults (45% vs. 28% in children, P = 0.08) while meningitis was more common in children (17% vs. 3.5%, P = 0.09). There was a seasonal pattern, with infections being more common during the winter and spring.

CONCLUSIONS

Invasive H. influenzae disease is uncommon but still exists in both children and adults. The disease course tends to be more severe in adults. Even in the global vaccination era, serotype b constitutes a significant portion of invasive disease.

Invasive pneumococcal disease in infants younger than 60 days

OBJECTIVE

To review the epidemiology and clinical course of invasive pneumococcal diseases of infants younger than 60 days.

STUDY DESIGN

All Streptococcus pneumoniae strains isolated from blood and cerebrospinal fluid cultures of infants below the age of 60 days during the years 1999-2009 were included in this study. Demographic, clinical, and laboratory data were collected from medical records.

RESULTS

In all, 24 cases of pneumococcal invasive infections were identified. The primary diagnoses were bacteremia without a focus (n = 13), meningitis (n = 6), bacteremia with otitis media (n = 3), and joint infection with bacteremia (n = 2). Only one of the serotypes found is included in the heptavalent pneumococcal conjugated vaccine (PCV7).

CONCLUSIONS

Streptococcus pneumoniae should be considered and treated empirically in infants with suspected invasive bacterial disease during the first 60 days of life. Routine vaccination with PCV7 in not expected to substantially reduce the incidence of invasive pneumococcal disease in Israeli infants of this age as a result of herd immunity.

Hospitalization of children with influenza A(H1N1) virus in Israel during the 2009 outbreak in Israel: a multicenter survey

OBJECTIVES

To describe the clinical characteristics of children hospitalized with 2009 influenza A(H1N1) infection in Israel and the risk factors associated with this infection.

DESIGN

Prospective collection of data on children hospitalized with 2009 influenza A(H1N1) infection.

SETTING

Seven medical centers around Israel. Patients From July 12, 2009, to December 24, 2009, all patients 18 years or younger hospitalized with acute respiratory or acute unspecified febrile illness were screened for 2009 influenza A(H1N1) virus by reverse transcription-polymerase chain reaction.

INTERVENTION

Prospective data collection for patients with confirmed infection.

MAIN OUTCOME MEASURES

Clinical characteristics of patients and hospitalization rates.

RESULTS

The mean age of 478 patients studied was 6.1 years. Forty-two patients (8.8%) were admitted to the pediatric intensive care unit; 3 patients (0.6%) died. The most frequent clinical presentations were pneumonia, influenza-like illness, wheezing exacerbation, and convulsions. Predisposing underlying illnesses were detected in 48.7% of patients. Patients with metabolic and neurologic disorders were at highest risk for severe complications (relative risk, 6.5 and 2.9, respectively). In addition, patients with cyanotic heart lesions and infants 3 months or younger who were born at 33 weeks' gestation or earlier tended to require higher rates of mechanical ventilation. The hospitalization rate for 2009 influenza A(H1N1) was 0.7 per 1000 children. The mortality rate was 3.6 per 1 000 000 children.

CONCLUSIONS

The severity variables for 2009 influenza A(H1N1) were similar to the figures reported for seasonal influenza. Patients with underlying metabolic and neurologic metabolic disorders and presumably patients with cyanotic heart lesions and infants born prematurely are at highest risk for severe complications following 2009 influenza A(H1N1) infection.

[Gastrointestinal carriage of Pseudomonas aeruginosa in children residing in chronic care institutes in Jerusalem: high prevalence and high rates of antibiotic resistance]

BACKGROUND

Pseudomonas aeruginosa carriage in the gastrointestinal tract is uncommon in healthy children. Children living in chronic care institutions are often carriers of P. aeruginosa in the respiratory tract, but data is lacking regarding gastrointestinal carriage in these children.

AIMS

To examine the carriage rate of P. aeruginosa in children living in chronic care institutions in Jerusalem and to assess resistance rates of the bacteria to different classes of antibiotics.

METHODS

Rectal swabs were taken from all children residing in two chronic care institutions in Jerusalem: "St. Vincent" and "Aleh". The swabs were examined for presence of Pseudomonas aeruginosa. The authors used disk diffusion technique and E Test to assess resistance for different antibiotics.

RESULTS

Gastrointestinal carriage of P. aeruginosa was detected in 37 out of 125 of the children (30%); 16% of the P. aeruginosa isolates were resistant to carbapenems; 16% were resistant to aminoglycosides, 14% to ureidopenicillins and 11% to quinolones. All isolates were sensitive to ceftazidime and colistin. In 84% of the isolates, the minimal inhibitory concentration (MIC) for meropenem was significantly lower than the MIC for imipenem.

SUMMARY

P. aeruginosa is a common colonizer of the gastrointestinal tract of children living in chronic care institutions. Empiric antibiotic treatment against P. aeruginosa should be considered when treating children with acute gastrointestinal pathologies. Antibiotic resistance, and particularly carbapenem resistance, is common in this population. There is a significant difference between the MICs for imipenem and meropenem. Future studies are needed to understand the clinical significance of this finding.