Pediatric Staphylococcus aureus bacteremia: clinical spectrum and predictors of poor outcome

Comparison of clinical outcomes of antibiotics used for Staphylococcus aureus bacteremia in pediatric patients

BACKGROUND

This study aims to evaluate the risk factors, clinical features, and clinical outcomes among pediatric hospitalized patients receiving treatment for Staphylococcus aureus bacteremia and compare the effects of antibiotics used in the treatment on clinical outcomes.

RESEARCH DESIGN AND METHODS

This single-center retrospective study included patients aged between 1 month and 18 years who received treatment for Staphylococcus aureus bacteremia (SAB) betweenSeptember 2019 and September 2022.

RESULTS

SAB was detected in 95 pediatric patients. In MRSA bacteremias, no difference in clinical outcomes was found between patients receiving vancomycin or teicoplanin. In MSSA bacteremias, the recurrence rate of SAB was 0% in the penicillin group and 23.5% in the cephalosporin group. The median duration of bacteremia-related hospital stay (10 vs. 14 days), and the median duration of bacteremia (2 vs. 3 days) were shorter in the ampicillin-sulbactam group than in the piperacillin-tazobactam group (p = 0.016, and p = 0.050, respectively).

CONCLUSIONS

Teicoplanin was found to have similar clinical outcomes to vancomycin in treating MRSA bacteremia. In addition, ampicillin sulbactam was found to have better clinical outcomes than other antibiotics in treating MSSA bacteremia. Teicoplanin and ampicillin sulbactam may be considered as a choice in the treatment of pediatric SAB.

Community-acquired Staphylococcus aureus bacteremia in healthy children-13 years of experience in a pediatric tertiary center

Staphylococcus aureus (SA) is an important pathogen in the pediatric population. Community-acquired SA bacteremia (SAB) may also occur in healthy individuals, yet literature on this matter is scarce. Our study aims to describe patient characteristics, clinical course, and outcomes of healthy children with SAB. This retrospective cohort study included all healthy patients aged 3 months-18 years, with a positive SA blood culture taken during the first 72 hours of hospitalization between 2009 and 2021. Demographic, laboratory, and clinical data were collected. Analysis was performed to assess factors associated with complicated disease. Fifty-seven patients aged 8.5 ± 4.5 years were included. Forty-one (71.9%) were males and 18 (31.6%) reported trauma before onset. Thirty-four (59.6%) were diagnosed with osteomyelitis, 14 (24.6%) with abscesses, 7 (12.3%) with isolated SAB, and 7 (12.3%) suffered from complex SAB. Factors associated with abscess formation were age ≥ 13 years and groin pain; OR 3.857 (p-value 0.01) and 20.0 (p-value 0.01), respectively. A CRP ≥ 13 mg/dL upon admission was found to be a predictor of complex disease (AUC of 0.765; 95% CI 0.559-0.971 (p-value 0.024)). Higher odds for complex SAB were seen in persistent bacteremia, prolonged time to eradication, and time to targeted therapy; OR 5.833 (p-value 0.048), OR 1.810 (p-value 0.017), and OR 3.214 (p-value 0.015), respectively. There were no cases of mortality.

CONCLUSION

This study describes various aspects of SAB in healthy children and could help to better recognize the signs and symptoms of the disease. Moreover, we report several indicators that may assist clinicians in identifying at-risk patients for a complicated disease.

WHAT IS KNOWN

•SAB is an important pediatric disease that can cause severe complications and mortality. •SAB is well described as a nosocomial infection and in high-risk populations such as premature babies, children with intravascular devices, immunodeficient individuals, and other major chronic illnesses. However, data regarding community-acquired SAB in healthy children is lacking.

WHAT IS NEW

•This is the first study to exclusively include previously healthy children with community-acquired SAB. •Higher CRP upon admission, persistent bacteremia, and longer time to targeted therapy are all in correlation with complications such as multifocal disease, sepsis, ICU admission, and endocarditis.

Epidemiological profile and antimicrobial resistance trends of Staphylococcus aureus in Chinese pediatric intensive care units from 2016 to 2022: a multi-center retrospective study

OBJECTIVE

This study aimed to analyze the profiles and evolution of Staphylococcus aureus in the pediatric intensive care units (PICUs) of 17 hospitals in China from 2016 to 2022.

METHODS

Susceptibility testing was performed to bacterial strains with a uniform monitoring protocol, which was provided by the US Clinical and Laboratory Standards Institute (CLSI) and used by the China Antimicrobial Surveillance Network (CHINET). The results were interpreted in accordance with the performance standards for antimicrobial susceptibility testing issued by the US Clinical and Laboratory Standards Institute.

RESULTS

Twenty-six thousand six hundred thirteen bacterial strains were isolated from 17 PICUs in China from 2016 to 2022, 3,147 of which were Staphylococcus aureus, ranking second among etiological agents of infections from PICUs. In 2022, Staphylococcus aureus had the highest detection rate, being 36.19%. And in 2021, MRSA had the highest detection rate, being 10.35% in Staphylococcus aureus. There were statistically significant differences in the annual detection rate of gram-positive bacteria, Staphylococcus aureus and MRSA between the years from 2016 to 2022 (P < 0.05). More males were found with Staphylococcus aureus or methicillin-resistant Staphylococcus aureus, but there were no statistical differences in gender distribution between any two years (P < 0.05). The top 3 highest detection rate of Staphylococcus aureus in age groups were infants (1244, 39.7%), toddlers (741, 23.7%), and children at school age and older (731, 23.4%). For MRSA, The top 3 in age groups were infants (91, 38.9%), children at school age and older (87, 29.1%), and toddlers (48, 20.5%). The detection rate of Staphylococcus aureus was statistically different in the distribution of age stratification (P < 0.05). There was no statistically significant difference in these two aspects of MRSA (P > 0.05). The top 3 highest detection rate of Staphylococcus aureus in infected sites were the lower respiratory tract (2,552, 81.7%), bloodstream (217, 6.5%), and skin wounds (110, 3.9%). For MRSA, The top 3 in infected sites were the lower respiratory tract (156, 77.9%), skin wounds (47, 8.8%), and bloodstream (15, 6.6%). The detection rate of Staphylococcus aureus and MRSA was statistically different in the distribution of infected sites (P < 0.05). All the strains of Staphylococcus aureus were sensitive to tigecycline, nitrofurantoin, vancomycin, and linezolid. The resistant rate of Staphylococcus aureus, to penicillin G was as high as 87.5% at least, to erythromycin was as high as 51.8% at least, to benzocillin was as high as 38.0% at least, to cefoxitin was as high as 35.5% at least, and to clindamycin was as high as 32.7% at least. All the strains of MRSA were sensitive to vancomycin, linezolid, quinupristin/dalfopristin, and tigecycline. Of these 234 strains of MRSA, 179 (76.5%) were resistant to erythromycin, 116 (49.6%) to clindamycin, 39 (16.7%) to tetracycline, 29 (12.4%) to levofloxacin, 27 (11.5%) to ciprofloxacin, 27 (11.5%) to moxifloxacin, 14 (6.0%) to TMP-SMX, eight (3.4%) to rifampicin, and six (2.6%) to gentamicin.

CONCLUSIONS

Staphylococcus aureus is the most common gram-positive bacterium in PICUs. Infants are most likely to be infected by Staphylococcus aureus and methicillin-resistant Staphylococcus aureus. And the lower respiratory tract is the most common infected site of Staphylococcus aureus. Staphylococcus aureus has a high resistant rates to commonly used antimicriobials in pediatrics, but no strains resistant to vancomycin and/or linezolid were found. When considering Staphylococcus aureus infection clinically, it is necessary to select antimicrobials reasonably based on the patient's age, infected site and local epidemiological characteristics.

Antimicrobial Resistance in Staphylococcus aureus and Enterococcus spp. Isolates From Bloodstream Infections in Australian Children, 2013-2021

BACKGROUND

Rising proportions of antimicrobial resistance (AMR) have been observed in both Staphylococcus aureus and Enterococcus spp. isolates.

METHODS

The Australian Group on Antimicrobial Resistance surveillance program captures clinical and microbiological data of isolates detected in blood cultures across Australia. EUCAST 2022 was used for interpretation and the AMR package in R for data analysis.

RESULTS

There were 2091 bloodstream infections (BSIs) with S. aureus and 534 enterococcal BSI episodes in children <18 years old over 9 years. Three quarters of S. aureus BSI episodes were community-onset (78.3%), while more than half of enterococcal BSIs were hospital-onset (56.9%). The median age for S. aureus BSIs was 6 years, while >50% of enterococcal BSIs were in children <12 months old. Fifteen percent of S. aureus isolates were methicillin-resistant. Overall, 85.3% of S. aureus were resistant to penicillin, 12.5% resistant to erythromycin, 10.3% to clindamycin, and 4.7% to ciprofloxacin. Resistance to penicillin decreased over time, while clindamycin resistance increased. Resistance in Enterococcus spp. was almost entirely observed in Enterococcus faecium; only 1 Enterococcus faecalis isolate was ampicillin-resistant, and no E. faecalis isolates were vancomycin or teicoplanin-resistant. Seventy-three percent of E. faecium were resistant to ampicillin, 25.5% to vancomycin (VREfm), and 8.8% to teicoplanin.

CONCLUSIONS

Significant shifts in the epidemiology and resistance profiles of S. aureus and Enterococcus spp. BSIs in Australian children were observed, making clear the importance of age-stratified reporting in AMR data.

Optimising detection of thrombosis in paediatric Staphylococcus aureus bacteraemia: A prospective interventional sub-study protocol

INTRODUCTION

Staphylococcus aureus bacteraemia (SAB) is the most common cause of sepsis, contributing to paediatric intensive care unit admission in Australia and New Zealand. While deep venous thrombosis (DVT) has been reported in children with invasive S. aureus infections, the actual frequency and possible effects of thrombosis on disease severity and outcome in paediatric SAB remain unknown. Moreover, guidance regarding imaging for paediatric SAB management are poorly defined.

METHODS AND ANALYSIS

We report the protocol for the SNOOPY (Staphylococcus aureus Network; ultrasOund for diagnOsis of endovascular disease in Paediatrics and Youth) study. SNOOPY is a pilot prospective single-arm interventional study that aims to investigate the proportion of children with SAB that have venous thrombosis detected using whole body doppler ultrasound.

Genomic characteristics and molecular epidemiology of MRSA from medical centers in Mexico: Results from the Invifar network

INTRODUCTION

The methicillin-resistant Staphylococcus aureus (MRSA) genome varies by geographical location. This study aims to determine the genomic characteristics of MRSA using whole-genome sequencing (WGS) data from medical centers in Mexico and to explore the associations between antimicrobial resistance genes and virulence factors.

METHODS

This study included 27 clinical isolates collected from sterile sites at eight centers in Mexico in 2022 and 2023. Antibiotic susceptibility testing was performed using VITEK 2. In addition, WGS was performed using a NovaSeq platform, and a bioinformatic analysis was conducted using several tools.

RESULTS

In this study, 21 strains were CC5, five were CC8, and one was CC93. Moreover, six strains were identified as ST5(CC5)-MRSA-IIa- t895, four strains were found to be ST1011(CC5)-MRSA-IIa-t895, five strains were found to be ST1011(CC5)-MRSA-IIa-t9364, one strain was found to be ST1011(CC5)-MRSA-IIa-t8116, another was found to be ST1011(CC5)-MRSA-IIa-t62, three were found to be ST8(CC8)-MRSA-IVa-t8, one strain was ST5(CC5)-MRSA-IVa-t2, one strain was as ST93(CC93)-MRSA-IVa-t3949, two strains were ST9003(CC8)-MRSA-IVa-t18492, and three strains were ST9034(CC5)-MRSA-V-t2. All SCCmec IIa strains showed resistance to levofloxacin and ciprofloxacin, and all but two strains were resistant to clindamycin. Among the strains that harbored the type IIa cassette, most had the aadD, blaZ, and ermA_SDS genes and the erm A gene. Multiple genes for adhesion, enzymes, immune evasion, and secretion system were detected, regardless of SCCmec type. Of the SCCmec IVa strains, most harbored the Panton-Valentine leukocidin encoding genes.

CONCLUSION

In this study, the most frequently detected CC was CC5, followed by CC8, and CC93, and the most frequently detected MRSA ST was ST1011, followed by ST5. Most SCCmec elements were found to be type IIa, followed by type IVa. High MIC values were observed for ciprofloxacin, erythromycin, and clindamycin, particularly within SCCmec IIa. Of the SCCmec IVa strains, most harbored the lukS-PV and lukF-PV genes.

Safety and Treatment Outcomes of Infants and Children Treated With Daptomycin: Six-Year Experience From a Pediatric Academic Medical Center

Daptomycin is a common treatment for serious infections caused by gram-positive bacteria in adult patients; however, data regarding its safety and efficacy in the pediatric population are limited. This was a retrospective chart review of adverse reactions and treatment outcomes associated with daptomycin use in children <13 years old who received at least 1 dose of daptomycin. At least 1 dose of daptomycin was received by 147 patients. Seventy-two patients received daptomycin for 5 or more days. New-onset loose stools on daptomycin initiation were reported for 14 (9.5%) patients, elevations in creatine kinase in 3 (2%) patients, and elevated aspartate transaminase and alanine transaminase in 13 (8.8%) and 9 (6.1%) patients, respectively. Two patients (1.4%) had daptomycin discontinued due to specific concerns for adverse drug reactions. Daptomycin was found to be safe and effective in this pediatric cohort that included young children and infants with a variety of types and severities of infections.

Severe Invasive Pneumococcal Disease Caused by Serotype 19A in Children Under Five Years in Tāmaki Makaurau Auckland, Aotearoa New Zealand

BACKGROUND

Increases in childhood invasive pneumococcal disease (IPD) have been reported in several countries following the easing of COVID-19 pandemic mitigations. In Aotearoa New Zealand (AoNZ), a surge in IPD is occurring in young children concurrent with changes in pneumococcal vaccines and declining immunization coverage. We sought to examine epidemiologic and clinical features of IPD among children under 5 years in a large urban region of AoNZ in the 3 years post-COVID-19.

METHODS

Demographic, clinical and laboratory data were collated from children under 5 years with Streptococcus pneumoniae identified from normally sterile sites between January 1, 2021, and December 31, 2023, in Tāmaki Makaurau Auckland, AoNZ.

RESULTS

We identified 93 episodes of IPD (annual incidence of 18-40 cases per 100,000 population per year). Serotype was identified in 68 episodes and 46 (68%) were serotype 19A. Incidence was higher in Pacific children compared with non-Māori, non-Pacific children (incidence rate ratio: 2.3; 95% confidence interval: 1.4-3.7). Bacteremia occurred in 65 (70%) episodes, empyema in 47 (51%), meningitis in 11 (12%) and hemolytic uremic syndrome in 7 (7.5%). All cases of hemolytic uremic syndrome and empyema were only among children with serotype 19A. Two children died, both had serotype 19A, and 13/91 survivors (14%) experienced serious sequelae.

CONCLUSIONS

The use of the pneumococcal conjugate vaccine with lower valency and easing of COVID-19 containment measures each may have contributed to an increase in IPD in AoNZ. Serotype 19A is associated with empyema and causes severe disease in young children. Urgent efforts are required to improve PCV13 coverage in AoNZ.

Systematic review and meta-analysis of the impact of infectious diseases consultation on outcomes of Staphylococcus aureus bacteremia in children

For adult patients with Staphylococcus aureus bacteremia (SAB), Infectious Diseases consultation (IDC) significantly lowers mortality and recurrence rate. Our systematic review and meta-analysis demonstrate that IDC is also associated with significantly lower mortality in children with SAB. Analysis of the impact of IDC on pediatric recurrence rates revealed moderate heterogeneity.

Early Oral Antibiotic Switch in Staphylococcus aureus Bacteraemia: The Staphylococcus aureus Network Adaptive Platform (SNAP) Trial Early Oral Switch Protocol

BACKGROUND

Staphylococcus aureus bloodstream infection (bacteremia) is traditionally treated with at least 2 weeks of intravenous (IV) antibiotics in adults, 3-7 days in children, and often longer for those with complicated disease. The current practice of treating S. aureus bacteremia (SAB) with prolonged IV antibiotics (rather than oral antibiotics) is based on historical observational research and expert opinion. Prolonged IV antibiotic therapy has significant disadvantages for patients and healthcare systems, and there is growing interest in whether a switch to oral antibiotics following an initial period of IV therapy is a safe alternative for clinically stable patients.

PROTOCOL

The early oral switch (EOS) domain of the S. aureus Network Adaptive Platform (SNAP) trial will assess early switch to oral antibiotics compared with continued IV treatment in clinically stable patients with SAB. The primary endpoint is 90-day all-cause mortality. Hospitalised SAB patients are assessed at platform day 7 ±2 (uncomplicated SAB) and day 14 ±2 (complicated SAB) to determine their eligibility for randomization to EOS (intervention) or continued IV treatment (current standard of care).

DISCUSSION

Recruitment is occurring in the EOS domain of the SNAP trial. As of August 2023, 21% of all SNAP participants had been randomized to the EOS domain, a total of 264 participants across 77 centers, with an aim to recruit at least 1000 participants. We describe challenges and facilitators to enrolment in this domain to aid those planning similar trials.

Whole-of-Life Inclusion in Bayesian Adaptive Platform Clinical Trials

Importance

There is a recognized unmet need for clinical trials to provide evidence-informed care for infants, children and adolescents. This Special Communication outlines the capacity of 3 distinct trial design strategies, sequential, parallel, and a unified adult-pediatric bayesian adaptive design, to incorporate children into clinical trials and transform this current state of evidence inequity. A unified adult-pediatric whole-of-life clinical trial is demonstrated through the Staphylococcus aureus Network Adaptive Platform (SNAP) trial.

Observations

Bayesian methods provide a framework for synthesizing data in the form of a probability model that can be used in the design and analysis of a clinical trial. Three trial design strategies are compared: (1) a sequential adult-pediatric bayesian approach that involves a separate, deferred pediatric trial that incorporates existing adult trial data into the analysis model to potentially reduce the pediatric trial sample size; (2) a parallel adult-pediatric bayesian trial whereby separate pediatric enrollment occurs in a parallel trial, running alongside an adult randomized clinical trial; and (3) a unified adult-pediatric bayesian adaptive design that supports the enrollment of both children and adults simultaneously in a whole-of-life bayesian adaptive randomized clinical trial. The SNAP trial whole-of-life design uses a bayesian hierarchical model that allows information sharing (also known as borrowing) between trial age groups by linking intervention effects of children and adults, thereby improving inference in both groups.

Conclusion and Relevance

Bayesian hierarchical models may provide more precision for estimates of safety and efficacy of treatments in trials with heterogenous populations compared to traditional methods of analysis. They facilitate the inclusion of children in clinical trials and a shift from children deemed therapeutic orphans to the vision of no child left behind in clinical trials to ensure evidence for clinical practice exists across the life course. The SNAP trial provides an example of a bayesian adaptive whole-of-life inclusion design that enhances trial population inclusivity and diversity overall, as well as generalizability and translation of findings into clinical practice.

Catheter salvage or removal in catheter-related bloodstream infections with Staphylococcus aureus in children with chronic intestinal failure receiving home parenteral nutrition and the use of prophylactic taurolidine catheter lock solution: A descriptive cohort study

BACKGROUND

Children with chronic IF require long-term home parenteral nutrition (HPN), administered through a central venous catheter. Catheter-related bloodstream infection (CRBSI) with Staphylococcus aureus is known to be a serious infection with a high mortality rate and risk of complications. A standardized protocol on the management of S aureus CRBSIs in children receiving HPN is lacking. The aim of this study is to evaluate the effectiveness and safety of the current management in an HPN expertise center in the Netherlands.

METHODS

We performed a retrospective descriptive cohort study between 2013 and 2022 on children 0-18 years of age with chronic IF requiring long-term HPN. Our primary outcomes were the incidence of S aureus CRBSI per 1000 catheter days, catheter salvage attempt rate, and successful catheter salvage rate. Our secondary outcomes included complications and mortality.

RESULTS

A total of 74 patients (39 male; 53%) were included, covering 327.8 catheter years. Twenty-eight patients (38%) had a total of 52 S aureus CRBSIs, with an incidence rate of 0.4 per 1000 catheter days. The catheter salvage attempt rate was 44% (23/52). The successful catheter salvage rate was 100%. No relapse occurred, and no removal was needed after catheter salvage. All complications that occurred were already present at admission before the decision to remove the catheter or not. No patients died because of an S aureus CRBSI.

CONCLUSION

Catheter salvage in S aureus CRBSIs in children receiving HPN can be attempted after careful consideration by a multidisciplinary team in an HPN expertise center.

Staphylococcus aureus Bacteremia in the Pediatric Emergency Department and Predictors of Poor Outcome

BACKGROUND

Staphylococcus aureus has become the leading cause of bacteremia among previously healthy children older than 5 years.

METHODS

We aimed to describe the infants presenting to pediatric emergency departments and diagnosed with S. aureus bacteremia (SAB) and identify predictors (clinical and laboratory variables) of poor outcome (complications, sequelae or death). We performed an observational study and subanalysis of a multicenter prospective registry, including every patient under the age of 18 years with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered chronic diseases, immunosuppressive treatment and the presence of mechanical devices as risk factors for SAB.

RESULTS

Of the 229 patients with SAB, 176 (76.9%) were previously healthy, 192 (83.8%) had a normal pediatric assessment triangle and 158 (69.0%) had an associated focal infection (mainly osteoarticular infection, skin and soft tissue infection and pneumonia). Fifty-three patients (23.1%) had 1 or more risk factors for SAB. Thirty-one (13.5%) presented a poor outcome, including 4 deaths (1.7%). A poor outcome was more common in patients with SAB risk factors [odds ratio (OR): 7.0; 95% CI: 3.2-15.4], abnormal PAT (OR: 5.9; 95% CI: 2.6-13.3), elevated procalcitonin (OR: 1.2; 95% CI: 1.05-1.3) and C-reactive protein, the latter being the only independent predictor of poor outcome (OR: 1.01; 95% CI: 1.01-1.02).

CONCLUSIONS

Overall, children with SAB are previously healthy, appear well, and have an associated focal infection. One of 7 had a poor outcome, with C-reactive protein being the only predictor identified.

Retrospective Study on Staphylococcus aureus Resistance Profile and Antibiotic Use in a Pediatric Population

The growing phenomenon of antibiotic resistance and the presence of limited data concerning the pediatric area prompted us to focus on Staphylococcus aureus infection in this study, its antibiotic resistance profile, and the therapeutic management of affected children. We conducted a retrospective study by collecting clinical data on infants and children with antibiogram-associated S. aureus infection. We enrolled 1210 patients with a mean age of 0.9 years. We analyzed the resistance patterns and found 61.5% resistance to oxacillin, 58.4% resistance to cephalosporins, 41.6% resistance to aminoglycosides, and 38.3% resistance to fluoroquinolones. Importantly, we found no resistance to glycopeptides, a key antibiotic for MRSA infections whose resistance is increasing worldwide. We also found that the main risk factors associated with antibiotic resistance are being aged between 0 and 28 days, the presence of devices, and comorbidities. Antibiotic resistance is a growing concern; knowing the resistance profiles makes it possible to better target the therapy; however, it is important to use antibiotics according to the principles of antibiotic stewardship to limit their spread.

Staphylococcus aureus Bacteremia in Pediatric Patients: Uncovering a Rural Health Challenge

Background

Staphylococcus aureus bacteremia poses significant risk for morbidity and mortality. This may be exacerbated in rural populations facing unique health challenges.

Methods

To investigate factors influencing S. aureus bacteremia outcomes, we conducted a retrospective cohort study of children admitted to St. Louis Children's Hospital (SLCH) from 2011 to 2019. Exposures included rurality (defined by the Rural-Urban Continuum Code), Area Deprivation Index, and outside hospital (OSH) admission before SLCH admission. The primary outcome was treatment failure, a composite of 90-day all-cause mortality and hospital readmission.

Results

Of 251 patients, 69 (27%) were from rural areas; 28 (11%) were initially admitted to an OSH. Treatment failure occurred in 39 (16%) patients. Patients from rural areas were more likely to be infected with methicillin-resistant S. aureus (45%) vs urban children (29%; P = .02). Children initially admitted to an OSH, vs those presenting directly to SLCH, were more likely to require intensive care unit-level (ICU) care (57% vs 29%; P = .002), have an endovascular source of infection (32% vs 12%; P = .004), have a longer duration of illness before hospital presentation (4.1 vs 3.0 days; P = .04), and have delayed initiation of targeted antibiotic therapy (3.9 vs 2.6 days; P = .01). Multivariable analysis revealed rural residence (adjusted odds ratio [aOR], 2.3; 95% CI, 1.1-5.0), comorbidities (aOR, 2.9; 95% CI, 1.3-6.2), and ICU admission (aOR, 3.9; 95% CI, 1.9-8.3) as predictors of treatment failure.

Conclusions

Children from rural areas face barriers to specialized health care. These challenges may contribute to severe illness and worse outcomes among children with S. aureus bacteremia.

Necrotizing Pneumonia in Children: Early Recognition and Management

Necrotizing pneumonia (NP) is an uncommon complicated pneumonia with an increasing incidence. Early recognition and timely management can bring excellent outcomes. The diagnosis of NP depends on chest computed tomography, which has radiation damage and may miss the optimal treatment time. The present review aimed to elaborate on the reported predictors for NP. The possible pathogenesis of Streptococcus pneumoniae, Staphylococcus aureus, Mycoplasma pneumoniae and coinfection, clinical manifestations and management were also discussed. Although there is still a long way for these predictors to be used in clinical, it is necessary to investigate early predictors for NP in children.

Diagnostic value of procalcitonin, hypersensitive C-reactive protein and neutrophil-to-lymphocyte ratio for bloodstream infections in pediatric tumor patients

OBJECTIVES

Bloodstream infection (BSI) is one of the major causes of death in pediatric tumor patients. Blood samples are relatively easy to obtain and thus provide a ready source of infection-related biological markers for the prompt evaluation of infection risk.

METHODS

A total of 259 pediatric tumor patients were included from May 2019 to March 2022. Patients were divided into BSI group (n=70) and control group (n=189). Clinical and biological data were collected using electronic medical records. Differences in biological markers between BSI group and control group and differences before and during infection in BSI group were analyzed.

RESULTS

The infected group showed higher levels of procalcitonin (PCT) and hypersensitive C-reactive-protein (hsCRP), and lower prealbumin (PA) than the uninfected group. Area under the receiver-operating curve (ROC) curves (AUC) of PCT, hsCRP and NLR (absolute neutrophil count to the absolute lymphocyte count) were 0.756, 0.617 and 0.612. The AUC of other biomarkers was ≤0.6. In addition, PCT, hsCRP, NLR and fibrinogen (Fg) were significantly increased during infection, while PA and lymphocyte (LYM) were significantly decreased. Antibiotic resistant of Gram-positive bacteria to CHL, SXT, OXA and PEN was lower than that of Coagulase-negative Staphylococcus. Resistant of Gram-positive bacteria to CHL was lower, while to SXT was higher than that of Gram-negative bacteria.

CONCLUSIONS

This study explored the utility of biomarkers to assist in diagnosis and found that the PCT had the greatest predictive value for infection in pediatric tumor patients with BSI. Additionally, the PCT, hsCRP, NLR, PA, LYM and Fg were changed by BSI.

Consumer perspectives on simplified, layered consent for a low risk, but complex pragmatic trial

BACKGROUND

For decades, the research community has called for participant information sheets/consent forms (PICFs) to be improved. Recommendations include simplifying content, reducing length, presenting information in layers and using multimedia. However, there are relatively few studies that have evaluated health consumers' (patients/carers) perspectives on the type and organisation of information, and the level of detail to be included in a PICF to optimise an informed decision to enter a trial. We aimed to elicit consumers' views on a layered approach to consent that provides the key information for decision-making in a short PICF (layer 1) with additional optional information that is accessed separately (layer 2). We also elicited consumers' views on the optimal content and layout of the layered consent materials for a large and complex Bayesian adaptive platform trial (the SNAP trial).

METHODS

We conducted a qualitative multicentre study (4 focus groups and 2 semi-structured interviews) involving adolescent and adult survivors of Staphylococcus aureus bloodstream infection (22) and their carers (2). Interview transcripts were examined using inductive thematic analysis.

RESULTS

Consumers supported a layered approach to consent. The primary theme that emerged was the value of agency; the ability to exert some control over the amount of information read before the consent form is signed. Three other themes emerged; the need to prioritise participants' information needs; the importance of health literacy; the importance of information about a trial's benefits (over its risks) for decision-making and the interplay between the two.

CONCLUSIONS

Our findings suggest that consumers may challenge the one-size-fits-all approach currently applied to the development of PICFs in countries like Australia. Consumers supported a layered approach to consent that offers choice in the amount of information to be read before deciding whether to enter a trial. A 3-page PICF was considered sufficient for decision-making for the SNAP trial, provided that further information was available and accessible.

The impact of infectious diseases consultation for children with Staphylococcus aureus bacteremia

BACKGROUND

Despite clear benefit of improved outcomes in adults, the impact of infectious diseases (ID) consultation for Staphylococcus aureus bacteremia in children remains understudied.

METHODS

To assess the impact of pediatric ID consultation on management and outcomes, we conducted a cohort study of children with S. aureus bacteremia at St. Louis Children's Hospital from 2011 to 2018. We assessed adherence to six established quality-of-care indicators (QCIs). We applied propensity score methodology to examine the impact of ID consultation on risk of treatment failure, a composite of all-cause mortality or hospital readmission within 90 days.

RESULTS

Of 306 patients with S. aureus bacteremia, 193 (63%) received ID consultation. ID consultation was associated with increased adherence to all QCIs, including proof-of-cure blood cultures, indicated laboratory studies, echocardiography, source control, targeted antibiotic therapy, and antibiotic duration. Obtaining proof-of-cure blood cultures and all indicated laboratory studies were associated with improved outcomes. In propensity score-weighted analyses, risk of treatment failure was similar among patients who did and did not receive ID consultation. However, the number of events was small and risk estimates were imprecise.

CONCLUSIONS

For children with S. aureus bacteremia, ID consultation improved adherence to QCIs, some of which were associated with improved clinical outcomes.

IMPACT

In children with Staphylococcus aureus bacteremia, consultation by an infectious diseases (ID) physician improved adherence to established quality-of-care indicators (QCIs). The current literature regarding ID consultation in pediatric S. aureus bacteremia is sparse. Three prior international studies demonstrated improved quality of care with ID consultation, though results were disparate regarding clinical outcomes. This article impacts the current literature by strengthening the evidence that ID consultation in children improves adherence to QCIs, and demonstrates that adherence to QCIs improves clinical outcomes.

The burden of bacterial skin infection, scabies and atopic dermatitis among urban-living Indigenous children in high-income countries: a protocol for a systematic review

BACKGROUND

Bacterial skin infections and scabies disproportionately affect children in resource-poor countries as well as underprivileged children in high-income countries. Atopic dermatitis is a common childhood dermatosis that predisposes to bacterial skin infection. In Australia, at any one time, almost half of all Aboriginal and Torres Strait Islander children living remotely will have impetigo, and up to one-third will also have scabies. Yet, there is a gap in knowledge of the skin infection burden for urban-living Australian Aboriginal and Torres Strait Islander children, as well as atopic dermatitis which may be a contributing factor. The objective of this study is to provide a global background on the burden of these disorders in Indigenous urban-living children in high-income countries. These countries share a similar history of colonisation, dispossession and subsequent ongoing negative impacts on Indigenous people.

METHODS

This protocol follows the Preferred Reporting Items for Systematic Review and Meta-Analyses Protocols statement. Observational studies reporting incidence and/or prevalence data on bacterial skin infection, scabies and/or atopic dermatitis in urban-living Indigenous children in high-income countries will be included. Literature searches will be conducted in several international electronic databases (from 1990 onwards), including MEDLINE, Embase, EmCare, Web of Science and PubMed. Reference lists and citation records of all included articles will be scanned for additional relevant manuscripts. Two investigators will independently perform eligibility assessment of titles, abstract and full-text manuscripts, following which both investigators will independently extract data. Where there is disagreement, the senior author will determine eligibility. The methodological quality of selected studies will be appraised using an appropriate tool. Data will be tabulated and narratively synthesised. We expect there will be insufficient data to perform meta-analysis.

DISCUSSION

This study will identify and evaluate epidemiological data on bacterial skin infection, scabies and atopic dermatitis in urban-living Indigenous children in high-income countries. Where available, the clinical features, risk factors, comorbidities and complications of these common childhood skin disorders will be described. The evidence will highlight the burden of disease in this population, to contribute to global burden of disease estimates and identify gaps in the current literature to provide direction for future research.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021277288.

Increasing Pediatric Infectious Diseases Consultation Rates for Staphylococcus aureus Bacteremia

Introduction

Staphylococcus aureus bacteremia (SAB) in children is associated with significant mortality and morbidity, including recurrent bacteremia. Infectious disease consultation (IDC) improves SAB outcomes in adult patients. However, increasing IDC and impact for pediatric patients with SAB is not well described.

Methods

This quality improvement project aimed to increase IDC for SAB events at a quaternary pediatric medical center. First, we evaluated the local practices regarding pediatric SAB and engaged stakeholders (July 2018-August 2020). We added an advisory comment supporting IDC for SAB to all blood culture results in September 2020. Using statistical process control charts, we monitored the number of SAB events with IDC before a SAB event without IDC. Finally, we evaluated SAB recurrences before and after initiating the advisory comment.

Results

In the baseline period, 30 of 49 (61%) SAB events received an IDC with a mean of 1.4 SAB events with IDC before a SAB event without IDC. Postintervention, 22 of 23 (96%) SAB events received IDC with a mean of 14 events with IDC before 1 event without IDC. The SAB recurrence rate was 8%, with 6 events in 4 children; none of the index cases resulting in recurrence received an IDC (P = 0.0002), and all occurred before any intervention.

Conclusions

An electronic advisory comment supporting IDC for SAB significantly increased the rate of pediatric IDC with no further SAB recurrence episodes following intervention. This low-resource intervention may be considered in other pediatric centers to optimize SAB management.

Right-sided endocarditis caused by polyclonal Staphylococcus aureus infection

We present a case of bacterial endocarditis with both methicillin-sensitive and methicillin-resistant Staphylococcus aureus, which based on typing, originated from two distinct clones. Such a case may be misinterpreted by microbiology lab automation to be a monoclonal multi-drug resistant Staphylococcus aureus, while simple microbiology techniques will instantly reveal distinct clonality.