Incidence and Outcomes of Infections Caused by Multidrug-Resistant Enterobacteriaceae in Children, 2007-2015

In vitro activity of ceftolozane/tazobactam against Gram-negative bacilli isolated from pediatric patients: Results from the Study for Monitoring Antimicrobial Resistance Trends (SMART) 2017-2021, China

OBJECTIVES

Ceftolozane-tazobactam (C/T) is a combination of a cephalosporin and a β-lactamase inhibitor with activity against Gram-negative bacilli (GNB). The study aims were to evaluate the activity of C/T in vitro vs. comparators against clinical GNB isolated from Chinese paediatric patients.

METHODS

From 2017-2021, 660 GNB isolates were collected from 20 hospitals across China. The minimum inhibitory concentrations were tested using a Trek Diagnostic System (Thermo Fisher Scientific). Susceptibility was determined by CLSI broth microdilution and the results were interpreted according to CLSI M100 (2021) breakpoints.

RESULTS

GNB isolates were obtained from paediatric patients < 18 years old, mainly from the bloodstream (n = 146), intraperitoneal cavity (n = 138), lower respiratory (n = 278) and urinary tract (n = 96). Overall, C/T was active against 76.6% of 436 Enterobacterales, with a descending susceptibility rate of 100.0% to S. marcescens, 92.2% to E. coli, 83.3% to K. oxytoca, 66.7% to K. aerogenes, 66.7% to P. mirabilis, 58.6% to K. pneumoniae and 57.1% to E. cloacae. The susceptibility of P. aeruginosa to C/T was 89.4%, which was the highest among the β-lactam antibiotics and was second only to amikacin (92.9%). Isolates of respiratory tract infection (RTI) derived P. aeruginosa were highly susceptible (93.8%) to C/T, while <75% of isolates of RTI derived P. aeruginosa were susceptible to the other β-lactam antibiotics tested, except for ceftazidime-avibactam (91.2%).

CONCLUSION

GNBs collected from paediatric patients in China showed a high susceptibility to C/T making this drug combination an effective choice for treating the paediatric population, especially those infected with P. aeruginosa.

Carbapenem-Resistant and Extended-Spectrum β-Lactamase-Producing Enterobacterales in Children, United States, 2016-2020

2019–2020 at 6 US sites. Among 159 CRE cases in children (median age 5 years), CRE was isolated from urine for 131 (82.4%) and blood from 20 (12.6%). Annual CRE incidence rate (cases/100,000 population) was 0.47–0.87. Among 207 ESBL-E cases in children (median age 6 years), ESBL-E was isolated from urine of 196 (94.7%) and blood of 8 (3.9%). Annual ESBL-E incidence rate was 26.5 in 2019 and 19.63 in 2020. CRE and ESBL-E rates were >2-fold higher among infants than other age groups. Most CRE and ESBL-E cases were healthcare-associated community-onset (68 [43.0%] for CRE vs. 40 [23.7%] for ESBL-E) or community-associated (43 [27.2%] for CRE vs. 109 [64.5%] for ESBL-E). Programs to detect, prevent, and treat multidrug-resistant infections must include pediatric populations (particularly the youngest) and outpatient settings.

Pharmacokinetics, Safety, and Tolerability of Imipenem/Cilastatin/Relebactam in Children with Confirmed or Suspected Gram-Negative Bacterial Infections: A Phase 1b, Open-Label, Single-Dose Clinical Trial

Imipenem/cilastatin/relebactam is approved for the treatment of serious gram-negative bacterial infections in adults. This study assessed the pharmacokinetics (PK), safety, and tolerability of a single dose of imipenem/cilastatin/relebactam (with a fixed 2:1 ratio of imipenem/cilastatin to relebactam, and with a maximum dose of 15 mg/kg imipenem and 15 mg/kg cilastatin [≤500 mg imipenem and ≤500 mg cilastatin] and 7.5 mg/kg relebactam [≤250 mg relebactam]) in children with confirmed/suspected gram-negative bacterial infections receiving standard-of-care antibacterial therapy. In this phase 1, noncomparative study (ClinicalTrials.gov identifier, NCT03230916), PK parameters from 46 children were analyzed using both population modeling and noncompartmental analysis. The PK/pharmacodynamic (PD) target for imipenem was percent time of the dosing interval that unbound plasma concentration exceeded the minimum inhibitory concentration (%fT>MIC) of ≥30% (MIC = 2 mcg/mL). For relebactam, the PK/PD target was a free drug area under the plasma concentration-time curve (AUC) normalized to MIC (at 2 mcg/mL) of ≥8.0 (equivalent to an AUC from time zero extrapolated to infinity of ≥20.52 mcg·h/mL). Safety was assessed up to 14 days after drug infusion. For imipenem, the ranges for the geometric mean %fT>MIC and maximum concentration (Cmax ) across age cohorts were 56.5%-93.7% and 32.2-38.2 mcg/mL, respectively. For relebactam, the ranges of the geometric mean Cmax and AUC from 0 to 6 hours across age cohorts were 16.9-21.3 mcg/mL and 26.1-55.3 mcg·h/mL, respectively. In total, 8/46 (17%) children experienced ≥1 adverse events (AEs) and 2/46 (4%) children experienced nonserious AEs that were deemed drug related by the investigator. Imipenem and relebactam exceeded plasma PK/PD targets; single doses of imipenem/cilastatin/relebactam were well tolerated with no significant safety concerns identified. These results informed imipenem/cilastatin/relebactam dose selection for further pediatric clinical evaluation.

Development and Validation of Questionnaire to Measure Parents' Knowledge, Attitude, and Practice on Self-Medication of Children with Antibiotics in Bandung, Indonesia

Purpose

This study aimed to develop and validate a questionnaire to measure the knowledge, attitude, and practice of parents regarding antibiotic use in Indonesian children using structural equation modeling (SEM) analysis.

Methods

The instrument development process was conducted from January 5 to 19, 2023, using the following steps: 1) literature review and item development, 2) internal review and refinement, 3) structural model analysis, and 4) measurement models' reliability and validity. A convenience sample was used to recruit parents as participants from Arcamanik District, Bandung, Indonesia. A total of 83 respondents completed the on-site interview questionnaire. Furthermore, statistical analyses were performed using SPSS Version 21.0 and Analysis of Moment Structures (AMOS) Version 26.0.

Results

The content validity for the scales was over 50%, and the reliabilities for the 38 items of the questionnaire were above 0.6, respectively. The suitability of the model was assessed, and the findings showed parameters for indicators: chi-square = 0.0004, CFI = 0.977, RMSEA = 0.044, CMIN/DF = 1.162, AGFI = 0.651, TLI = 0.973, and NFI = 0.860. The GFI parameter did not fit with the output value of 0.718, while the convergent and divergent validity of scores provided evidence in the expected direction.

Conclusion

This psychometric development study provides preliminary evidence that the 38-item scales were reliable and valid for assessing knowledge, attitude, and practice toward parents in the self-medication of antibiotics in children.

Variation in antibiotic resistance patterns for children and adults treated at 166 non-affiliated US facilities using EHR data

Background

Antibiotic resistance (AR) is a global public health threat. Surveillance of baseline AR and trends and emerging resistance among priority bacterial isolates with respect to the age of the patients and the type of healthcare setting are required due to differences in antimicrobial need and use in these populations.

Methods

We performed a retrospective study using deidentified electronic health record (EHR) data in the Cerner Health Facts™ data warehouse. Antibiotic susceptibility data were extracted for all bacterial isolates of interest at 166 non-affiliated healthcare facilities reporting microbiology susceptibility results of the FDA recommended antibiotics between the years 2012 to 2017. We assessed and visualized the slope coefficient from linear regression to compare changes in resistance over time for the four patient care groups.

Results

The trends in resistance rates to clinically relevant antibiotics were influenced by age and care setting. For example, ertapenem-resistant Enterobacter cloacae isolates from children overall increased significantly compared with adults (0.7% to 9.8%, 2.1% to 2.8%, P = 0.00013) and isolates from children in paediatric facilities increased significantly compared with facilities treating adults and children (0.1% to 27.1%, 0.9% to 3.8%, P = 0.0002).

Conclusions

Large-scale analysis of EHR data from 166 facilities shows that AR patterns for some bug-drug combinations vary by care setting and patient age. We describe novel data visualizations to interpret large-scale EHR data on the prevalence and trends of AR that should influence antimicrobial prescribing and antimicrobial stewardship programme interventions.

Balancing the Risks and Benefits of Pet Ownership in Pediatric Transplant Recipients

In recent decades, the number of pediatric transplantations and their survival rates have increased. Psychological problems and poorer quality of life are notable among children undergoing transplantation and can have long-lasting consequences and affect immunosuppressive therapy adherence. Pet ownership and animal contact have been associated with physical, mental, and social health benefits. Despite these potential benefits, however, companion animals are known to be a source of infection, which is one of the main concerns for clinicians. Because of immunosuppression, these children are particularly vulnerable to infections. Zoonoses comprise a long list of infectious diseases and represent a major public health problem. Nevertheless, many families and most healthcare providers are unaware of these potential risks, and there is a worrisome lack of recommendations to manage the risk-benefit balance, which could pose a risk for acquiring a zoonosis. Furthermore, no data are available on the number of transplanted patients with pets, and this risk-benefit balance is difficult to adequately evaluate. In this document, we review the currently available evidence regarding the epidemiology of zoonotic infections in patients undergoing transplantation, focusing on pediatric patients from a risk-benefit perspective, to help inform decision-making for clinicians. Families and healthcare professionals should be aware of the risks, and clinicians should actively screen for pets and offer comprehensive information as part of routine clinical practice. A multidisciplinary approach will ensure proper care of patients and pets and will establish preventive measures to ensure patients are safe living with their pets.

Quantitative method for the determination of antibiotic-resistant gut bacterial strains for the early diagnosis of chronic arthritis

Based on the clinical and microbiological monitoring of two groups of children aged 3 to 17 years with acute (n=78) and chronic (n=46) course of reactive arthritis (ReA), a method for early diagnosis of chronic arthritis was developed by determining the number of antibiotic-resistant coprostrains in patients with ReA, characterized by the absence of the need to isolate a pure culture of the pathogen and its identification; inoculation of faeces at a dilution of 10-5 on solid 1.5% GRM-agar with an antibacterial agents used in the treatment of a particular patient, at a minimum inhibitory concentration in the resistance range, followed by incubation and counting of the colonies of microorganisms grown on the plate. A significant relationship between the number of antibiotic-resistant gut bacterial strains and the course of arthritis (acute, chronic) was revealed, and the borderline value of the number of antibiotic-resistant gut bacterial strains was determined - 5×103 CFU/g, which allows differentiating the acute course from the chronic one: in the acute course< 5×103 CFU/g, with chronic - ≥ 5×103 CFU/g. The method allows, at the stage of completion of anti-inflammatory therapy in the active phase of the disease, to identify a risk group for the development of a chronic course of arthritis among patients with ReA, which can contribute to timely therapeutic measures aimed at preventing recurrence of the disease and making the patient disabled.

Treatment and Epidemiology of Third-Generation Cephalosporin-Resistant Urinary Tract Infections

BACKGROUND AND OBJECTIVES

Limited data are available on the contemporary epidemiology, clinical management, and health care utilization for pediatric urinary tract infection (UTI) due to third-generation cephalosporin-resistant Enterobacterales (G3CR) in the United States. The objective is to describe the epidemiology, antimicrobial treatment and response, and health care utilization associated with G3CR UTI.

METHODS

Multisite, matched cohort-control study including children with G3CR UTI versus non-G3CR UTI. UTI was defined as per American Academy of Pediatrics guidelines, and G3CR as resistance to ceftriaxone, cefotaxime, or ceftazidime. We collected data from the acute phase of illness to 6 months thereafter.

RESULTS

Among 107 children with G3CR UTI and 206 non-G3CR UTI with documented assessment of response, the proportion with significant improvement on initial therapy was similar (52% vs 57%; odds ratio [OR], 0.81; 95% confidence interval [CI], 0.44-1.50). Patients with G3CR were more frequently hospitalized at presentation (38% vs 17%; OR, 3.03; 95% CI, 1.77-5.19). In the follow-up period, more patients with G3CR had urine cultures (75% vs 53%; OR, 2.61; 95% CI, 1.33-5.24), antimicrobial treatment of any indication (53% vs 29%; OR, 2.82; 95% CI, 1.47-5.39), and subspecialty consultation (23% vs 6%; OR, 4.52; 95% CI, 2.10-10.09). In multivariate analysis, previous systemic antimicrobial therapy remained a significant risk factor for G3CR UTI (adjusted OR, 1.91; 95% CI, 1.06-3.44).

CONCLUSIONS

We did not observe a significant difference in response to therapy between G3CR and susceptible UTI, but subsequent health care utilization was significantly increased.

Risk factors for antibiotic-resistant bacteria colonisation in children with chronic complex conditions

To assess drug-resistant bacterial colonisation rates and associated risk factors in children with complex chronic conditions admitted to a national reference unit in Spain. Cross-sectional study that included all children admitted to our unit from September 2018 to July 2019. Rectal swabs were obtained to determine multidrug-resistant Gram-negative bacilli (MR-GNB) colonisation, and nasal swab to determine S. aureus and methicillin-resistant S. aureus (MRSA) colonisation. Medical records were reviewed. 100 children were included, with a median of four complex chronic conditions. Sixteen percent had S. aureus colonisation, including two MRSA. S. aureus colonisation was associated with technology-dependent children, while being on antibiotic prophylaxis or having undergone antibiotic therapy in the previous month were protective factors. The prevalence of MR-GNB colonisation was 27%, which was associated with immunosuppressive therapy (aOR 31; 2.02–47]; p = 0.01), antibiotic prophylaxis (aOR 4.56; 1.4–14.86; p = 0.012), previously treated skin-infections (aOR 2.9; 1.07–8.14; p = 0.03), surgery in the previous year (aOR 1.4; 1.06–1.8; p = 0.014), and hospital admission in the previous year (aOR 1.79; [1.26–2.56]; p = 0.001). The rate of S. aureus nasal colonisation in this series was not high despite the presence of chronic conditions, and few cases corresponded to MRSA. Antibiotic prophylaxis, immunosuppressive therapies, history of infections, previous surgeries, and length of admission in the previous year were risk factors for MR-GNB colonisation.

Therapeutic Drug Monitoring of Antibiotics in Critically Ill Children: An Observational Study in a Pediatric Intensive Care Unit

BACKGROUND

Septic critically ill children are at a high risk of inadequate antibiotic exposure, requiring them to undergo therapeutic drug monitoring (TDM). The aim of this study was to describe the use of TDM for antibiotics in critically ill children.

METHODS

The authors conducted a single-center observational study between June and December 2019, with all children treated with antibiotics in a pediatric intensive care unit located in a French university hospital. Standard clinical and laboratory data were recorded. Blood samples were collected for routine laboratory tests, and plasma antibiotic levels were assayed using validated analytical methods.

RESULTS

A total of 209 children received antibiotics. TDM was performed in 58 patients (27.8%) who had a greater mean organ dysfunction (according to the International Pediatric Sepsis Consensus Conference) (3 versus 1 in the non-TDM group; P < 0.05) and were treated with antibiotics for longer. A total of 208 samples were analyzed. The median [interquartile range] assay turnaround time was 3 (1-5) days, and 48 (46.2%) of the 104 initial antibiotic concentration values were below the pharmacokinetic/pharmacodynamic targets. A total of 34 (46%) of the 74 off-target TDM measurements available before the end of the antibiotic treatment prompted dose adjustment. This dose adjustment increased the proportion of on-target TDM measurements (70% versus 20% without adjustment). Subsequent measurements of the minimum inhibitory concentration showed that the use of the European Committee on Antimicrobial Susceptibility Testing's epidemiological cutoff values led to underestimation of pharmacokinetic/pharmacodynamic target attainment in 10 cases (20%).

CONCLUSIONS

TDM seems to be an effective means of optimizing antibiotic exposure in critically ill children. This requires timely plasma antibiotic assays and minimum inhibitory concentration measurements. It is important to define which patients should undergo TDM and how this monitoring should be managed.

Population Pharmacokinetic Modeling and Probability of Pharmacodynamic Target Attainment for Ceftazidime-Avibactam in Pediatric Patients Aged 3 Months and Older

Increasing prevalence of infections caused by antimicrobial-resistant gram-negative bacteria represents a global health crisis, and while several novel therapies that target various aspects of antimicrobial resistance have been introduced in recent years, few are currently approved for children. Ceftazidime-avibactam is a novel β-lactam β-lactamase inhibitor combination approved for adults and children 3 months and older with complicated intra-abdominal infection, and complicated urinary tract infection or hospital-acquired ventilator-associated pneumonia (adults only in the United States) caused by susceptible gram-negative bacteria. Extensive population pharmacokinetic (PK) data sets for ceftazidime and avibactam obtained during the adult clinical development program were used to iteratively select, modify, and validate the approved adult dosage regimen (2,000-500 mg by 2-hour intravenous (IV) infusion every 8 hours (q8h), with adjustments for renal function). Following the completion of one phase I (NCT01893346) and two phase II ceftazidime-avibactam studies (NCT02475733 and NCT02497781) in children, adult PK data sets were updated with pediatric PK data. This paper describes the development of updated combined adult and pediatric population PK models and their application in characterizing the population PK of ceftazidime and avibactam in children, and in dose selection for further pediatric evaluation. The updated models supported the approval of ceftazidime-avibactam pediatric dosage regimens (all by 2-hour IV infusion) of 50-12.5 mg/kg (maximum 2,000-500 mg) q8h for those ≥6 months to 18 years old, and 40-10 mg/kg q8h for those ≥3 to 6 months old with creatinine clearance > 50 mL/min/1.73 m2 .

Surveillance of Multidrug-Resistant Bacterial Infections in Non-Adult Patients - Zhejiang Province, China, 2014-2019

Introduction

Antimicrobial resistance has become a major public health threat globally. The prevalence of multidrug-resistant (MDR) bacterial infections increased substantially among inpatients under 18 years of age in recent years. In Zhejiang Province, China, the trends of drug-resistance in non-adult patients from 2014 to 2019 were monitored, aiming to determine the variation patterns and epidemiological features of MDR strains.

Methods

Patient data were collected from the Annual Review of Hospital Infection Resistance Survey in Zhejiang Province, 2014–2019. Statistical analysis was performed to analyze the pattern of distribution of five key bacterial pathogens in different age groups, ward settings, and bloodstream infections.

Results

From 2014 to 2019, a total of 30,163 multidrug-resistant strains were identified among 212,252 clinical isolates. The prevalence of extended spectrum β-lactamase-producing Enterobacteriaceae (ESBL-E), carbapenem-resistant Enterobacteriaceae (CRE), carbapenem-resistant Acinetobacter baumannii, carbapenem-resistant Pseudomonas aeruginosa (CRPA), and methicillin-resistant Staphylococcus aureus (MRSA) were 40.6%, 2.3%, 14.7%, 9.0%, and 27.4%, respectively. The prevalence of these key pathogens was lower than that reported in the national surveillance system (China Antimicrobial Resistance Surveillance System and Infectious Diseases Surveillance of Pediatrics). The prevalence of ESBL-E and CRE decreased since 2015 but that of CRPA and MRSA increased from 2014 to 2018.

Conclusions

Despite an overall decrease in the prevalence of drug-resistant bacteria in 2019, the rising prevalence of MRSA and CRPA still warrant much attention. Multidrug-resistant bacteria prevention and control strategies should be adjusted in a timely manner based on the surveillance results.

Antibiotic Resistance in Paediatric Febrile Urinary Tract Infections

Febrile urinary tract infection (UTI) is currently considered the most frequent cause of serious bacterial illness in children in the first 2 years of life. UTI in paediatrics can irreversibly damage the renal parenchyma and lead to chronic renal insufficiency and related problems. To avoid this risk, an early effective antibiotic treatment is essential. Moreover, prompt treatment is mandatory to improve the clinical condition of the patient, prevent bacteraemia, and avoid the risk of bacterial localization in other body sites. However, antibiotic resistance for UTI-related bacterial pathogens continuously increases, making recommendations rapidly outdated and the definition of the best empiric antibiotic therapy more difficult. Variation in pathogen susceptibility to antibiotics is essential for the choice of an effective therapy. Moreover, proper identification of cases at increased risk of difficult-to-treat UTIs can reduce the risk of ineffective therapy. In this review, the problem of emerging antibiotic resistance among pathogens associated with the development of paediatric febrile UTIs and the best potential solutions to ensure the most effective therapy are discussed. Literature analysis showed that the emergence of antibiotic resistance is an unavoidable phenomenon closely correlated with the use of antibiotics themselves. To limit the emergence of resistance, every effort to reduce and rationalise antibiotic consumption must be made. An increased use of antibiotic stewardship can be greatly effective in this regard.

Challenges of Antibiotic Stewardship in the Pediatric and Neonatal Intensive Care Units

The goals of antimicrobial stewardship programs (ASPs) are to optimize antimicrobial prescribing habits in order to improve patient outcomes, reduce antimicrobial resistance, and reduce hospital costs. Multiple society-endorsed guidelines and government policies reinforce the importance of ASP implementation. Effective antimicrobial stewardship can impact unique patients, hospitals, and societal antibiotic-resistance burden. The role and subsequent success of these programs has largely been reported in the adult population. Pediatric and neonatal intensive care units present unique challenges for traditional antimicrobial stewardship approaches. The purpose of this review article is to explore the challenges of appropriate antibiotic use in the pediatric and neonatal intensive care units and to summarize strategies ASPs can use to overcome these challenges. These problems include non-specific disease presentations, limited evidence for definitive treatment durations in many pediatric infections, fewer pediatric-trained infectious disease physicians, and applicability of intensive laboratory obtainment, collection, and interpretation. Additionally, many ASP implementation studies evaluating the efficacy of ASPs exclude the PICU and NICU. Areas of focus for pediatric ASPs should likely include appropriate antibiotic initiation, appropriate antibiotic duration, and appropriate antibiotic de-escalation.

Risk Factors for Acquisition of Extended-spectrum Beta-lactamase and AmpC Resistant Gram-negative Bacteria in Critically Ill Infants With Congenital Heart Disease

In a cohort of 257 infants with congenital heart disease admitted to the pediatric intensive care unit, 22 infants had positive cultures for extended-spectrum beta-lactamase or AmpC Gram-negative bacteria. These infants had longer exposure to broad-spectrum antibiotics, greater support with invasive devices and longer intensive care and hospital lengths of stay.

Associations of Antimicrobial-Resistant Gram-Negative Bloodstream Infections with Outcomes among Hospitalized Pediatric Patients in the United States

Objective The aim of this study was to assess the impact of pediatric antimicrobial-resistant gram-negative bloodstream infections (GNBSIs).

Methods A retrospective cohort study (2009–2016) was conducted using the Premier Healthcare Database among pediatric admissions with GNBSIs at hospitals reporting microbiology data. Infections for neonates and nonneonates were classified as multidrug resistance (MDR), resistant to one or two antibiotic drug classes (1–2DR), or susceptible.

Results Among 1,276 GNBSIs, 266 (20.8%) infections were 1–2DR and 23 (1.8%) MDR. Compared with susceptible GNBSIs, MDR nonneonates had higher mortality and higher costs, whereas 1–2DR neonates had longer stays and higher costs.

Conclusions Antimicrobial-resistant GNBSIs were associated with worse outcomes among pediatric hospitalized patients.

Prevalence and risk factors associated with multi-drug resistant organisms (MDRO) carriage among pediatric patients at the time of admission in a tertiary care hospital of a developing country. A cross-sectional study

Background

The rise of Multidrug-resistant organisms (MDROs) poses a considerable burden on the healthcare systems, particularly in low-middle income countries like Pakistan. There is a scarcity of data on the carriage of MDRO particularly in the pediatrics population therefore, we aimed to determine MDRO carriage in pediatric patients at the time of admission to a tertiary care hospital in Karachi, Pakistan, and to identify the risk factors associated with it.

Methods

A cross-sectional study conducted at the pediatric department of Aga Khan University Hospital (AKUH) from May to September 2019 on 347 children aged 1–18 years. For identification of MDRO (i.e., Extended Spectrum Beta-Lactamase (ESBL) producers, Carbapenem Resistant Enterobacteriaceae (CRE), Vancomycin Resistant Enterococci (VRE), Methicillin Resistant Staphylococcus aureus (MRSA), Multidrug-resistant (MDR) Acinetobacter species and MDR Pseudomonas aeruginosa), nasal swabs and rectal swabs or stool samples were cultured on specific media within 72 h of hospitalization. Data was collected on a predesigned structured questionnaire on demographics, prior use of antibiotics for > 48 h in the last 6 months, history of vaccination in last 6 months, exposure to health care facility regardless of the time of exposure, ICU stay for > 72 h, and about the prior use of medical devices (urinary catheter, central venous lines etc.) in last 1 year. Statistical analysis was performed by Standard statistical software.

Results

Out of 347 participants, 237 (68.3%) were found to be MDRO carriers. Forty nine nasal swabs from 346 children (14.2%) showed growth of MRSA. The majority of the stool/rectal swabs (n = 222 of 322; 69%) collected were positive for MDRO. The most isolated species were ESBL Escherichia coli 174/222 (78.3%) followed by ESBL Enterobacter species 37/222 (16.7%) and ESBL Klebsiella pneumoniae 35/222 (15.8%). On univariate analysis, none of the risk factors showed statistically significant association with MDRO carriage.

Conclusion

Overall, a high prevalence of MDRO carriage was identified among admitted pediatric patients. Implementation of systematic screening may help to identify true burden of MDROs carriage in the health care settings.

Antibiotic Resistance in Pediatric Infections: Global Emerging Threats, Predicting the Near Future

Antibiotic resistance is a public health threat of the utmost importance, especially when it comes to children: according to WHO data, infections caused by multidrug resistant bacteria produce 700,000 deaths across all ages, of which around 200,000 are newborns. This surging issue has multipronged roots that are specific to the pediatric age. For instance, the problematic overuse and misuse of antibiotics (for wrong diagnoses and indications, or at wrong dosage) is also fueled by the lack of pediatric-specific data and trials. The ever-evolving nature of this age group also poses another issue: the partly age-dependent changes of a developing system of cytochromes determine a rather diverse population in terms of biochemical characteristics and pharmacokinetics profiles, hard to easily codify in an age- or weight-dependent dosage. The pediatric population is also penalized by the contraindications of tetracyclines and fluoroquinolones, and by congenital malformations which often require repeated hospitalizations and pharmacological and surgical treatments from a very young age. Emerging threats for the pediatric age are MRSA, VRSA, ESBL-producing Enterobacteriaceae, carbapenem-resistant Enterobacteriaceae and the alarming colistin resistance. Urgent actions need to be taken in order to step back from a now likely post-antibiotic era, where simple infections might cause infant death once again.

In Vitro Activity of Imipenem/Relebactam Against Gram-Negative Bacilli from Pediatric Patients-Study for Monitoring Antimicrobial Resistance Trends (SMART) global surveillance program 2015-2017

BACKGROUND

Studies describing the activity of imipenem/relebactam against gram-negative bacilli (GNB) isolated from pediatric patients are lacking in the peer-reviewed literature. We address this deficiency by reporting on GNB tested against imipenem/relebactam as part of the Study for Monitoring Antimicrobial Resistance Trends global surveillance program.

METHODS

In 2015-2017, 221 laboratories in 59 countries collected 9149 consecutive, aerobic or facultative GNB from pediatric patients (age <18 years) and 100 785 from adult patients with intraabdominal, respiratory, and urinary tract infections. Susceptibility was determined using Clinical and Laboratory Standards Institute (CLSI) broth microdilution methodology and CLSI breakpoints (and US Food and Drug Administration breakpoints for imipenem/relebactam).

RESULTS

The 4 most common species of GNB isolated from pediatric patients were Escherichia coli (40.4%), Pseudomonas aeruginosa (17.1%), Klebsiella pneumoniae (13.9%), and Enterobacter cloacae (4.7%); non-Morganellaceae Enterobacterales (NME) accounted for 70.1% of isolates. Imipenem/relebactam inhibited 97.8% of NME from pediatric patients; susceptibility to imipenem was 1.9% lower, and susceptibility to β-lactam comparators (cefepime, ceftazidime, ceftriaxone, piperacillin/tazobactam) was 9.2-25.2% lower. Imipenem/relebactam inhibited 94.2% of P. aeruginosa from pediatric patients; susceptibility to imipenem was 16.2% lower, and susceptibility to β-lactam comparators was 10.2-15.6% lower. Susceptibility was generally slightly higher for isolates from pediatric than adult patients. All K. pneumoniae carbapenemase (KPC)-positive isolates, 93.3% of multidrug-resistant (MDR) NME isolates, and 70.5% of MDR P. aeruginosa isolates from pediatric patients were susceptible to imipenem/relebactam.

CONCLUSIONS

Imipenem/relebactam provides a new treatment option for infections caused by resistant gram-negative bacilli, including KPC-positive NME, MDR NME, and MDR P. aeruginosa.

Comparative in vitro effectiveness of ceftolozane/tazobactam against pediatric gram-negative drug-resistant isolates

Ceftolozane/tazobactam (C/T), a cephalosporin/beta-lactamase inhibitor combination, was evaluated in vitro vs. 10 comparators against 299 pediatric extended-spectrum-cephalosporin-resistant or carbapenem-resistant (ESC-R/CR) Gram-negative Enterobacteriaceae from three freestanding pediatric centers. Isolates were from urine or other sterile sites of children and adolescents through 21 years of age. Susceptibilities were assayed by microbroth dilution via custom Sensititre plates (Thermo Fisher Scientific). Susceptibility was determined using the Sensititre Vizion® system (Thermo Fisher Scientific). Susceptibility breakpoint criteria were those of the Clinical and Laboratory Standards Institute (CLSI) for 2017, except for colistin (EUCAST 2019). Overall, 87.5% isolates were C/T susceptible (MIC ≤2 μg/ml; MIC_50/90, 0.25/4 μg/ml). Susceptibility to C/T was detected more frequently as compared to all other antimicrobials tested except for colistin (95.4%) and meropenem (97.4%). Percent susceptibility to C/T was high for E. coli (91%) and Klebsiella spp. (73.3%). C/T demonstrated good in-vitro activity and high potency against most beta-lactam resistant pediatric Enterobacteriaceae from three geographically diverse U.S. regions.

Short-term increase in the carriage of azithromycin-resistant Escherichia coli and Klebsiella pneumoniae in mothers and their newborns following intra-partum azithromycin: a post hoc analysis of a double-blind randomized trial

Objectives

To evaluate the impact of one oral dose of intrapartum azithromycin (2 g) on the carriage and antibiotic resistance of Escherichia coli and Klebsiella pneumoniae in the nasopharynx, breast milk and vaginal swabs of mothers and K. pneumoniae in the nasopharynx of their newborns.

Methods

We performed a post hoc analysis of a double-blind, placebo-controlled randomized-trial (ratio 1:1) conducted in The Gambia. Breast milk (BM) and vaginal swabs (VS) from mothers and nasopharyngeal swabs (NPS) from mother-newborn pairs were collected at different timepoints during the 4 week follow-up. Samples were processed using standard microbiological procedures. For BM and NPS post-intervention results were combined for analysis.

Results

In the original trial 829 mothers were randomized. In this analysis, complete sample sets were available for 630 mothers for E. coli analysis (76.0%) and 564 mother-newborn pairs for K. pneumoniae analysis (68.0%). For E. coli, carriage prevalence in BM and VS was similar in both arms but resistance was higher in the azithromycin arm in VS (2.6% versus 0%, P = 0.004). For K. pneumoniae, carriage prevalence was higher in the azithromycin arm for BM (13.8% versus 8.7%, P = 0.055) but not for VS or NPS. Prevalence of azithromycin resistant K. pneumoniae was higher in the azithromycin arm for BM (3.6% versus 1.0%, P = 0.050) and VS (1.5% versus 0% P = 0.057).

Conclusions

Oral intrapartum azithromycin did not reduce carriage of E. coli and K. pneumoniae and was associated with an increase in the prevalence of azithromycin-resistant E. coli and K. pneumoniae isolates in BM and VS.

Multidrug-resistant organisms in urinary tract infections in children

The global spread of multidrug-resistant organisms has led to an increase in urinary tract infections (UTIs) in children that are difficult to treat. This review explores the current literature regarding multidrug-resistant UTIs in childhood and proposes an approach to management. Multidrug-resistant organisms include a wide range of potential urinary tract pathogens and, while most literature on drug resistance in UTIs during childhood has focused on extended-spectrum beta-lactamase producing organisms, in this review, we have included a discussion of multidrug resistance including and beyond beta-lactamase production. We provide definitions for multidrug-resistant organisms in line with current consensus guidelines and summarise clinically relevant mechanisms of resistance. Additionally, in this review, we outline the global epidemiology of multidrug-resistant UTIs in children, summarising published prevalence rates, which range from 5 to 90% in different settings. Finally, we also critically review the evidence on risk factors for colonisation and infection of the urinary tract with multidrug-resistant organisms, including prior antibiotic use, hospitalisation and underlying urological malformations. We also highlight multidrug-resistant UTI occurring in children without any identifiable risk factors, reflecting an increasing prevalence of colonisation with these organisms in the general community. Taken as a whole, this emphasises a need for careful and evidence-based use of antibiotics when treating UTIs in children and, to aide clinicians, we have outlined here potential management strategies for when infection with a multidrug-resistant organism is suspected or confirmed.

A Potential Inhibitor of MCR-1: An Attempt to Enhance the Efficacy of Polymyxin Against Multidrug-Resistant Bacteria

The irrational use of broad-spectrum antibiotics has led to increasing resistance of bacteria to antibiotics, and the emergence of the plasmid-mediated colistin resistance gene mcr-1 has led to the dilemma of infections with no available cure. Here, we have found a potential MCR-1 inhibitor for use against infections caused by MCR-1 positive resistant bacteria. A checkerboard MIC (minimum inhibitory concentration) assay, growth curve assay, kill curve assay, cytotoxicity assay, molecular dynamics simulation analysis, Western blot assay and mouse pneumonia model in vivo protection rate assay were used to evaluate the synergy effect between genistein and polymyxins. The results showed that genistein could restore the bactericidal activity against MCR-1-positive strains for which there was no antibacterial activity, and reduce the bacterial load to some extent. Genistein does not inhibit the expression of MCR-1, but inhibits the binding of MCR-1 to its substrate by binding to the amino acids of the active region of MCR-1, thereby inhibiting the biological activity of MCR-1. The in vivo results also showed that the protection rate of mice treated with the combination therapy of genistein and polymyxins increased by 20% compared to that of mice treated with polymyxins alone. Our results confirm that genistein is an inhibitor of MCR-1 and promote its potential use in combination with polymyxins to treat severe infections caused by MCR-1 positive Enterobacteriaceae.

Clinical Performance and Impact of Accelerate Pheno for Gram-negative Bacteremia in Hospitalized Children

PURPOSE

Accelerate Pheno provides rapid identification and antimicrobial susceptibility tests (ASTs) of pathogens that cause blood stream infections (BSIs). The study objective was to assess the accuracy of the Accelerate Pheno platform and its impact on antimicrobial modification in children with gram-negative BSIs.

METHODS

A retrospective review was conducted of patients at a children's hospital with gram-negative BSIs from November 2018 to November 2019. Proportion of agreement between Accelerate Pheno and standard of care (SOC) was determined for organism identification (matrix-assisted laser desorption ionization time-of-flight mass spectrometry) and susceptibilities (MicroScan). Time from culture collection to Gram stain, identification and AST by the Accelerate Pheno method, and AST results by MicroScan were calculated. Antibiotic modifications and opportunities to optimize antimicrobial stewardship were recorded.

FINDINGS

Of 115 BSIs from 90 patients, 90 monomicrobial gram-negative BSIs with an organism included on the Accelerate Pheno panel were found. Compared with SOC, the organism was correctly identified in 90 patients (100%). Overall, 5 of 732 ASTs (0.7%) reported susceptible by Accelerate Pheno were resistant by SOC, and 8 of 109 (7.3%) reported resistant by Accelerate Pheno were susceptible by SOC. On the basis of the Accelerate Pheno AST results, antibiotic spectrum was increased in 10 of 11 instances to correct organism-drug mismatch and narrowed in 16 of 33 instances. Median times from culture collection to reporting of Gram stain, Accelerate Pheno identification, Accelerate Pheno AST, and SOC AST were 12.6, 14.6, 19.9, and 60.6 h, respectively. Median time to optimal therapy was 21.8 h for infections with actionable AST data.

IMPLICATIONS

Accelerate Pheno was accurate and decreased time to optimal therapy by almost 40 h for children with gram-negative BSIs. Antibiotic spectrum was increased in multiple instances, but opportunities to decrease spectrum were underused.

Greater optimisation of pharmacokinetic/pharmacodynamic parameters through a loading dose of intravenous colistin in paediatric patients

Use of colistin in children is rising in line with the increase of multidrug-resistant Gram-negative bacteria (MDR-GNB). In adults, a colistin loading dose is recommended to achieve therapeutic concentrations within 12-24 h. Here we aimed to describe the pharmacokinetic (PK) parameters of a loading dose versus a recommended initial dose of intravenous colistimethate sodium (CMS) in paediatric patients. A prospective, open-label, PK study was conducted in paediatric patients (age 2-18 years) with normal renal function. Patients (n = 20) were randomly assigned to receive either a CMS loading dose (LD group) of 4 mg of colistin base activity (CBA)/kg/dose or a standard initial dose (NLD group) of 2.5 mg (12-h interval) or 1.7 mg (8-h interval) of CBA/kg/dose. Serial blood samples were collected. Plasma concentrations of formed colistin were measured by LC-MS/MS. PK parameters were reported. Acute kidney injury (AKI) was monitored by serum creatinine and urine NGAL. The median (interquartile range) age and body weight were 8.5 (3.5-11.3) years and 21.5 (13.5-20.0) kg. The mean (standard deviation) of first-dose PK parameters of the LD group versus the NLD group were: C_max, 6.1 (2.4) vs. 4.1 (1.3) mg/L; AUC_0-t, 26.5 (12.5) vs. 13.5 (3.6) mg/L·h; V_d, 0.7 (0.4) vs. 0.6 (0.3) L/kg; and t_1/2, 2.9 (0.6) vs. 2.6 (0.4) h. No patient developed AKI by serum creatinine criteria. A CMS loading dose is beneficial for improvement of colistin exposure without increased AKI. A higher daily dose of CMS should be considered, especially for MDR-GNB treatment.

Chronic nail biting, orthodontic treatment and Enterobacteriaceae in the oral cavity

Background

Chronic nail biting is common in children and young adults. Auto inoculation of environmental pathogens can manifest as infection in distant organs. Multi-drug resistance gram negative bacteria are on the rise globally. Several of the foodborne bacteria fall within the Enterobacteriaceae family but very few studies have explored these microbes in the oral cavity of children with chronic nail-biting habit or orthodontic treatment. The study aims to investigate oral load of Enterobacteriaceae in children with chronic nail-biting habit and or those undergoing orthodontic treatment.

Material and Methods

150 children (no nail-biting n=30, nail biting n=60, fixed orthodontic treatment n =30 and a combination of fixed orthodontic appliance use and nail-biting habit n =30) were assessed for culture based microbiological investigation. The concentrated oral rinse technique was used. The rinse was inoculated in MacConkey’s and Blood Agar. The gram stained culture was subjected to biochemical tests for sub-species identification using Biomerieux Vitek 2 Compact Automated Microbiological Analyzer. Fisher’s exact and Kruskal Wallis with post hoc analysis using Dunn method was performed to test association and difference between groups.

Results

Enterobacteriaceae was positive for 72% of the children. Of them, nail biting or orthodontic treatment group comprised 89%. Those with a combination of nail biting and undergoing orthodontic treatment exhibited highest CFU/ml and those without nail biting or orthodontic treatment exhibited the lowest. Three of the four organisms isolated tested positive in the orthodontic treatment group. E. coli was positive in 38% of the children while Klebsiella and E. cloacae were isolated exclusively in the orthodontic treatment group.

Conclusions

Chronic nail biting or the use of fixed orthodontic appliances is associated with higher incidence of Enterobacteriaceae in the oral cavity. Oral health professionals play an important role in preventing multi drug resistance infectious diseases.

Key words:Enterobacteriaceae, nail-biting, Onychophagia, orthodontic treatment.

Molecular characterization of carbapenem-resistant Klebsiella pneumoniae isolates with focus on antimicrobial resistance

Background

The enhancing incidence of carbapenem-resistant Klebsiella pneumoniae (CRKP)-mediated infections in Mengchao Hepatobiliary Hospital of Fujian Medical University in 2017 is the motivation behind this investigation to study gene phenotypes and resistance-associated genes of emergence regarding the CRKP strains. In current study, seven inpatients are enrolled in the hospital with complete treatments. The carbapenem-resistant K. pneumoniae whole genome is sequenced using MiSeq short-read and Oxford Nanopore long-read sequencing technology. Prophages are identified to assess genetic diversity within CRKP genomes.

Results

The investigation encompassed eight CRKP strains that collected from the patients enrolled as well as the environment, which illustrate that bla_KPC-2 is responsible for phenotypic resistance in six CRKP strains that K. pneumoniae sequence type (ST11) is informed. The plasmid with IncR, ColRNAI and pMLST type with IncF[F33:A-:B-] co-exist in all ST11 with KPC-2-producing CRKP strains. Along with carbapenemases, all K. pneumoniae strains harbor two or three extended spectrum β-lactamase (ESBL)-producing genes. fosA gene is detected amongst all the CRKP strains. The single nucleotide polymorphisms (SNP) markers are indicated and validated among all CRKP strains, providing valuable clues for distinguishing carbapenem-resistant strains from conventional K. pneumoniae.

Conclusions

ST11 is the main CRKP type, and bla_KPC-2 is the dominant carbapenemase gene harbored by clinical CRKP isolates from current investigations. The SNP markers detected would be helpful for characterizing CRKP strain from general K. pneumoniae. The data provides insights into effective strategy developments for controlling CRKP and nosocomial infection reductions.

Prior antibiotic use and acquisition of multidrug-resistant organisms in hospitalized children: A systematic review

Objective:

Multidrug-resistant organisms (MDROs) cause ~5%–10% of infections in hospitalized children, leading to an increased risk of death, prolonged hospitalization, and additional costs. Antibiotic exposure is considered a driving factor of MDRO acquisition; however, consensus regarding the impact of antibiotic factors, especially in children, is lacking. We conducted a systematic review to examine the relationship between antibiotic use and subsequent healthcare-associated infection or colonization with an MDRO in children.

Design:

Systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guideline.

Methods:

We searched PubMed and Embase for all English, peer-reviewed original research studies published before September 2018. Included studies evaluated hospitalized children, antibiotic use as an exposure, and bacterial MDRO as an outcome.

Results:

Of the 535 studies initially identified, 29 met the inclusion criteria. Overall, a positive association was identified in most studies evaluating a specific antibiotic exposure (17 of 21, 81%), duration of antibiotics (9 of 12, 75%), and number of antibiotics received (2 of 3, 67%). Those studies that evaluated any antibiotic exposure had mixed results (5 of 10, 50%). Study sites, populations, and definitions of antibiotic use and MDROs varied widely.

Conclusions:

Published studies evaluating this relationship are limited and are of mixed quality. Limitations include observation bias in recall of antibiotic exposure, variations in case definitions, and lack of evaluation of antibiotic dosing and appropriateness. Additional studies exploring the impact of antibiotic use and MDRO acquisition may be needed to develop effective antibiotic stewardship programs for hospitalized children.

Direct antimicrobial susceptibility testing of positive blood cultures: a comparison of the Accelerate Pheno™ and VITEK® 2 systems

OBJECTIVES

To compare the performance and time-to-result (TTR) for antimicrobial susceptibility testing (AST) of positive blood cultures (PBC) using the Accelerate Pheno™ system (AXDX) and both a direct VITEK® 2 card inoculation workflow (DV2) and traditional FDA-approved VITEK® 2 workflow using subcultured isolates (V2).

METHODS

Patient samples with monomicrobial Gram-negative rod bacteremia were tested on AXDX and DV2 in tandem and compared to V2 AST results. Categorical agreement (CA) errors were adjudicated using broth microdilution. Instrumentation times and AST TTR were compared.

RESULTS

AXDX and DV2 had a CA of 93.4% and 97.4%, respectively, compared to V2. Postadjudication, AXDX, DV2, and V2 had CA of 94.7%, 95.7%, and 96.5%, respectively. Instrument run times were 6.6 h, 9.4 h, and 9.2 h, and AST TTR were 8.9 h, 12.9 h and 35.5 h, respectively.

CONCLUSIONS

AXDX and DV2 ASTs are fast and reliable, which may have significant antimicrobial stewardship implications.

The Future of Maternal and Child Health

INTRODUCTION

The purpose of this commentary is to start a national conversation about the future of maternal and child health (MCH). In the coming decades, we will have unprecedented opportunities to improve MCH, but will also face unprecedented threats.

METHODS

This paper examines emerging opportunities and threats to MCH, and discusses strategies for leading the future of MCH.

RESULTS

Scientific advancements will continue to drive improvements in MCH, but to unleash its full potential for improving population health future MCH research must become more transdisciplinary, translational, and precise. Technological innovations could dramatically transform our work in MCH while big data could enhance predictive analytics and precision health; our challenge will be to assure equitable access. The greatest gains in MCH will continue to come from improving social conditions, which will require advancing MCH in all policies. Climate change, infectious outbreaks and antimicrobial resistance pose increasing threats to MCH, which can be averted by reducing global warming, implementing global early warning systems, and instituting responsible antimicrobial stewardship. The growing burden of chronic diseases in children and adults need to be addressed from an ecological and life course perspective. The water crisis in Flint shined a spotlight on the growing health threats from America's decaying infrastructure.

DISCUSSION

We can lead the future of MCH by starting a national conversation, improving MCH research, and preparing future MCH workforce, but the future of MCH will depend on our effectiveness in bringing about social and political change in the coming decades.

The Clinical and Molecular Epidemiology of CTX-M-9 Group Producing Enterobacteriaceae Infections in Children

Introduction

The pandemic of extended-spectrum beta-lactamase-(ESBL)-producing Enterobacteriaceae (Ent) is strongly linked to the dissemination of CTX-M-type-ESBL-Ent. We sought to define the epidemiology of infections in children due to an emerging resistance type, CTX-M-9-group-producing-Ent (CTX-M-9-grp-Ent).

Methods

A retrospective matched case-control analysis of children with CTX-M-9-grp-Ent infections who received medical care at three Chicago area hospitals was performed. Cases were defined as children possessing extended-spectrum cephalosporin-resistant (ESC-R) infections due to bla_CTX-M-9. PCR and DNA analysis assessed beta-lactamase (bla) genes, multi-locus sequence types (MLST) and phylogenetic grouping of E. coli. Controls were children with ESC-susceptible (ESC-S)-Ent infections matched one case to three controls by age, source, and hospital. The clinical-epidemiologic predictors of CTX-M-9-grp-Ent infection were assessed.

Results

Of 356 ESC-R-Ent isolates from children (median age 4.1 years), the CTX-M-9-group was the solely detected bla gene in 44 (12.4%). The predominant species was E. coli (91%) of virulent phylogroups D (60%) and B2 (40%). MLST revealed multiple strain types. On multivariable analysis, CTX-M-9-grp-Ent occurred more often in E. coli than other Ent genera (OR 7.4, 95% CI 2.4, 27.2), children of non-Black-White-Hispanic race (OR 7.4, 95% CI 2.4, 28.2), and outpatients (OR 4.5, 95% CI 1.7, 12.3), which was a very unexpected finding for infections due to antibiotic-resistant bacteria. Residents of South Chicago had a 6.7 times higher odds of having CTX-M-9-grp-Ent infections than those in the reference region (West), while residence in Northwestern Chicago was associated with an 81% decreased odds of infection. Other demographic, comorbidity, invasive-device, and antibiotic use differences were not found.

Conclusion

CTX-M-9-grp-Ent infection may be associated with patient residence and is occurring in children without traditional in-patient exposure risk factors. This suggests that among children, the community environment may be a key contributor in the spread of these resistant pathogens.

Advances in pediatric antimicrobial agents development

PURPOSE OF REVIEW

Rising rates of multidrug-resistant organisms has necessitated the development of novel antimicrobials. In this review, we will highlight agents that have recently received licensure and those that are in clinical development.

RECENT FINDINGS

In recent years, development of novel antimicrobial agents has accelerated. Although most studies have targeted the adult population, studies in pediatric patients are underway. Adequately powered clinical trials are needed to establish the safety and role of these new drugs.

SUMMARY

The recent development of novel antimicrobials to combat multidrug-resistant organisms is encouraging; however, more studies in the pediatric population are needed.

Antibiotic-Resistant Bacteria and the Use of Novel Antibiotics in Children

Infections due to antibiotic-resistant bacteria in children are on the rise worldwide. Treating these infections is a challenge for pediatric caregivers. In this arms race, the armamentarium of antibiotics is quickly being depleted. This article reviews the problems facing clinicians caring for children with resistant bacterial infections, examines some of the newer antibiotics, and discusses other methods for pediatric caregivers to combat these infections. Only through an informed and concerted effort will we be able to address this growing problem in children. [Pediatr Ann. 2018;47(9):e354-e358.].