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Thampi N, Guzman-Cottrill J, Bartlett AH, Berg W, Cantey JB, Kitt E, Ravin K, Zangwill KM, Elward A. SHEA NICU white paper series: Practical approaches for the prevention of viral respiratory infections. Infect Control Hosp Epidemiol 2024; 45:267-276. [PMID: 37877172 DOI: 10.1017/ice.2023.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023]
Abstract
This white paper provides clinicians and hospital leaders with practical guidance on the prevention and control of viral respiratory infections in the neonatal intensive care unit (NICU). This document serves as a companion to Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee (HICPAC)'s "Prophylaxis and Screening for Prevention of Viral Respiratory Infections in Neonatal Intensive Care Unit Patients: A Systematic Review." It provides practical, expert opinion and/or evidence-based answers to frequently asked questions about viral respiratory detection and prevention in the NICU. It was developed by a writing panel of pediatric and pathogen-specific experts who collaborated with members of the HICPAC systematic review writing panel and the SHEA Pediatric Leadership Council to identify questions that should be addressed. The document has been endorsed by SHEA, the American Hospital Association (AHA), The Joint Commission, the Pediatric Infectious Diseases Society (PIDS), the Association for Professionals in Infection Control and Epidemiology (APIC), the Infectious Diseases Society of America (IDSA), and the National Association of Neonatal Nurses (NANN).
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Affiliation(s)
- Nisha Thampi
- Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Allison H Bartlett
- University of Chicago and Comer Children's Hospital, Chicago, Illinois, USA
| | - Wendy Berg
- Children's Minnesota, St. Paul, Minnesota, USA
| | - Joseph B Cantey
- The University of Texas Health Science Center, San Antonio, Texas, USA
| | - Eimear Kitt
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Karen Ravin
- Nemours Children's Health, Wilmington, Delaware, USA
| | | | - Alexis Elward
- Washington University School of Medicine, St. Louis, Missouri, USA
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Mo M, Guilak F, Elward A, Quayle K, Thompson D, Brouillet K, Luhmann SJ. The Use of Biomarkers in the Early Diagnosis of Septic Arthritis and Osteomyelitis-A Pilot Study. J Pediatr Orthop 2022; 42:e526-e532. [PMID: 35405729 DOI: 10.1097/bpo.0000000000002052] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The diagnosis of septic arthritis (SA) and osteomyelitis (OM) has remained challenging in the pediatric population, often accompanied by delays and requiring invasive interventions. The purpose of this pilot study is to identify a novel panel of biomarkers and cytokines that can accurately differentiate SA and OM at initial presentation using serum alone. METHODS Twenty patients below 18 years old whose working diagnosis included SA (n=10) and OM (n=10) were identified. Serum was collected at initial evaluation. Each sample underwent seven ELISA [C1-C2, COMP, CS-846, hyaluronan, procalcitonin, PIIANP, C-terminal telopeptide of type II collagen (CTX-II)] and 65-plex cytokine panels. Principal component and Lasso regression analysis were performed to identify a limited set of predictive biomarkers. RESULTS Mean age was 4.7 and 9.5 years in SA and OM patients, respectively (P=0.029). 50% of SA patients presented within 24 hours of symptom onset, compared with 0% of OM patients (P=0.033). 30% of SA patients were discharged home with an incorrect diagnosis and re-presented to the emergency department days later. At time of presentation: temperature ≥38.5°C was present in 10% of SA and 40% of OM patients (P=0.12), mean erythrocyte sedimentation rate (mm/h) was 51.6 in SA and 44.9 in OM patients (P=0.63), mean C-reactive protein (mg/dL) was 55.8 in SA and 71.8 in OM patients (P=0.53), and mean white blood cells (K/mm3) was 12.5 in SA and 10.4 in OM patients (P=0.34). 90% of SA patients presented with ≤2 of the Kocher criteria. 100% of SA and 40% of OM patients underwent surgery. 70% of SA cultures were culture negative, 10% MSSA, 10% Kingella, and 10% Strep pyogenes. 40% of OM cultures were culture negative, 50% MSSA, and 10% MRSA. Four biomarkers [CTx-II, transforming growth factor alpha (TGF-α), monocyte chemoattractant protein 1 (MCP-1), B cell-attracting chemokine 1] were identified that were able to classify and differentiate 18 of the 20 SA and OM cases correctly, with 90% sensitivity and 80% specificity. CONCLUSIONS This pilot study identifies a panel of biomarkers that can differentiate between SA and OM at initial presentation using serum alone. LEVEL OF EVIDENCE Level II-diagnostic study.
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Affiliation(s)
| | - Farshid Guilak
- Departments of Orthopedic Surgery
- Shriners Hospitals for Children, St. Louis, MO
| | | | - Kimberly Quayle
- Emergency Medicine, Washington University School of Medicine, Saint Louis Children's Hospital
| | - Dominic Thompson
- Departments of Orthopedic Surgery
- Shriners Hospitals for Children, St. Louis, MO
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Abstract
COVID-19 is a nonspecific viral illness caused by a novel coronavirus, SARS-CoV-2, and led to an ongoing global pandemic. Transmission is primarily human-to-human via contact with respiratory particles containing infectious virus. The risk of transmission to health care personnel is low with proper use of personal protective equipment, including gowns, gloves, N95 or surgical mask, and eye protection. Additional measures affecting the risk of transmission include physical distancing, hand hygiene, routine cleaning and disinfection, appropriate air handling and ventilation, and public health interventions such as universal masking and stay-at-home orders.
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Affiliation(s)
- Patrick Reich
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Washington University School of Medicine, 660 S. Euclid Avenue, Campus Box 8116, St Louis, MO 63110-1093, USA.
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Schwartz DJ, Elward A, Storch GA, Rosen DA. Ureaplasma urealyticum pyelonephritis presenting with progressive dysuria, renal failure, and neurologic symptoms in an immunocompromised patient. Transpl Infect Dis 2018; 21:e13032. [PMID: 30472777 DOI: 10.1111/tid.13032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 10/23/2018] [Accepted: 11/16/2018] [Indexed: 11/30/2022]
Abstract
Ureaplasma urealyticum is a bacterial species correlated with urethritis in healthy individuals and invasive infections in immunocompromised patients. We describe a 20-year-old female with a history of remote heart transplant on everolimus, mycophenolate, and rituximab presenting with progressive urinary tract symptoms, renal failure, and neurologic symptoms. An extensive workup ultimately identified U urealyticum infection, and the patient successfully recovered after a course of azithromycin and doxycycline.
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Affiliation(s)
- Drew J Schwartz
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
| | - Alexis Elward
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
| | - Gregory A Storch
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
| | - David A Rosen
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Washington University School of Medicine, Saint Louis, Missouri
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Barton K, Davis TK, Marshall B, Elward A, White NH. Posaconazole-induced hypertension and hypokalemia due to inhibition of the 11β-hydroxylase enzyme. Clin Kidney J 2018; 11:691-693. [PMID: 30289132 PMCID: PMC6165748 DOI: 10.1093/ckj/sfx156] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Accepted: 12/12/2017] [Indexed: 11/14/2022] Open
Abstract
Posaconazole is an antifungal therapy reported to cause incident hypertension. Hypokalemia is also a known side effect. The combination of hypertension and hypokalemia suggests mineralocorticoid excess. We present the case of a 15-year-old adolescent male with hypertensive urgency while on prophylactic posaconazole therapy for a combined immunodeficiency. We identify the mechanism of posaconazole-induced hypertension to be inhibition of the 11β-hydroxylase enzyme, resulting in elevated levels of the mineralocorticoid receptor activator deoxycorticosterone. Loss of function of the 11β-hydroxylase enzyme is responsible for a rare form of congenital adrenal hyperplasia and can be associated with life-threatening adrenal crisis.
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Affiliation(s)
- Kevin Barton
- Department of Pediatrics, Division of Nephrology, Washington University, St. Louis, MO, USA
| | - T Keefe Davis
- Department of Pediatrics, Division of Nephrology, Washington University, St. Louis, MO, USA
| | - Bess Marshall
- Department of Pediatrics, Division of Endocrinology, Washington University, St. Louis, MO, USA
| | - Alexis Elward
- Department of Pediatrics, Division of Infectious Disease, Washington University, St. Louis, MO, USA
| | - Neil H White
- Department of Pediatrics, Division of Endocrinology, Washington University, St. Louis, MO, USA
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Zerr DM, Weissman SJ, Zhou C, Kronman MP, Adler AL, Berry JE, Rayar J, Myers J, Haaland WL, Burnham CAD, Elward A, Newland J, Selvarangan R, Sullivan KV, Zaoutis T, Qin X. The Molecular and Clinical Epidemiology of Extended-Spectrum Cephalosporin- and Carbapenem-Resistant Enterobacteriaceae at 4 US Pediatric Hospitals. J Pediatric Infect Dis Soc 2017; 6:366-375. [PMID: 28339623 PMCID: PMC5907845 DOI: 10.1093/jpids/piw076] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 11/10/2016] [Indexed: 12/31/2022]
Abstract
OBJECTIVE In this report, we aim to describe the epidemiology of extended-spectrum cephalosporin-resistant (ESC-R) and carbapenem-resistant (CR) Enterobacteriaceae infections in children. METHODS ESC-R and CR Enterobacteriaceae isolates from normally sterile sites of patients aged <22 years from 4 freestanding pediatric medical centers were collected along with the associated clinical data. RESULTS The overall frequencies of ESC-R and CR isolates according to hospital over the 4-year study period ranged from 0.7% to 2.8%. Rates of ESC-R or CR Escherichia coli and Klebsiella pneumoniae varied according to hospital and ranged from 0.75 to 3.41 resistant isolates per 100 isolates (P < .001 for any differences). E coli accounted for 272 (77%) of the resistant isolates; however, a higher rate of resistance was observed in K pneumoniae isolates (1.78 vs 1.27 resistant isolates per 100 same-species isolates, respectively; P = .005). One-third of the infections caused by ESC-R or CR E coli were community-associated. In contrast, infections caused by ESC-R or CR K pneumoniae were more likely than those caused by resistant E coli to be healthcare- or hospital-associated and to occur in patients with an indwelling device (P ≤ .003 for any differences, multivariable logistic regression). Nonsusceptibility to 3 common non-β-lactam agents (ciprofloxacin, gentamicin, and trimethoprim-sulfamethoxazole) occurred in 23% of the ESC-R isolates. The sequence type 131-associated fumC/fimH-type 40-30 was the most prevalent sequence type among all resistant E coli isolates (30%), and the clonal group 258-associated allele tonB79 was the most prevalent allele among all resistant K pneumoniae isolates (10%). CONCLUSIONS The epidemiology of ESC-R and CR Enterobacteriaceae varied according to hospital and species (E coli vs K pneumoniae). Both community and hospital settings should be considered in future research addressing pediatric ESC-R Enterobacteriaceae infection.
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Affiliation(s)
- Danielle M Zerr
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington,Correspondence: D. M. Zerr, MD, MPH, Seattle Children’s Hospital, 4800 Sand Point Way, NE, Seattle, WA 98105 ()
| | - Scott J Weissman
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington
| | - Chuan Zhou
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington
| | - Matthew P Kronman
- Departments of Pediatrics University of Washington, Seattle,Seattle Children’s Research Institute, Washington
| | | | | | | | - Jeff Myers
- Seattle Children’s Research Institute, Washington
| | | | - Carey-Ann D Burnham
- Departments of Pathology & Immunology, Washington University School of Medicine, St. Louis, Missouri,Department of Pediatrics, St. Louis Children’s Hospital, Missouri
| | - Alexis Elward
- Department of Pediatrics, St. Louis Children’s Hospital, Missouri,Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri
| | - Jason Newland
- Department of Pediatrics, University of Missouri, Kansas City, Missouri,Children’s Mercy, Kansas City, Missouri
| | - Rangaraj Selvarangan
- Children’s Mercy, Kansas City, Missouri,Department of Pathology and Laboratory Medicine, University of Missouri, Kansas City, Missouri
| | - Kaede V Sullivan
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia,Children’s Hospital of Philadelphia, Pennsylvania
| | - Theoklis Zaoutis
- Children’s Hospital of Philadelphia, Pennsylvania,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Xuan Qin
- Seattle Children’s Research Institute, Washington,Departments of Laboratory Medicine, University of Washington, Seattle
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Pierce R, Elward A, Bryant K, Lessler J, Milstone AM. The Impact of active surveillance culture and decolonization programs on NICU MRSA transmission: A multicenter, mechanistic modeling approach. Open Forum Infect Dis 2017. [PMCID: PMC5631675 DOI: 10.1093/ofid/ofx162.108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Methicillin-resistant Staphylococcus aureus (MRSA) remains a major threat to patient safety in the neonatal intensive care unit (NICU). The aim of this study was to assess the effectiveness of active surveillance cultures (ASC) and decolonization in reducing MRSA transmission in the NICU. Methods Retrospective cohort data, including admission and discharge times, weekly surveillance culture results and mupirocin-administration information, were collected from three urban, tertiary care NICU in the US. The study period was 2007–2014, during which ASC and decolonization strategies were employed for MRSA control. We used Markov-Chain Monte Carlo methods to fit a probabilistic transmission model to the data. To account for the interval-censored nature of weekly surveillance screening, we used an integrated Bayesian framework to impute the date of conversion to MRSA-positive. We estimated the risk of MRSA acquisition associated with non-patient sources, undetected MRSA carriers, detected MRSA carriers on contact precautions, and MRSA carriers on contact precautions that also received decolonization treatment. Results Of the 12,677 neonates that were screened for MRSA colonization at study sites, 533 (4.2%) had a MRSA-positive surveillance culture. Neonates with undetected MRSA colonization were estimated to be the source of 67% (95% credible interval [CI]: 0.64–0.69) of MRSA acquisition. Compared with undetected MRSA carriers, detection and placement on contact precautions deceased the odds of transmission by 99.8% (odds ratio [OR]: 0.0016, 95% CI: 0.0000026–0.033), 99.6% (OR = 0.0036, 95% CI: 0.0000025–0.13), and 99.8% (OR = 0.0024; 95% CI: 0.00000042–0.043) at sites A, B, C, respectively. A 99.9% reduction in transmissibility was sustained among MRSA carriers who also received decolonization treatment (OR = 0.0014, 95% CI: 0.0000080–0.024). Conclusion In this multi-centered NICU cohort, ASC and decolonization programs were highly effective in reducing transmission risk from MRSA carriers. Detection of MRSA carriers and the use of contact precautions, alone, were associated with a near-complete reduction in transmission risk. Improving time-to-detection as well as prioritizing nonpatient reservoirs of MRSA could further reduce MRSA acquisition in the NICU. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Rebecca Pierce
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Alexis Elward
- Washington University School of Medicine, St. Louis, Missouri
| | | | - Justin Lessler
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Aaron M Milstone
- Pediatrics, The Johns Hopkins Medical Institutions, Baltimore, Maryland
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Vachharajani AJ, Vachharajani NA, Morris H, Niesen A, Elward A, Linck DA, Mathur AM. Reducing peripherally inserted central catheters in the neonatal intensive care unit. J Perinatol 2017; 37:409-413. [PMID: 28079867 DOI: 10.1038/jp.2016.243] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Revised: 11/11/2016] [Accepted: 11/15/2016] [Indexed: 11/09/2022]
Abstract
OBJECTIVE Our objective was to safely reduce the number of peripherally inserted central catheters (PICCs) inserted in infants with umbilical venous catheter using quality improvement methods. STUDY DESIGN In a tertiary neonatal intensive care unit, a questionnaire designed to prompt critical thinking around the decision to place a PICC, along with an updated standardized feeding guideline was introduced. PICC insertion in 86 infants with umbilical venous catheter (pre intervention) with birth weight 1000-1500 g were compared with 115 infants (post intervention) using Fisher's exact test. RESULTS PICC lines inserted after the intervention decreased by 37.5% (67/86; 77.9% vs 56/115; 48.7%; P<0.001). The proportion of central line-associated blood stream infection were 2.49 vs 2.82/1000 umbilical venous catheter days; P=0.91 in the two epochs, respectively. CONCLUSION Quality improvement methodology was successful in significantly reducing the number of PICCs inserted without an increase in central line-associated blood stream infection.
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Affiliation(s)
- A J Vachharajani
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - N A Vachharajani
- Department of Surgery, Washington University in St. Louis, St. Louis, MO, USA
| | - H Morris
- St Louis Children's Hospital, St. Louis, MO, USA
| | - A Niesen
- St Louis Children's Hospital, St. Louis, MO, USA
| | - A Elward
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
| | - D A Linck
- St Louis Children's Hospital, St. Louis, MO, USA
| | - A M Mathur
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO, USA
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Adler A, Qin X, Weissman S, Kronman M, Miles-Jay A, Burnham CAD, Elward A, Newland J, Selvarangan R, Sullivan KV, Zaoutis T, Zerr D. Molecular and Clinical Epidemiology of Extended-Spectrum Cephalosporin-Resistant Infections Caused by Enterobacteriaceae Species Other Than Escherichia coli and Klebsiella pneumoniae. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Amanda Adler
- Seattle Children's Research Institute, Seattle, Washington
| | - Xuan Qin
- Seattle Children's Research Institute, Seattle, Washington
- Laboratory Medicine, University of Washington, Seattle, Washington
| | - Scott Weissman
- Seattle Children's Research Institute, Seattle, Washington
- Pediatrics, University of Washington, Seattle, Washington
| | - Matthew Kronman
- Seattle Children's Research Institute, Seattle, Washington
- Pediatrics, University of Washington, Seattle, Washington
| | - Arianna Miles-Jay
- Seattle Children's Research Institute, Seattle, Washington
- Epidemiology, University of Washington, Seattle, Washington
| | - Carey-Ann D. Burnham
- Pathology and Immunology, Washington University, St. Louis, Missouri
- St. Louis Children's Hospital, St. Louis, Missouri
| | - Alexis Elward
- St. Louis Children's Hospital, St. Louis, Missouri
- Pediatrics, Washington University, St Louis, Missouri
| | - Jason Newland
- Children's Mercy Hospital and Clinics, Kansas City, Missouri
- Pediatrics, University of Missouri-Kansas City, Kansas City, Missouri
| | - Rangaraj Selvarangan
- Children's Mercy Hospital and Clinics, Kansas City, Missouri
- Pathology and Laboratory Medicine, University of Missouri, Kansas City, Kansas City, Missouri
| | - Kaede V. Sullivan
- Pathology and Laboratory Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Theoklis Zaoutis
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
- Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Danielle Zerr
- Seattle Children's Research Institute, Seattle, Washington
- Pediatrics, University of Washington, Seattle, Washington
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Pierce R, Bryant K, Elward A, Lessler J, Milstone AM. Gram-Negative and Fungal Infections Following Mupirocin-Based Methicillin-Resistant Staphylococcus aureus Decolonization in Neonates. Open Forum Infect Dis 2016. [DOI: 10.1093/ofid/ofw172.557] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Rebecca Pierce
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Kristina Bryant
- Pediatrics, University of Louisville School of Medicine, Louisville, Kentucky
| | - Alexis Elward
- Pediatrics, Washington University, St. Louis, Missouri
| | - Justin Lessler
- Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Elward A, Grim A, Schroeder P, Kieffer P, Sellenriek P, Ferrett R, Adams HC, Phillips V, Bartow R, Mays D, Lawrence S, Seed P, Holzmann-Pazgal G, Polish L, Leet T, Fraser V. Outbreak ofSalmonella javianaInfection at a Children's Hospital. Infect Control Hosp Epidemiol 2016; 27:586-92. [PMID: 16755478 DOI: 10.1086/506483] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2004] [Accepted: 03/21/2005] [Indexed: 11/03/2022]
Abstract
Objective.To determine the source of an outbreak of Salmonella javiana infection.Design.Case-control study.Participants.A total of 101 culture-confirmed cases and 540 epidemiologically linked cases were detected between May 26, 2003, and June 16, 2003, in hospital employees, patients, and visitors. Asymptomatic employees who had eaten in the hospital cafeteria between May 30 and June 4, 2003, and had had no gastroenteritis symptoms after May 1, 2003, were chosen as control subjects.Setting.A 235-bed academic tertiary care children's hospital.Results.Isolates from 100 of 101 culture-confirmed cases had identical pulsed-field gel electrophoresis patterns. A foodhandler with symptoms of gastroenteritis was the presumed index subject. In multivariate analysis, case subjects were more likely than control subjects to have consumed items from the salad bar (adjusted odds ratio [aOR], 5.3; 95% confidence interval [CI], 2.3-12.1) and to have eaten in the cafeteria on May 28 (aOR, 9.4; 95% CI, 1.8-49.5), May 30 (aOR, 3.6; 95% CI, 1.0-12.7), and/or June 3 (aOR, 4.0; 95% CI, 1.4-11.3).Conclusions.Foodhandlers who worked while they had symptoms of gastroenteritis likely contributed to the propagation of the outbreak. This large outbreak was rapidly controlled through the use of an incident command center.
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Affiliation(s)
- Alexis Elward
- Division of Infectious Diseases, Department of Pediatrics, St. Louis, MO, USA.
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Adler A, Miles-Jay A, Weissman S, Qin X, Kronman M, Berry J, Rayar J, Myers J, Burnham CAD, Elward A, Newland J, Selvarangan R, Sullivan KV, Zaoutis T, Zerr D. The Clonal Distribution of Extended-Spectrum Cephalosporin-Resistant and Susceptible Extraintestinal E. coli Isolates in a Pediatric Setting. Open Forum Infect Dis 2015. [DOI: 10.1093/ofid/ofv133.1337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Rodriguez M, Nelson M, Kelly JE, Elward A, Morley SC. Successful Use of Temocillin as Salvage Therapy for Cervical Osteomyelitis Secondary to Multidrug-Resistant Burkholderia cepacia. J Pediatric Infect Dis Soc 2014; 3:77-80. [PMID: 26624908 DOI: 10.1093/jpids/pis110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 10/16/2012] [Indexed: 11/12/2022]
Abstract
Infection with multidrug resistant Burkholderia cepacia presents a therapeutic challenge in patients with cystic fibrosis. In this study, we present a case of progressive cervical osteomyelitis secondary to B cepacia that failed surgical drainage and extended therapy with meropenem, piperacillin-tazobactam, doxycycline, and aminoglycosides. Temocillin (Negaban) was successfully used to clear the infection.
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Affiliation(s)
- Marcela Rodriguez
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield; and Departments of
| | | | - James E Kelly
- Radiology, Washington University School of Medicine, St Louis, Missouri
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Milstone AM, Elward A, Song X, Zerr DM, Orscheln R, Speck K, Obeng D, Reich NG, Coffin SE, Perl TM. Daily chlorhexidine bathing to reduce bacteraemia in critically ill children: a multicentre, cluster-randomised, crossover trial. Lancet 2013; 381:1099-106. [PMID: 23363666 PMCID: PMC4128170 DOI: 10.1016/s0140-6736(12)61687-0] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Bacteraemia is an important cause of morbidity and mortality in critically ill children. Our objective was to assess whether daily bathing in chlorhexidine gluconate (CHG) compared with standard bathing practices would reduce bacteraemia in critically ill children. METHODS In an unmasked, cluster-randomised, two-period crossover trial, ten paediatric intensive-care units at five hospitals in the USA were randomly assigned a daily bathing routine for admitted patients older than 2 months, either standard bathing practices or using a cloth impregnated with 2% CHG, for a 6-month period. Units switched to the alternative bathing method for a second 6-month period. 6482 admissions were screened for eligibility. The primary outcome was an episode of bacteraemia. We did intention-to-treat (ITT) and per-protocol (PP) analyses. This study is registered with ClinicalTrials.gov (identifier NCT00549393). FINDINGS 1521 admitted patients were excluded because their length of stay was less than 2 days, and 14 refused to participate. 4947 admissions were eligible for analysis. In the ITT population, a non-significant reduction in incidence of bacteraemia was noted with CHG bathing (3·52 per 1000 days, 95% CI 2·64-4·61) compared with standard practices (4·93 per 1000 days, 3·91-6·15; adjusted incidence rate ratio [aIRR] 0·71, 95% CI 0·42-1·20). In the PP population, incidence of bacteraemia was lower in patients receiving CHG bathing (3·28 per 1000 days, 2·27-4·58) compared with standard practices (4·93 per 1000 days, 3·91-6·15; aIRR 0·64, 0·42-0·98). No serious study-related adverse events were recorded, and the incidence of CHG-associated skin reactions was 1·2 per 1000 days (95% CI 0·60-2·02). INTERPRETATION Critically ill children receiving daily CHG bathing had a lower incidence of bacteraemia compared with those receiving a standard bathing routine. Furthermore, the treatment was well tolerated. FUNDING Sage Products, US National Institutes of Health.
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Affiliation(s)
- Aaron M Milstone
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA.
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Abstract
We conducted a 2-sample pharmacokinetic study of oseltamivir in 12 premature infants. Oseltamivir 1 mg/kg/dose twice daily in infants <38 weeks postmenstrual age (n=8) resulted in oseltamivir carboxylate exposure comparable to previously published pediatric data, which helps prospectively validate this regimen. Oseltamivir 3 mg/kg/dose once daily in premature infants >38 weeks postmenstrual age (born prematurely but chronologically past term, n=4) resulted in similar oseltamivir and oseltamivir carboxylate exposure. Although these results suggest persistence of immature renal function in this subgroup, further pharmacokinetic/pharmacodynamic description is required to confirm the appropriateness of this regimen.
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Milstone AM, Song X, Coffin S, Elward A. Identification and eradication of methicillin-resistant Staphylococcus aureus colonization in the neonatal intensive care unit: results of a national survey. Infect Control Hosp Epidemiol 2010; 31:766-8. [PMID: 20470034 DOI: 10.1086/653615] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
We surveyed members of the Society for Healthcare Epidemiology of America to assess current practice with regard to identifying and eradicating methicillin-resistant Staphylococcus aureus (MRSA) colonization in the neonatal intensive care unit (NICU). Although most respondents (86%) screened patients for MRSA colonization, variation existed in the number of anatomic sites sampled and in the use of culture at NICU admission, empirical institution of isolation precautions, and MRSA decolonization therapy. Evidence-based prevention strategies for MRSA transmission and infection are needed.
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Affiliation(s)
- Aaron M Milstone
- Department of Pediatrics, Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland 21287, USA.
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White NA, Elward A, Moga KS, Ward DL, Sampson DM. Use of web-based data collection to evaluate analgesic administration and the decision for surgery in horses with colic. Equine Vet J 2010; 37:347-50. [PMID: 16028625 DOI: 10.2746/0425164054529391] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
REASONS FOR PERFORMING STUDY There is no current veterinary information with regard to data entry on a website. We therefore completed a prospective study on use of analgesics in relation to the need for abdominal surgery using a web-based survey instrument. OBJECTIVES To establish an internet-based data entry system that could be used to record prospective data on horses with colic. HYPOTHESIS Failure of horses to respond to the initial administration of an analgesic is an indicator of the need for abdominal surgery. METHODS A survey was developed to determine if the response to administration of an analgesic during a veterinarian's first examination of a horse with colic was related to the need for surgery. Veterinarians were contacted via AAEP and ECN listservs requesting submission of cases using a log-in system at a data entry website. The survey was completed by submission of a data entry page. RESULTS Twenty-seven veterinarians submitted details of 119 cases of colic, 28 of which required surgery. The need for surgery was significantly associated with moderate or severe pain observed during the first examination compared to mild or no pain, and with constant pain or return of pain after administration of one or more analgesics and the need to administer a second analgesic treatment. Abnormal findings on rectal examination were not associated with the need for surgery, whereas total absence or decrease of intestinal sounds was significantly related to the odds that surgery was needed. The web-based data collection was successful in collecting all data points on the survey for each case. CONCLUSIONS This study reinforced veterinarians' use of response to therapy as a way to determine the need for abdominal surgery. POTENTIAL RELEVANCE When a specific diagnosis has not been made, lack of response or resumption of colic after analgesic administration should be considered as an indicator of the need for surgery. Web-based collection of data allows veterinary practitioners to participate in clinical research by providing prospective data.
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Affiliation(s)
- N A White
- Marion duPont Scott Equine Medical Center, PO Box 1938, Leesburg, Virginia 20177, USA
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18
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Blossom DB, Kallen AJ, Patel PR, Elward A, Robinson L, Gao G, Langer R, Perkins KM, Jaeger JL, Kurkjian KM, Jones M, Schillie SF, Shehab N, Ketterer D, Venkataraman G, Kishimoto TK, Shriver Z, McMahon AW, Austen KF, Kozlowski S, Srinivasan A, Turabelidze G, Gould CV, Arduino MJ, Sasisekharan R. Outbreak of adverse reactions associated with contaminated heparin. N Engl J Med 2008; 359:2674-84. [PMID: 19052120 PMCID: PMC3810025 DOI: 10.1056/nejmoa0806450] [Citation(s) in RCA: 187] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND In January 2008, the Centers for Disease Control and Prevention began a nationwide investigation of severe adverse reactions that were first detected in a single hemodialysis facility. Preliminary findings suggested that heparin was a possible cause of the reactions. METHODS Information on clinical manifestations and on exposure was collected for patients who had signs and symptoms that were consistent with an allergic-type reaction after November 1, 2007. Twenty-one dialysis facilities that reported reactions and 23 facilities that reported no reactions were included in a case-control study to identify facility-level risk factors. Unopened heparin vials from facilities that reported reactions were tested for contaminants. RESULTS A total of 152 adverse reactions associated with heparin were identified in 113 patients from 13 states from November 19, 2007, through January 31, 2008. The use of heparin manufactured by Baxter Healthcare was the factor most strongly associated with reactions (present in 100.0% of case facilities vs. 4.3% of control facilities, P<0.001). Vials of heparin manufactured by Baxter from facilities that reported reactions contained a contaminant identified as oversulfated chondroitin sulfate (OSCS). Adverse reactions to the OSCS-contaminated heparin were often characterized by hypotension, nausea, and shortness of breath occurring within 30 minutes after administration. Of 130 reactions for which information on the heparin lot was available, 128 (98.5%) occurred in a facility that had OSCS-contaminated heparin on the premises. Of 54 reactions for which the lot number of administered heparin was known, 52 (96.3%) occurred after the administration of OSCS-contaminated heparin. CONCLUSIONS Heparin contaminated with OSCS was epidemiologically linked to adverse reactions in this nationwide outbreak. The reported clinical features of many of the cases further support the conclusion that contamination of heparin with OSCS was the cause of the outbreak.
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Affiliation(s)
- David B Blossom
- Epidemic Intelligence Service Program, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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Fritz SA, Garbutt J, Elward A, Shannon W, Storch GA. Prevalence of and risk factors for community-acquired methicillin-resistant and methicillin-sensitive staphylococcus aureus colonization in children seen in a practice-based research network. Pediatrics 2008; 121:1090-8. [PMID: 18519477 DOI: 10.1542/peds.2007-2104] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE We sought to define the prevalence of and risk factors for methicillin-resistant Staphylococcus aureus nasal colonization in the St Louis pediatric population. METHODS Children from birth to 18 years of age presenting for sick and well visits were recruited from pediatric practices affiliated with a practice-based research network. Nasal swabs were obtained, and a questionnaire was administered. RESULTS We enrolled 1300 participants from 11 practices. The prevalence of methicillin-resistant S aureus nasal colonization varied according to practice, from 0% to 9% (mean: 2.6%). The estimated population prevalence of methicillin-resistant S aureus nasal colonization for the 2 main counties of the St Louis metropolitan area was 2.4%. Of the 32 methicillin-resistant S aureus isolates, 9 (28%) were health care-associated types and 21 (66%) were community-acquired types. A significantly greater number of children with community-acquired methicillin-resistant S aureus were black and were enrolled in Medicaid, in comparison with children colonized with health care-associated methicillin-resistant S aureus. Children with both types of methicillin-resistant S aureus colonization had increased contact with health care, compared with children without colonization. Methicillin-sensitive S aureus nasal colonization ranged from 9% to 31% among practices (mean: 24%). The estimated population prevalence of methicillin-sensitive S aureus was 24.6%. Risk factors associated with methicillin-sensitive S aureus colonization included pet ownership, fingernail biting, and sports participation. CONCLUSIONS Methicillin-resistant S aureus colonization is widespread among children in our community and includes strains associated with health care-associated and community-acquired infections.
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Affiliation(s)
- Stephanie A Fritz
- Department of Pediatrics, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8116, St Louis, MO 63110, USA
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20
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Abstract
Ventilator-associated pneumonia (VAP) is the second most common hospital-acquired infection among pediatric intensive care unit (ICU) patients. Empiric therapy for VAP accounts for approximately 50% of antibiotic use in pediatric ICUs. VAP is associated with an excess of 3 days of mechanical ventilation among pediatric cardiothoracic surgery patients. The attributable mortality and excess length of ICU stay for patients with VAP have not been defined in matched case control studies. VAP is associated with an estimated $30,000 in attributable cost. Surveillance for VAP is complex and usually performed using clinical definitions established by the CDC. Invasive testing via bronchoalveolar lavage increases the sensitivity and specificity of the diagnosis. The pathogenesis in children is poorly understood, but several prospective cohort studies suggest that aspiration and immunodeficiency are risk factors. Educational interventions and efforts to improve adherence to hand hygiene for children have been associated with decreased VAP rates. Studies of antibiotic cycling in pediatric patients have not consistently shown this measure to prevent colonization with multidrug-resistant gram-negative rods. More consistent and precise approaches to the diagnosis of pediatric VAP are needed to better define the attributable morbidity and mortality, pathophysiology, and appropriate interventions to prevent this disease.
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Affiliation(s)
- Elizabeth Foglia
- Division of Infectious Diseases, Department of Pediatrics, Washington University School of Medicine, Box 8116, St. Louis Children's Hospital, One Children's Place, St. Louis, MO 63110, USA
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