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Wattier RL, Bucayu RFT, Boge CLK, Ross RK, Yildirim I, Zaoutis TE, Palazzi DL, Vora SB, Castagnola E, Avilés-Robles M, Danziger-Isakov L, Tribble AC, Sharma TS, Arrieta AC, Maron G, Berman DM, Yin DE, Sung L, Green M, Roilides E, Belani K, Romero J, Soler-Palacin P, López-Medina E, Nolt D, Bin Hussain IZ, Muller WJ, Hauger SB, Halasa N, Dulek D, Pong A, Gonzalez BE, Abzug MJ, Carlesse F, Huppler AR, Rajan S, Aftandilian C, Ardura MI, Chakrabarti A, Hanisch B, Salvatore CM, Klingspor L, Knackstedt ED, Lutsar I, Santolaya ME, Shuster S, Johnson SK, Steinbach WJ, Fisher BT. Adjunctive Diagnostic Studies Completed Following Detection of Candidemia in Children: Secondary Analysis of Observed Practice From a Multicenter Cohort Study Conducted by the Pediatric Fungal Network. J Pediatric Infect Dis Soc 2023; 12:487-495. [PMID: 37589394 PMCID: PMC10533205 DOI: 10.1093/jpids/piad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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] [Received: 05/08/2023] [Accepted: 08/11/2023] [Indexed: 08/18/2023]
Abstract
BACKGROUND Adjunctive diagnostic studies (aDS) are recommended to identify occult dissemination in patients with candidemia. Patterns of evaluation with aDS across pediatric settings are unknown. METHODS Candidemia episodes were included in a secondary analysis of a multicenter comparative effectiveness study that prospectively enrolled participants age 120 days to 17 years with invasive candidiasis (predominantly candidemia) from 2014 to 2017. Ophthalmologic examination (OE), abdominal imaging (AbdImg), echocardiogram, neuroimaging, and lumbar puncture (LP) were performed per clinician discretion. Adjunctive diagnostic studies performance and positive results were determined per episode, within 30 days from candidemia onset. Associations of aDS performance with episode characteristics were evaluated via mixed-effects logistic regression. RESULTS In 662 pediatric candidemia episodes, 490 (74%) underwent AbdImg, 450 (68%) OE, 426 (64%) echocardiogram, 160 (24%) neuroimaging, and 76 (11%) LP; performance of each aDS per episode varied across sites up to 16-fold. Longer durations of candidemia were associated with undergoing OE, AbdImg, and echocardiogram. Immunocompromised status (58% of episodes) was associated with undergoing AbdImg (adjusted odds ratio [aOR] 2.38; 95% confidence intervals [95% CI] 1.51-3.74). Intensive care at candidemia onset (30% of episodes) was associated with undergoing echocardiogram (aOR 2.42; 95% CI 1.51-3.88). Among evaluated episodes, positive OE was reported in 15 (3%), AbdImg in 30 (6%), echocardiogram in 14 (3%), neuroimaging in 9 (6%), and LP in 3 (4%). CONCLUSIONS Our findings show heterogeneity in practice, with some clinicians performing aDS selectively, potentially influenced by clinical factors. The low frequency of positive results suggests that targeted application of aDS is warranted.
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Affiliation(s)
- Rachel L Wattier
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Robert F T Bucayu
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Craig L K Boge
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rachael K Ross
- Department of Epidemiology, University of North Carolina Chapel Hill, Chapel Hill, North Carolina, USA
| | - Inci Yildirim
- Department of Pediatrics, Yale University School of Medicine, Connecticut, USA
- Yale Institute for Global Health, Yale University, New Haven, Connecticut, USA
- Yale Center for Infection and Immunity, New Haven, Connecticut, USA
- Department of Epidemiology, Yale School of Public Health, New Haven, Connecticut, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Debra L Palazzi
- Department of Pediatrics, Baylor College of Medicine and Texas Children’s Hospital, Houston, Texas, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington, Division of Infectious Diseases, Seattle Children’s Hospital, Seattle, Washington, USA
| | - Elio Castagnola
- Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Martha Avilés-Robles
- Department of Infectious Diseases, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Alison C Tribble
- Division of Infectious Diseases, Department of Pediatrics, University of Michigan and C.S. Mott Children’s Hospital, Ann Arbor, Michigan, USA
| | - Tanvi S Sharma
- Division of Infectious Diseases, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Antonio C Arrieta
- Department of Infectious Diseases, Children’s Hospital of Orange County, Orange, California, USA
- Department of Pediatrics, University of California Irvine, Irvine, California, USA
| | - Gabriela Maron
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
| | - David M Berman
- Division of Pediatric Infectious Diseases, Johns Hopkins All Children’s Hospital, St. Petersburg, Florida, USA
| | - Dwight E Yin
- Department of Pediatrics, Children’s Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Lillian Sung
- Division of Haematology/Oncology, The Hospital for Sick Children, Toronto, Canada
| | - Michael Green
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Emmanuel Roilides
- Infectious Diseases Unit, 3rd Department of Pediatrics, Aristotle University and Hippokration Hospital, Thessaloniki, Greece
| | - Kiran Belani
- Pediatric Infectious Diseases, Children’s Minnesota, Minneapolis, Minnesota, USA
| | - José Romero
- National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d’Hebron, Barcelona, Catalonia, Spain
| | - Eduardo López-Medina
- Centro de Estudios en Infectología Pediátrica, Clínica Imbanaco Grupo Quirónsalud and Universidad del Valle, Cali, Colombia
| | - Dawn Nolt
- Department of Pediatrics, Oregon Health and Science University and Doernbecher Children’s Hospital, Portland, Oregon, USA
| | - Ibrahim Zaid Bin Hussain
- Pediatric Infectious Diseases, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - William J Muller
- Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago and Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Sarmistha B Hauger
- Department of Pediatrics, University of Texas at Austin and Dell Children’s Medical Center, Austin, Texas, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Daniel Dulek
- Department of Pediatrics, Vanderbilt University Medical Center and Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee, USA
| | - Alice Pong
- Department of Pediatrics, University of California San Diego and Rady Children’s Hospital San Diego, San Diego, California, USA
| | - Blanca E Gonzalez
- Center for Pediatric Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Mark J Abzug
- Department of Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Fabianne Carlesse
- Instituto de Oncologia Pediatrica–IOP/GRAACC-UNIFESP, São Paulo, Brazil
| | - Anna R Huppler
- Department of Pediatrics, Medical College of Wisconsin and Children’s Wisconsin, Milwaukee, Wisconsin, USA
| | - Sujatha Rajan
- Division of Pediatric Infectious Diseases, Cohen Children’s Medical Center, New Hyde Park, New York, USA
| | - Catherine Aftandilian
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Monica I Ardura
- Division of Infectious Diseases and Host Defense Program, Department of Pediatrics, Nationwide Children’s Hospital and The Ohio State University, Columbus, Ohio, USA
| | | | - Benjamin Hanisch
- Pediatric Infectious Diseases, Children’s National Health System, Washington, District of Columbia, USA
| | - Christine M Salvatore
- Division of Pediatric Infectious Diseases, Weill Cornell Medicine and Komansky Children’s Hospital, New York, New York, USA
| | - Lena Klingspor
- Department of Laboratory Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Irja Lutsar
- Department of Microbiology, University of Tartu, Tartu, Estonia
| | - Maria E Santolaya
- Hospital Dr. Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - Sydney Shuster
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sarah K Johnson
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - William J Steinbach
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Brian T Fisher
- Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Nolt D, Moore S, Yan AC, Melnick L. Head Lice. Pediatrics 2022; 150:189566. [PMID: 36156158 DOI: 10.1542/peds.2022-059282] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 11/24/2022] Open
Abstract
Head lice infestation is associated with limited morbidity but causes a high level of anxiety among caregivers of school-aged children and adolescents. Since the 2015 clinical report on head lice was published by the American Academy of Pediatrics, new medications have been approved, and an algorithm for management of affected patients is included. This revised clinical report clarifies current diagnosis and treatment protocols.
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Affiliation(s)
- Dawn Nolt
- Division of Infectious Diseases, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Scot Moore
- Department of Pediatrics, Indiana University Health, Bloomington, Indiana
| | - Albert C Yan
- Section of Dermatology, Children's Hospital of Philadelphia; Departments of Pediatrics and Dermatology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Laura Melnick
- Department of Dermatology, Weill Cornell Medicine, New York, New York
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Abstract
The purpose of this report is to educate providers about the risk of infectious diseases associated with emerging alternative peripartum and neonatal practices. This report will provide information pediatricians may use to counsel families before birth and to appropriately evaluate and treat neonates who have been exposed to these practices.
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Affiliation(s)
- Dawn Nolt
- Division of Infectious Diseases, Department of Pediatrics, Oregon Health and Science University, Portland, Oregon,Address correspondence to Dawn Nolt, MD, MPH.
| | - Sean T. O’Leary
- Divisions of Infectious Diseases and General Academic Pediatrics, Department of Pediatrics, University of Colorado Denver Anschutz Medical Campus/Children’s Hospital Colorado, Aurora, Colorado
| | - Susan W. Aucott
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
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Abstract
Tuberculosis (TB) remains an important problem among children in the United States and throughout the world. There is no diagnostic reference standard for latent tuberculosis infection (also referred to as tuberculosis infection [TBI]). The tuberculin skin test (TST) has many limitations, including difficulty in administration and interpretation, the need for a return visit by the patient, and false-positive results caused by cross-reaction with Mycobacterium bovis-bacille Calmette-Guerin vaccines and many nontuberculous mycobacteria. Interferon-gamma release assays (IGRAs) are blood tests that use antigens specific for M tuberculosis; as a result, IGRAs yield fewer false-positive results than the TST. Both IGRAs and the TST have reduced sensitivity in immunocompromised children, including children with severe TB disease. Both methods have high positive predictive value when applied to children with risk factors for TBI, especially recent contact with a person who has TB disease. The advantages of using IGRAs and diminished experience with the placement and interpretation of the TST favor expanded use of IGRAs in children in the United States. There are now several effective and safe regimens for the treatment of TBI in children. For improved adherence to therapy, the 3 rifamycin-based regimens are preferred because of their short duration. Daily isoniazid can be used if there is intolerance or drug interactions with rifamycins. A TB specialist should be involved when there are questions regarding testing interpretation, selection of an appropriate treatment regimen, or management of adverse effects.
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Affiliation(s)
- Dawn Nolt
- Department of Pediatrics, Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon
| | - Jeffrey R Starke
- Department of Pediatrics, Division of Infectious Diseases, Baylor College of Medicine, Houston, Texas
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5
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Fisher BT, Zaoutis TE, Xiao R, Wattier RL, Castagnola E, Pana ZD, Fullenkamp A, Boge CLK, Ross RK, Yildirim I, Palazzi DL, Danziger-Isakov L, Vora SB, Arrieta A, Yin DE, Avilés-Robles M, Sharma T, Tribble AC, Maron G, Berman D, Green M, Sung L, Romero J, Hauger SB, Roilides E, Belani K, Nolt D, Soler-Palacin P, López-Medina E, Muller WJ, Halasa N, Dulek D, Hussain IZB, Pong A, Hoffman J, Rajan S, Gonzalez BE, Hanisch B, Aftandilian C, Carlesse F, Abzug MJ, Huppler AR, Salvatore CM, Ardura MI, Chakrabarti A, Santolaya ME, Localio AR, Steinbach WJ. Comparative Effectiveness of Echinocandins vs Triazoles or Amphotericin B Formulations as Initial Directed Therapy for Invasive Candidiasis in Children and Adolescents. J Pediatric Infect Dis Soc 2021:piab024. [PMID: 34374424 DOI: 10.1093/jpids/piab024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 08/09/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND Invasive candidiasis is the most common invasive fungal disease in children and adolescents, but there are limited pediatric-specific antifungal effectiveness data. We compared the effectiveness of echinocandins to triazoles or amphotericin B formulations (triazole/amphotericin B) as initial directed therapy for invasive candidiasis. METHODS This multinational observational cohort study enrolled patients aged >120 days and <18 years with proven invasive candidiasis from January 1, 2014, to November 28, 2017, at 43 International Pediatric Fungal Network sites. Primary exposure was initial directed therapy administered at the time qualifying culture became positive for yeast. Exposure groups were categorized by receipt of an echinocandin vs receipt of triazole/amphotericin B. Primary outcome was global response at 14 days following invasive candidiasis onset, adjudicated by a centralized data review committee. Stratified Mantel-Haenszel analyses estimated risk difference between exposure groups. RESULTS Seven-hundred and fifty invasive candidiasis episodes were identified. After exclusions, 541 participants (235 in the echinocandin group and 306 in the triazole/amphotericin B group) remained. Crude failure rates at 14 days for echinocandin and triazole/amphotericin B groups were 9.8% (95% confidence intervals [CI]: 6.0% to 13.6%) and 13.1% (95% CI: 9.3% to 16.8%), respectively. The adjusted 14-day risk difference between echinocandin and triazole/amphotericin B groups was -7.1% points (95% CI: -13.1% to -2.4%), favoring echinocandins. The risk difference was -0.4% (95% CI: -7.5% to 6.7%) at 30 days. CONCLUSIONS In children with invasive candidiasis, initial directed therapy with an echinocandin was associated with reduced failure rate at 14 days but not 30 days. These results may support echinocandins as initial directed therapy for invasive candidiasis in children and adolescents. CLINICAL TRIALS REGISTRATION NCT01869829.
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Affiliation(s)
- Brian T Fisher
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Theoklis E Zaoutis
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Rui Xiao
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - Rachel L Wattier
- Department of Pediatrics, Division of Infectious Diseases and Global Health, University of California-San Francisco, San Francisco, California, USA
| | - Elio Castagnola
- Infectious Diseases Unit, Department of Pediatrics, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Zoi Dorothea Pana
- Infectious Disease Unit, 3rd Department of Pediatrics, Aristotle University and Hippokration Hospital, Thessaloniki, Greece
| | - Allison Fullenkamp
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Craig L K Boge
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Rachael K Ross
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Epidemiology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Inci Yildirim
- Division of Infectious Diseases, Department of Pediatrics Emory University, Atlanta, Georgia, USA
| | - Debra L Palazzi
- Section of Infectious Diseases, Department of Pediatrics, Baylor College of Medicine and Texas Children's Hospital, Houston, Texas, USA
| | - Lara Danziger-Isakov
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Surabhi B Vora
- Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington, USA
| | - Antonio Arrieta
- Division of Pediatric Infectious Diseases, Children's Hospital - Orange County, Orange, California, US
| | - Dwight E Yin
- Division of Infectious Diseases, Department of Pediatrics, Children's Mercy and University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Martha Avilés-Robles
- Infectious Diseases Department, Hospital Infantil de México Federico Gómez, Mexico City, Mexico
| | - Tanvi Sharma
- Division of Infectious Diseases Children's Hospital Boston, Boston, Massachusetts, USA
| | - Alison C Tribble
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Division of Infectious Diseases, Department of Pediatrics, University of Michigan and CS Mott Children's Hospital, Ann Arbor, Michigan, USA
| | - Gabriela Maron
- Department of Infectious Diseases St. Jude Children's Hospital, Memphis, Tennessee, USA
| | - David Berman
- Division of Pediatric Infectious Diseases, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA
| | - Michael Green
- Division of Infectious Diseases, Department of Pediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, USA
| | - Lillian Sung
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - José Romero
- Division of Pediatric Infectious Diseases, Arkansas Children's Hospital Research Institute, Little Rock, Arkansas, USA
| | - Sarmistha B Hauger
- Pediatric Infectious Diseases, Dell Children's Medical Center, Austin, Texas, USA
| | - Emmanuel Roilides
- Infectious Disease Unit, 3rd Department of Pediatrics, Aristotle University and Hippokration Hospital, Thessaloniki, Greece
| | - Kiran Belani
- Pediatric Infectious Diseases, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Dawn Nolt
- Division of Pediatric Infectious Diseases, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon, USA
| | - Pere Soler-Palacin
- Pediatric Infectious Diseases and Immunodeficiencies Unit, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Eduardo López-Medina
- Centro de Estudios en Infectología Pediátrica and Universidad del Valle, Cali Colombia
| | - William J Muller
- Division of Infectious Diseases, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Natasha Halasa
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, US
| | - Daniel Dulek
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, US
| | - Ibrahim Zaid Bin Hussain
- Pediatric Infectious Diseases King Faisal Specialist Hospital & Research Center, Riyadh, Saudi Arabia
| | - Alice Pong
- Department of Pediatrics, University of California San Diego, San Diego, California, USA
| | - Jill Hoffman
- Pediatric Infectious Diseases, University of California Los Angeles, Los Angeles, California, USA
| | - Sujatha Rajan
- Division of Pediatric Infectious Diseases, Cohen Children's Medical Center, New Hyde Park, New York, USA
| | - Blanca E Gonzalez
- Center for Pediatric Infectious Diseases, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Benjamin Hanisch
- Pediatric Infectious Diseases, Children's National Health System, Washington, DC, USA
| | - Catherine Aftandilian
- Pediatric Hematology/Oncology, Stanford University School of Medicine, Palo Alto, California, USA
| | - Fabianne Carlesse
- Instituto de Oncologia Pediatrica-IOP/GRAACC-UNIFESP, Sao Paulo, Brazil
| | - Mark J Abzug
- Division of Pediatric Infectious Diseases, University of Colorado School of Medicine and Children's Hospital Colorado, Aurora, Colorado, USA
| | - Anna R Huppler
- Department of Pediatrics, Division of Infectious Diseases, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Christine M Salvatore
- Department of Pediatrics, Division of Pediatric Infectious Diseases Weill Cornell Medicine, New York, New York, USA
| | - Monica I Ardura
- Pediatric Infectious Diseases and Host Defense, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio, USA
| | - Arunaloke Chakrabarti
- Department of Medical Microbiology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Maria E Santolaya
- Hospital Dr. Luis Calvo Mackenna, Facultad de Medicina, Universidad de Chile, Santiago, Chile
| | - A Russell Localio
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia Pennsylvania, USA
| | - William J Steinbach
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA
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Nolt D. Granulomas and Guidelines: The Search for Tuberculosis During Tumor Necrosis Factor-α Inhibition. Clin Infect Dis 2021; 71:2570-2571. [PMID: 31855246 DOI: 10.1093/cid/ciz1139] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Accepted: 11/19/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Dawn Nolt
- Division of Pediatric Infectious Diseases, Oregon Health & Science University, Portland, Oregon, USA
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Abstract
Encephalitis is defined as altered mental status for more than 24 hours accompanied by 2 or more findings concerning for inflammation of the brain parenchyma: fever, seizures or other focal neurologic disorders, cerebrospinal fluid pleocytosis, and abnormal neuroimaging and electroencephalographic findings. Herpes simplex virus causes the most severe form of virus-induced encephalitis; the early administration of acyclovir can improve the prognosis of this disease. The rising interest in autoimmune causes of encephalitis, most notably anti-N-methyl-d-aspartate receptor, should prompt the clinician to consider immunomodulatory treatments, which may improve outcomes. A broad testing panel may be necessary to detect the etiologic agent; a few published pediatric cases suggest that infectious and autoimmune causes may occur concurrently in the same patient with encephalitis. More than 40% of children diagnosed as having encephalitis will not return to their previous level of neurologic function after resolution of their disease, although outcomes are highly variable depending on the etiologic agent.
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Affiliation(s)
| | | | - Dawn Nolt
- Division of Pediatric Infectious Diseases, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
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Ray MJ, McCracken CM, Tucker KJ, Yu D, Underwood M, Wu E, Kastelic K, Nolt D, McGregor JC. 225. Evaluating Appropriateness of Antibiotic Prescribing in Pediatric Inpatients. Open Forum Infect Dis 2020. [PMCID: PMC7778239 DOI: 10.1093/ofid/ofaa439.269] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Antibiotic appropriateness is the gold standard for informing antimicrobial stewardship efforts to optimize prescribing. The objectives of this study were to evaluate appropriateness of antibiotics for resistant gram-positive infections in pediatric inpatients and identify factors associated with inappropriate prescribing. Methods We included pediatric inpatients between July 2017 and July 2018 where an antibiotic typically used for resistant Gram-positive infections (per NHSN) was administered. We developed an algorithm based on laboratory data and diagnosis codes to categorize each antibiotic day of therapy as appropriate, inappropriate, or indeterminate. If indeterminate, we reviewed charts to assess appropriateness. We calculated total, appropriate, and inappropriate days of therapy (DOT) overall and per patient-day. We evaluated clinical characteristics and indications as potential predictors of inappropriate DOT using Chi-squared or Kruskal-Wallis tests. Results Among 591 included encounters, we assessed 708 total antibiotic courses. The algorithm allowed for classification of 422 encounters (71%) and the remaining 171 encounters (29%) were classified using manual record review. The most frequent antibiotics were vancomycin (68%) and clindamycin (29%). Patients received a median of 3 days of gram-positive agent therapy per visit, or 5 per every 10 patient-days. Most common indications for gram-positive therapy were surgical prophylaxis (28% of encounters) and empiric therapy (10%) (Figure 1). Of the 1,754 total days of therapy assessed, 94.8% were ruled appropriate. Thirty-one (4.4%) courses were classified as at least partially inappropriate among 27 unique encounters (4.6%). There was a median of 2 inappropriate days among those with any inappropriate therapy. The reason for inappropriate rulings for empiric or prophylaxis indications was most often “longer than necessary duration,” which was the case for 16 of 21 (76%) occurrences. Figure 1. Appropriate and Inappropriate Days of Therapy (DOT) by Indication and Antibiotic ![]()
Conclusion Inappropriate antibiotic use for Gram-positive infections was low in our patient population for the agents studied. We identified limiting the duration for patients receiving prophylactic or empiric therapy as a potential stewardship intervention target. Disclosures All Authors: No reported disclosures
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Affiliation(s)
| | | | | | - Diana Yu
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, OR
| | | | - Erin Wu
- Oregon State University College of Pharmacy, Portland, Oregon
| | | | - Dawn Nolt
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, OR
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Cunningham AJ, McClellan KV, Dewey E, Krishnaswami S, Butler MW, Nolt D, Fialkowski E, Haag MC, Hamilton NA. Perioperative neutropenia is not an independent risk factor for infectious complications of central venous line placement in children: A propensity score-matched analysis. J Pediatr Surg 2020; 55:1339-1343. [PMID: 31515110 DOI: 10.1016/j.jpedsurg.2019.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 03/28/2019] [Revised: 07/08/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
BACKGROUND The infectious risk of central venous line (CVL) placement in children with neutropenia (absolute neutrophil count [ANC] <500/mm3) is not well defined. This study aims to investigate the early (≤30 days) and late (>30 days) infectious complications of CVLs placed in pediatric patients with and without neutropenia. METHODS A retrospective review was conducted of all CVLs placed by pediatric surgeons at two institutions from 2010 to 2017. Multivariable logistic regression was performed to identify risk factors for line infection. Propensity score-matched cohorts of patients with and without neutropenia were compared in a 1:1 ratio. Wilcoxon rank-sum, Chi-square, Fisher's exact, and log-rank tests were also performed. RESULTS Review identified 1,102 CVLs placed in 937 patients. Fifty-four patients were neutropenic at the time of placement. Multivariable analysis demonstrated tunneled catheters and subclavian access as associated with line infection. The propensity score-matched cohort included 94 patients, 47 from each group. Demographic and preoperative data were similar between the groups (p > 0.05). Patients with neutropenia were no more likely to develop early (4.3% vs. 2.1%, p = 1.000) or late (19.1% vs. 17.0%, p = 1.000) infectious complications than patients without neutropenia, with similar median time to infection (141 vs. 222 days, p = 0.370). CONCLUSION A policy of selective CVL placement in neutropenic patients with standardized postoperative line maintenance is safe. Future directions include defining criteria by which neutropenic patients could be prospectively selected for safe CVL placement. LEVEL OF EVIDENCE II - Retrospective cohort study.
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Affiliation(s)
- Aaron J Cunningham
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA.
| | | | - Elizabeth Dewey
- Department of Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Sanjay Krishnaswami
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Marilyn W Butler
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Dawn Nolt
- Division of Pediatric Infectious Diseases, Oregon Health & Science University, Portland, OR, USA
| | - Elizabeth Fialkowski
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
| | - Meredith C Haag
- School of Medicine, Oregon Health & Science University, Portland, OR, USA
| | - Nicholas A Hamilton
- Division of Pediatric Surgery, Oregon Health & Science University, Portland, OR, USA
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10
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Yu D, Bateman A, Nolt D. 1129. Assessment of Nurses’ Views on Antimicrobial Stewardship at a Pediatric Hospital. Open Forum Infect Dis 2019. [PMCID: PMC6811023 DOI: 10.1093/ofid/ofz360.993] [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: 11/24/2022] Open
Abstract
Background Regulatory agencies strongly encourage the development of hospital-based antimicrobial stewardship (AS) programs (ASP) to support appropriate antimicrobial prescribing. One component of an ASP is a multidisciplinary team. While the initial conception centered on a physician and a pharmacist, including nurses in AS has been highlighted due to the nurse’s vital role in patient care. There are little data on nurses’ knowledge, attitudes, and practices in AS. The aim of this project was to determine ideas, concerns, and gaps in knowledge of bedside nurses at a local hospital level. Methods This project was conducted at an academic pediatric hospital in an urban setting. A survey was designed to obtain nurses’ attitudes and views of AS and to address their frequency and confidence of various AS activities, including triage/isolation, allergy history, obtainment of appropriate diagnostic studies, interpretation of microbiology results, antibiotic de-/escalation, intravenous-to-oral switches of antibiotics, patient/family education, and identification of antimicrobial-associated adverse events. Respondents were asked to identify barriers to AS participation and to propose educational topics of interest. The survey was sent out to nurses, with 3 weekly reminders. Results 155 of 513 respondents initiated the survey (response rate 30.2%); however, 112 participants completed the entire survey (completion rate 72.3%). Of the respondents, 67% believed that nurses should provide AS but only 32% themselves provided AS; furthermore, 26% of the respondents felt that nurses were equipped to provide AS. The most frequent AS activity reported was patient/family education while the least reported activity was the interpretation of microbiology reports. A correlation was identified between frequency and confidence of performing various AS-related tasks (R2 = 0.95). Barriers identified by respondents included antimicrobial knowledge, other timely priorities, and inclusion of nurses on bedside rounds. Conclusion Although few respondents felt prepared to provide antimicrobial stewardship, the majority (74%) were interested in learning more about how nurses could be involved. We are currently developing a nurse-centric educational curriculum based on the feedback from the survey. Disclosures All authors: No reported disclosures.
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Affiliation(s)
- Diana Yu
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, Oregon
| | - Anne Bateman
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, Oregon
| | - Dawn Nolt
- Oregon Health and Science University/Doernbecher Children’s Hospital, Portland, Oregon
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11
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Puopolo KM, Lynfield R, Cummings JJ, Hand I, Adams-Chapman I, Poindexter B, Stewart DL, Aucott SW, Goldsmith JP, Mowitz M, Watterberg K, Maldonado YA, Zaoutis TE, Banerjee R, Barnett ED, Campbell JD, Gerber JS, Kourtis AP, Munoz FM, Nolt D, Nyquist AC, O’Leary ST, Sawyer MH, Steinbach WJ, Zangwill K. Management of Infants at Risk for Group B Streptococcal Disease. Pediatrics 2019; 144:peds.2019-1881. [PMID: 31285392 DOI: 10.1542/peds.2019-1881] [Citation(s) in RCA: 152] [Impact Index Per Article: 30.4] [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] [Indexed: 11/24/2022] Open
Abstract
Group B streptococcal (GBS) infection remains the most common cause of neonatal early-onset sepsis and a significant cause of late-onset sepsis among young infants. Administration of intrapartum antibiotic prophylaxis is the only currently available effective strategy for the prevention of perinatal GBS early-onset disease, and there is no effective approach for the prevention of late-onset disease. The American Academy of Pediatrics joins with the American College of Obstetricians and Gynecologists to reaffirm the use of universal antenatal microbiologic-based testing for the detection of maternal GBS colonization to facilitate appropriate administration of intrapartum antibiotic prophylaxis. The purpose of this clinical report is to provide neonatal clinicians with updated information regarding the epidemiology of GBS disease as well current recommendations for the evaluation of newborn infants at risk for GBS disease and for treatment of those with confirmed GBS infection. This clinical report is endorsed by the American College of Obstetricians and Gynecologists (ACOG), July 2019, and should be construed as ACOG clinical guidance.
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Affiliation(s)
- Karen M. Puopolo
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ruth Lynfield
- Minnesota Department of Health, St Paul, Minnesota; and
| | - James J. Cummings
- Departments of Pediatrics and Bioethics, Alden March Bioethics Institute, Albany Medical College, Albany, New York
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12
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Puopolo KM, Benitz WE, Zaoutis TE, Cummings J, Juul S, Hand I, Eichenwald E, Poindexter B, Stewart DL, Aucott SW, Goldsmith JP, Watterberg K, Byington CL, Maldonado YA, Banerjee R, Barnett ED, Campbell JD, Gerber JS, Lynfield R, Munoz FM, Nolt D, Nyquist AC, O’Leary ST, Rathore MH, Sawyer MH, Steinbach WJ, Tan TQ. Management of Neonates Born at ≤34 6/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics 2018; 142:peds.2018-2896. [PMID: 30455344 DOI: 10.1542/peds.2018-2896] [Citation(s) in RCA: 129] [Impact Index Per Article: 21.5] [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
Early-onset sepsis (EOS) remains a serious and often fatal illness among infants born preterm, particularly among newborn infants of the lowest gestational age. Currently, most preterm infants with very low birth weight are treated empirically with antibiotics for risk of EOS, often for prolonged periods, in the absence of a culture-confirmed infection. Retrospective studies have revealed that antibiotic exposures after birth are associated with multiple subsequent poor outcomes among preterm infants, making the risk/benefit balance of these antibiotic treatments uncertain. Gestational age is the strongest single predictor of EOS, and the majority of preterm births occur in the setting of other factors associated with risk of EOS, making it difficult to apply risk stratification strategies to preterm infants. Laboratory tests alone have a poor predictive value in preterm EOS. Delivery characteristics of extremely preterm infants present an opportunity to identify those with a lower risk of EOS and may inform decisions to initiate or extend antibiotic therapies. Our purpose for this clinical report is to provide a summary of the current epidemiology of preterm neonatal sepsis and provide guidance for the development of evidence-based approaches to sepsis risk assessment among preterm newborn infants.
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Affiliation(s)
- Karen M. Puopolo
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia, and
| | - William E. Benitz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Theoklis E. Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Roberts Center for Pediatric Research, Philadelphia, Pennsylvania; and
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13
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Puopolo KM, Benitz WE, Zaoutis TE, Cummings J, Juul S, Hand I, Eichenwald E, Poindexter B, Stewart DL, Aucott SW, Goldsmith JP, Watterberg K, Byington CL, Maldonado YA, Banerjee R, Barnett ED, Campbell JD, Gerber JS, Lynfield R, Munoz FM, Nolt D, Nyquist AC, O’Leary ST, Rathore MH, Sawyer MH, Steinbach WJ, Tan TQ. Management of Neonates Born at ≥35 0/7 Weeks' Gestation With Suspected or Proven Early-Onset Bacterial Sepsis. Pediatrics 2018; 142:peds.2018-2894. [PMID: 30455342 DOI: 10.1542/peds.2018-2894] [Citation(s) in RCA: 178] [Impact Index Per Article: 29.7] [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
The incidence of neonatal early-onset sepsis (EOS) has declined substantially over the last 2 decades, primarily because of the implementation of evidence-based intrapartum antimicrobial therapy. However, EOS remains a serious and potentially fatal illness. Laboratory tests alone are neither sensitive nor specific enough to guide EOS management decisions. Maternal and infant clinical characteristics can help identify newborn infants who are at risk and guide the administration of empirical antibiotic therapy. The incidence of EOS, the prevalence and implications of established risk factors, the predictive value of commonly used laboratory tests, and the uncertainties in the risk/benefit balance of antibiotic exposures all vary significantly with gestational age at birth. Our purpose in this clinical report is to provide a summary of the current epidemiology of neonatal sepsis among infants born at ≥35 0/7 weeks' gestation and a framework for the development of evidence-based approaches to sepsis risk assessment among these infants.
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Affiliation(s)
- Karen M. Puopolo
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Children’s Hospital of Philadelphia, and
| | - William E. Benitz
- Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Palo Alto, California
| | - Theoklis E. Zaoutis
- Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
- Roberts Center for Pediatric Research, Philadelphia, Pennsylvania; and
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14
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Abstract
Staphylococcus aureus is a bacterium that can cause a variety of illnesses through suppurative or nonsuppurative (toxin-mediated) means. S aureus is a common cause of skin and skin structure infections as well as osteoarticular infections in the pediatric population. S aureus is also identified in cases of septicemia, infective endocarditis, pneumonia, ocular infections, and central nervous system infections. To design appropriate empirical therapy, pediatricians should be knowledgeable about the resistance patterns of S aureus in their communities, including methicillin and clindamycin resistance. This article reviews the microbiology, colonization and transmission, and antibiotic resistance of and clinical diseases caused by S aureus.
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Affiliation(s)
| | - Dawn Nolt
- Division of Pediatric Infectious Diseases, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
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15
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Newland JG, Gerber JS, Kronman MP, Meredith G, Lee BR, Thurm C, Hersh AL, Berman DM, Handy L, Chan S, Tribble AC, Klein K, Maples H, Stahl D, Flett KB, Shapiro C, Fernandez AJ, Child J, Hurst AL, Parker SK, Pearce K, Mongkolrattanothai K, Metjian T, Grapentine S, Pomputius W, Goldman J, Yu D, Patel K, Yarbrough A, Cassady KA, Courter J, Haslam D, Thurman R, Mazade M, Varman M, Green A, Zwiener J, Simonsen K, Stec R, Bennett N, Girotto JE, Nolt D, Thomas J, Olivero R, Van Dyke C, Smith MJ, Lee K, Arnold SR, Schwenk H, Lee B, Patel SJ, Patel R, Calderon R, Dixon TC, Jaggi P, Tansmore J, Olson J, Thorell EM, Pong A, Nichols K, Cox E, Weissman S, Brothers A, Pak D, Bridger K, Poole N, Nelson M, Hymes S, Taylor R, Palazzi D, Wattier R, Faldasz J, Naeem F, Kuzmic B, Islam S. Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS): A Quality Improvement Collaborative. J Pediatric Infect Dis Soc 2018; 7:124-128. [PMID: 28379408 DOI: 10.1093/jpids/pix020] [Citation(s) in RCA: 26] [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] [Received: 10/10/2016] [Accepted: 02/22/2017] [Indexed: 11/14/2022]
Abstract
BACKGROUND Although many children's hospitals have established antimicrobial stewardship programs (ASPs), data-driven benchmarks for optimizing antimicrobial use across centers are lacking. We developed a multicenter quality improvement collaborative focused on sharing data reports and benchmarking antimicrobial use to improve antimicrobial prescribing among hospitalized children. METHODS A national antimicrobial stewardship collaborative among children's hospitals, Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS), was established in 2013. Characteristics of the hospitals and their ASPs were obtained through a standardized survey. Antimicrobial-use data reports were developed on the basis of input from the participating hospitals. Collaborative learning opportunities were provided through monthly webinars and annual meetings. RESULTS Since 2013, 36 US hospitals have participated in the SHARPS collaborative. The median full-time equivalent (pharmacist and physician) dedicated to 30 of these ASPs was 0.75 (interquartile range, 0.45-1.4). To date, the collaborative has developed 26 data reports that include benchmarking reports according to specific antimicrobial agents, indications, and clinical service lines. The collaborative has conducted 27 webinars and 3 in-person meetings to highlight the stewardship work being conducted in the hospitals. The data reports and learning opportunities have resulted in approximately 36 distinct stewardship interventions. CONCLUSION A pediatric antimicrobial stewardship collaborative has been successful in promoting the development of and innovation among pediatric ASPs. Additional research is needed to determine the impact of these efforts.
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Affiliation(s)
- Jason G Newland
- Division of Pediatric Infectious Diseases, Washington University in St. Louis School of Medicine, Missouri
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Pennsylvania.,Department of Biostatistics and Epidemiology, Perelman School of Medicine of the University of Pennsylvania, Philadelphia
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle.,Center for Clinical and Translational Research, Seattle Children's Hospital Research Institute, Washington
| | - Georgann Meredith
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, Kansas City, Missouri
| | - Brian R Lee
- Division of Pediatric Infectious Diseases, Children's Mercy Hospital and Clinics, Kansas City, Missouri.,Health Services and Outcomes Research, Children's Mercy Hospital and Clinics, Kansas City, Missouri
| | - Cary Thurm
- Children's Hospital Association, Statistical Analysis Services, Washington, DC
| | - Adam L Hersh
- Division of Pediatric Infectious Diseases, University of Utah School of Medicine, Salt Lake City
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16
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Rathore MH, Jackson MA, Byington CL, Maldonado YA, Barnett ED, Davies HD, Edwards KM, Lynfield R, Munoz FM, Nolt D, Nyquist AC, Sawyer MH, Steinbach WJ, Tan TQ, Zaoutis TE. Infection Prevention and Control in Pediatric Ambulatory Settings. Pediatrics 2017; 140:peds.2017-2857. [PMID: 29061869 DOI: 10.1542/peds.2017-2857] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [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
Since the American Academy of Pediatrics published its statement titled "Infection Prevention and Control in Pediatric Ambulatory Settings" in 2007, there have been significant changes that prompted this updated statement. Infection prevention and control is an integral part of pediatric practice in ambulatory medical settings as well as in hospitals. Infection prevention and control practices should begin at the time the ambulatory visit is scheduled. All health care personnel should be educated regarding the routes of transmission and techniques used to prevent the transmission of infectious agents. Policies for infection prevention and control should be written, readily available, updated every 2 years, and enforced. Many of the recommendations for infection control and prevention from the Centers for Disease Control and Prevention for hospitalized patients are also applicable in the ambulatory setting. These recommendations include requirements for pediatricians to take precautions to identify and protect employees likely to be exposed to blood or other potentially infectious materials while on the job. In addition to emphasizing the key principles of infection prevention and control in this policy, we update those that are relevant to the ambulatory care patient. These guidelines emphasize the role of hand hygiene and the implementation of diagnosis- and syndrome-specific isolation precautions, with the exemption of the use of gloves for routine diaper changes and wiping a well child's nose or tears for most patient encounters. Additional topics include respiratory hygiene and cough etiquette strategies for patients with a respiratory tract infection, including those relevant for special populations like patients with cystic fibrosis or those in short-term residential facilities; separation of infected, contagious children from uninfected children when feasible; safe handling and disposal of needles and other sharp medical devices; appropriate use of personal protective equipment, such as gloves, gowns, masks, and eye protection; and appropriate use of sterilization, disinfection, and antisepsis. Lastly, in this policy, we emphasize the importance of public health interventions, including vaccination for patients and health care personnel, and outline the responsibilities of the health care provider related to prompt public health notification for specific reportable diseases and communication with colleagues who may be providing subsequent care of an infected patient to optimize the use of isolation precautions and limit the spread of contagions.
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Affiliation(s)
- Mobeen H. Rathore
- University of Florida Center for HIV/AIDS Research, Education and Service (UF CARES) and Infectious Diseases and Immunology, Wolfson Children’s Hospital, Jacksonville, Florida; and
| | - Mary Anne Jackson
- Division of Infectious Diseases, Department of Pediatrics, University of Missouri–Kansas City School of Medicine and Children’s Mercy Kansas City, Kansas City, Missouri
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17
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Nolt D, Williamson K, Burnett N, Cortes-Ramos C. Control of a Hospital Norovirus Outbreak Using Hydrogen Peroxide and Peroxyacetic Acid (H2O2-PAA) Disinfectant Cleaner. Open Forum Infect Dis 2017. [DOI: 10.1093/ofid/ofx163.309] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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18
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Davies HD, Jackson MA, Rice SG, Byington CL, Maldonado YA, Barnett ED, Campbell JD, Lynfield R, Munoz FM, Nolt D, Nyquist AC, O’Leary S, Rathore MH, Sawyer MH, Steinbach WJ, Tan TQ, Zaoutis TE, LaBella CR, Brooks MA, Canty GS, Diamond A, Hennrikus W, Logan K, Moffatt KA, Nemeth B, Pengel B, Peterson A, Stricker P. Infectious Diseases Associated With Organized Sports and Outbreak Control. Pediatrics 2017; 140:peds.2017-2477. [PMID: 28947608 DOI: 10.1542/peds.2017-2477] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Participation in organized sports has a variety of health benefits but also has the potential to expose the athlete to a variety of infectious diseases, some of which may produce outbreaks. Major risk factors for infection include skin-to-skin contact with athletes who have active skin infections, environmental exposures and physical trauma, and sharing of equipment and contact with contaminated fomites. Close contact that is intrinsic to team sports and psychosocial factors associated with adolescence are additional risks. Minimizing risk requires leadership by the organized sports community (including the athlete's primary care provider) and depends on outlining key hygiene behaviors, recognition, diagnosis, and treatment of common sports-related infections, and the implementation of preventive interventions.
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Affiliation(s)
- H. Dele Davies
- Pediatric Infectious Diseases and Public Health, University of Nebraska Medical Center, Omaha, Nebraska
| | - Mary Anne Jackson
- Infectious Diseases, Children’s Mercy Kansas City and Department of Pediatrics, School of Medicine, University of Missouri-Kansas City, Kansas City, Missouri; and
| | - Stephen G. Rice
- Sports Medicine, Jersey Shore University Medical Center and Department of Pediatrics, Robert Wood Johnson Medical School, Rutgers University, Neptune, New Jersey
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19
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Williamson K, Hale M, Nolt D. Validating Nurse Sick Call Data as a Method of Early Warning Outbreak Response in an Academic Teaching Hospital. Am J Infect Control 2017. [DOI: 10.1016/j.ajic.2017.04.081] [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: 10/16/2022]
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20
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Bernstein HH, Bocchini JA, Byington CL, Maldonado YA, Barnett ED, Campbell JD, Davies HD, Lynfield R, Munoz FM, Nolt D, Nyquist AC, O’Leary S, Rathore MH, Sawyer MH, Steinbach WJ, Tan TQ, Zaoutis TE. Practical Approaches to Optimize Adolescent Immunization. Pediatrics 2017; 139:peds.2016-4187. [PMID: 28167515 DOI: 10.1542/peds.2016-4187] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [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
With the expansion of the adolescent immunization schedule during the past decade, immunization rates notably vary by vaccine and by state. Addressing barriers to improving adolescent vaccination rates is a priority. Every visit can be viewed as an opportunity to update and complete an adolescent's immunizations. It is essential to continue to focus and refine the appropriate techniques in approaching the adolescent patient and parent in the office setting. Health care providers must continuously strive to educate their patients and develop skills that can help parents and adolescents overcome vaccine hesitancy. Research on strategies to achieve higher vaccination rates is ongoing, and it is important to increase the knowledge and implementation of these strategies. This clinical report focuses on increasing adherence to the universally recommended vaccines in the annual adolescent immunization schedule of the American Academy of Pediatrics, the American Academy of Family Physicians, the Centers for Disease Control and Prevention, and the American Congress of Obstetricians and Gynecologists. This will be accomplished by (1) examining strategies that heighten confidence in immunizations and address patient and parental concerns to promote adolescent immunization and (2) exploring how best to approach the adolescent and family to improve immunization rates.
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Affiliation(s)
- Henry H. Bernstein
- Department of Pediatrics, Cohen Children's Medical Center of New York, New Hyde Park, New York; and
| | - Joseph A. Bocchini
- Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, Louisiana
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21
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Muirhead CA, Sanford JN, McCullar BG, Nolt D, MacDonald KD. One Center's Guide to Outpatient Management of Pediatric Cystic Fibrosis Acute Pulmonary Exacerbation. Clin Med Insights Pediatr 2016; 10:57-65. [PMID: 27429564 PMCID: PMC4944828 DOI: 10.4137/cmped.s38336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Revised: 06/06/2016] [Accepted: 06/13/2016] [Indexed: 01/20/2023]
Abstract
Cystic fibrosis (CF) is a chronic disorder characterized by acute pulmonary exacerbations that comprise increased cough, chest congestion, increased mucus production, shortness of breath, weight loss, and fatigue. Typically, severe episodes are treated in the inpatient setting and include intravenous antimicrobials, airway clearance therapy, and nutritional support. Children with less-severe findings can often be managed as outpatients with oral antimicrobials and increased airway clearance therapy at home without visiting the specialty CF center to begin treatment. Selection of specific antimicrobial agents is dependent on pathogens found in surveillance culture, activity of an agent in patients with CF, and the unique physiology of these patients. In this pediatric review, we present our practice for defining acute pulmonary exacerbation, deciding treatment location, initiating treatment either in-person or remotely, determining the frequency of airway clearance, selecting antimicrobial therapy, recommending timing for follow-up visit, and recognizing and managing treatment failures.
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Affiliation(s)
- Corinne A Muirhead
- Department of Pharmacy, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, OR, USA
| | - Jillian N Sanford
- Department of Pediatrics, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, OR, USA
| | - Benjamin G McCullar
- Department of Nursing, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, OR, USA
| | - Dawn Nolt
- Department of Pediatrics, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, OR, USA
| | - Kelvin D MacDonald
- Department of Pediatrics, Oregon Health and Science University, Doernbecher Children's Hospital, Portland, OR, USA
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22
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Nolt D, Lindemulder S, Meyrowitz J, Chang BH, Malempati S, Thomas G, Stork L. Preventive antibiotics in pediatric patients with acute myeloid leukemia (AML). Pediatr Blood Cancer 2015; 62:1149-54. [PMID: 25728418 DOI: 10.1002/pbc.25463] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [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: 07/23/2014] [Accepted: 01/07/2015] [Indexed: 11/09/2022]
Abstract
BACKGROUND Treatment of acute myeloid leukemia (AML) comes with a significant risk of life-threatening infection during periods of prolonged severe neutropenia. We studied the impact of preventive intravenous (IV) antibiotic administration at onset of absolute neutropenia on the incidence and outcome of life-threatening infections during treatment of childhood AML. PROCEDURES This is a retrospective study on pediatric patients (aged 0-18 years) consecutively diagnosed with de novo AML and treated at a single institution from April 2005 through February 2013. Patients were treated on the Children's Oncology Group (COG) AAML0531 protocol or with a modified United Kingdom Medical Research Council (UK MRC) AML 10 regimen. Pertinent data were extracted from hard copy or electronic chart review. RESULTS A total of 76 chemotherapy phases were analyzed from 29 patients. In each phase reported, preventive antibiotics were initiated when the daily absolute neutrophil count was <500 cells/mcl, before onset of fever. Seven episodes of bacteremia were documented with predominantly coagulase-negative staphylococci and viridans group streptococci. One infection-related death occurred, attributed to progressive respiratory failure occurring months after documented candidal pneumonia. CONCLUSIONS Initiation of preventive antibiotics at the onset of absolute neutropenia was associated with no mortality from bacteremia. This preventive approach appears feasible and safe.
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Affiliation(s)
- Dawn Nolt
- Division of Infectious Diseases, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Susan Lindemulder
- Division of Hematology and Oncology, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Jeffrey Meyrowitz
- Division of Hematology and Oncology, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Bill H Chang
- Division of Hematology and Oncology, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Suman Malempati
- Division of Hematology and Oncology, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Gregory Thomas
- Division of Hematology and Oncology, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Linda Stork
- Division of Hematology and Oncology, Department of Pediatrics, Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
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23
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Olson J, Mann JA, White K, Cartwright VW, Bauer J, Nolt D. Multicentric reticulohistiocytosis: a case report of an atypical presentation in a 2-year-old. Pediatr Dermatol 2015; 32:e70-3. [PMID: 25727569 DOI: 10.1111/pde.12531] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [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: 11/30/2022]
Abstract
Multicentric reticulohistiocytosis (MRH) is a rare systemic inflammatory granulomatous disease marked by severe and often rapidly progressive polyarticular arthritis and cutaneous papulonodules. Initial clinical diagnosis may be difficult. We describe a 2-year-old girl presenting with pink dermal papules on the forehead, thighs, elbows, knees, and palms of the hands. Based on clinical findings and skin biopsy results, she was initially diagnosed with granuloma annulare. At 5 years of age, she developed arthritis, fatigue, and more widespread skin papules leading to the diagnosis of MRH. To our knowledge, this is the youngest individual with MRH yet described. We outline the timeline and unique features of her case and review the literature pertaining to MRH in children. Although rare, MRH can be permanently debilitating, making prompt diagnosis critical. A standardized approach to investigation and management needs to be developed.
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Affiliation(s)
- Jaleh Olson
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon
| | - Julianne A Mann
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon.,Department of Dermatology, Oregon Health and Science University, Portland, Oregon
| | - Kevin White
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon.,Department of Dermatology, Oregon Health and Science University, Portland, Oregon.,Department of Dermatopathology, Oregon Health and Science University, Portland, Oregon
| | - Victoria W Cartwright
- Division of Rheumatology, Department of Pediatrics, Randall Children's Hospital, Portland, Oregon
| | - Jeremy Bauer
- Shriners Hospital for Children, Portland, Oregon
| | - Dawn Nolt
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon.,Division of Infectious Diseases, Oregon Health and Science University, Portland, Oregon
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Carlberg VM, Lofgren SM, Mann JA, Austin JP, Nolt D, Shereck EB, Davila-Saldana B, Zonana J, Krol AL. Hypohidrotic ectodermal dysplasia, osteopetrosis, lymphedema, and immunodeficiency in an infant with multiple opportunistic infections. Pediatr Dermatol 2014; 31:716-21. [PMID: 23405946 DOI: 10.1111/pde.12103] [Citation(s) in RCA: 14] [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] [Indexed: 01/21/2023]
Abstract
Osteopetrosis, lymphedema, hypohidrotic ectodermal dysplasia, and immunodeficiency (OL-HED-ID) is a rare X-linked disorder with only three reported prior cases in the English-language literature. We describe a case of OL-HED-ID in a male infant who initially presented with congenital lymphedema, leukocytosis, and thrombocytopenia of unknown etiology at 7 days of age. He subsequently developed gram-negative sepsis and multiple opportunistic infections including high-level cytomegalovirus viremia and Pneumocystis jiroveci pneumonia. The infant was noted to have mildly xerotic skin, fine sparse hair, and periorbital wrinkling, all features suggestive of ectodermal dysplasia. Skeletal imaging showed findings consistent with osteopetrosis, and immunologic investigation revealed hypogammaglobulinemia and mixed T- and B-cell dysfunction. Genetic testing revealed a novel mutation in the nuclear factor kappa beta (NF-KB) essential modulator (NEMO) gene, confirming the diagnosis of OL-HED-ID. Mutations in the NEMO gene have been reported in association with hypohidrotic ectodermal dysplasia with immunodeficiency (HED-ID), OL-HED-ID, and incontinentia pigmenti. In this case, we report a novel mutation in the NEMO gene associated with OL-HED-ID. This article highlights the dermatologic manifestations of a rare disorder, OL-HED-ID, and underscores the importance of early recognition and prompt intervention to prevent life-threatening infections.
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Affiliation(s)
- Valerie M Carlberg
- Department of Dermatology, Oregon Health and Science University, Portland, Oregon; School of Medicine, Oregon Health and Science University, Portland, Oregon
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Abstract
The primary goal of this study was to determine how chronic exposure to Ag influences the functionality of Mycobacterium tuberculosis-specific T cell responses. The frequency of IFN-gamma-producing effector CD4(+) and CD8(+) T cells dynamically changed during persistent M. tuberculosis infection. CD8(+) T cells used differential effector functions during acute and chronic phases of the immune response, where CD8(+) T cells produced negligible amounts of IFN-gamma early in infection, but switched to cytokine production during the chronic stage of infection. Using limiting dilution analysis, CD8(+) T cells isolated during the initial phase of infection demonstrated lytic potential, but this waned in the chronic stage. The apparent loss of cytotoxic activity was not associated with the lack of perforin. Ag dose could potentially govern the functional program of CD8(+) T cells. Collectively, these results depict a host immune response mounted against M. tuberculosis of a significantly more dynamic nature than previously recognized.
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Affiliation(s)
- Vanja Lazarevic
- Department of Molecular Genetics and Biochemistry, University of Pittsburgh School of Medicine, 200 Lothrop Street, Pittsburgh, PA 15261, USA
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Abstract
Reports of clinical manifestations of West Nile virus (WNV) infections in children have been relatively rare. Four cases of WNV infection in children are described: the first report of prolonged encephalitis and fulminant hepatitis caused by WNV, and 3 other presentations of WNV, including the first report of ocular involvement in a child.
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Affiliation(s)
- Robert Yim
- Division of Allergy, Immunology and Infectious Diseases, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213-2583, USA
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Abstract
Alternate modalities for the treatment of Mycobacterium tuberculosis are needed due to the rise in numbers of immunosuppressed individuals at risk for serious disease and the increasing prevalence of multidrug-resistant isolates. Interleukin-12 (IL-12) has been shown to improve immune responses against M. tuberculosis infection in both humans and mice. Previous studies using high-dose IL-12 in various disease models reported a paradoxical immunosuppression. We demonstrate here that exogenous administration of IL-12 for 8 weeks after an aerosolized low dose of M. tuberculosis results in increased survival and decreased pulmonary bacterial loads for CD4-T-cell-deficient mice, most likely due to an early increase in gamma interferon. IL-12 treatment did not impair or enhance the ability of the wild-type mice to control infection, as measured by bacterial numbers. Two novel findings are reported here regarding exogenous IL-12 therapy for M. tuberculosis infections: (i). IL-12 treatment resulted in decreased numbers of immune cells and reduced frequencies of lymphocytes (CD8(+), CD4(+), and NK cells) in the lungs of infected mice and (ii). IL-12 therapy reduced the pathology of M. tuberculosis-infected lungs, as granulomas were smaller and less numerous. These studies support an immunoregulatory role for IL-12 in tuberculosis.
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Affiliation(s)
- Dawn Nolt
- Division of Allergy, Immunology, and Infectious Diseases, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261, USA
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Abstract
Pulmonary disease caused by nontuberculous mycobacteria (NTM) is a relatively rare occurrence in immunocompetent children. Two cases of endobronchial NTM infection in immunocompetent children are described. In addition, 41 other children with NTM pulmonary disease reported in the English literature between 1930 and 2003 are reviewed. Clinical manifestations are either purely respiratory or respiratory with more widespread systemic symptoms. Compared with children with only respiratory complaints, children with constitutional symptoms from NTM pulmonary disease 1) had symptoms for a shorter period before presentation (10 vs 28 days), 2) had more radiographic evidence of pulmonary disease, and 3) were treated longer with antimycobacterial agents (11.5 months vs 6 months). The most common causative organism was Mycobacterium avium complex. Pediatricians should be increasingly aware of NTM in the differential diagnosis of persistent pulmonary disease in previously healthy children.
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Affiliation(s)
- Dawn Nolt
- University of Pittsburgh School of Medicine, Division of Allergy, Immunology, and Infectious Diseases, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Abstract
Congenital syphilis continues to occur despite the advances in testing of pregnant women in many countries and the availability of penicillin since 1943. This is a report of a child with multiple systemic manifestations of congenital syphilis. This is one of the few cases of survival with pituitary involvement from congenital syphilis and the first noted case in which diabetes insipidus developed. Institution of routine testing in all countries might have prevented the severe manifestations of syphilis seen in this child.
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Affiliation(s)
- Dawn Nolt
- University of Pittsburgh School of Medicine, Division of Allergy, Immunology and Infectious Diseases, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania 15213, USA.
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Chun T, Serbina NV, Nolt D, Wang B, Chiu NM, Flynn JL, Wang CR. Induction of M3-restricted cytotoxic T lymphocyte responses by N-formylated peptides derived from Mycobacterium tuberculosis. J Exp Med 2001; 193:1213-20. [PMID: 11369792 PMCID: PMC2193330 DOI: 10.1084/jem.193.10.1213] [Citation(s) in RCA: 56] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Major histocompatibility complex (MHC) class I–restricted CD8+ T cells play a critical role in the protective immunity against Mycobacterium tuberculosis (Mtb). However, only a few Mtb peptides recognized by MHC class Ia–restricted CD8+ T cells have been identified. Information on epitopes recognized by class Ib–restricted T cells is even more limited. M3 is an MHC class Ib molecule that preferentially presents N-formylated peptides to CD8+ T cells. Because bacteria initiate protein synthesis with N-formyl methionine, the unique binding specificity of M3 makes it especially suitable for presenting these particular bacterial epitopes. We have scanned the full sequence of the Mtb genome for NH2-terminal peptides that share features with other M3-binding peptides. Synthetic peptides corresponding to these sequences were tested for their ability to bind to M3 in an immunofluorescence-based peptide-binding assay. Four of the N-formylated Mtb peptides were able to elicit cytotoxic T lymphocytes (CTLs) from mice immunized with peptide-coated splenocytes. The Mtb peptide–specific, M3-restricted CTLs lysed the Mtb-infected macrophages effectively, suggesting that these N-formylated Mtb peptides are presented as the naturally processed epitopes by Mtb-infected cells. Furthermore, T cells from Mtb-infected lungs, spleen, and lymph nodes responded to N-formylated Mtb peptides in an M3-restricted manner. Taken together, our data suggest that M3-restricted T cells may participate in the immune response to Mtb.
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Affiliation(s)
- Taehoon Chun
- Gwen Knapp Center for Lupus and Immunology Research, Committee on Immunology and Department of Pathology, University of Chicago, Chicago, Illinois 60637
| | - Natalya V. Serbina
- Department of Molecular Genetics and Biochemistry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261
| | - Dawn Nolt
- Department of Molecular Genetics and Biochemistry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261
- Department of Pediatrics, Division of Infectious Disease, Children's Hospital, Pittsburgh, Pennsylvania 15261
| | - Bin Wang
- Gwen Knapp Center for Lupus and Immunology Research, Committee on Immunology and Department of Pathology, University of Chicago, Chicago, Illinois 60637
| | - Nancy M. Chiu
- Gwen Knapp Center for Lupus and Immunology Research, Committee on Immunology and Department of Pathology, University of Chicago, Chicago, Illinois 60637
| | - JoAnne L. Flynn
- Department of Molecular Genetics and Biochemistry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania 15261
| | - Chyung-Ru Wang
- Gwen Knapp Center for Lupus and Immunology Research, Committee on Immunology and Department of Pathology, University of Chicago, Chicago, Illinois 60637
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Affiliation(s)
- D Nolt
- Department of Pediatrics, University of Pittsburgh School of Medicine, PA, USA.
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