Andrea T. Cruz

Pantoea agglomerans, a Plant Pathogen Causing Human Disease

ABSTRACT We present 53 pediatric cases of Pantoea agglomerans infections cultured from normally sterile sites in patients seen at a childrens hospital over 6 years. Isolates included 23 from the bloodstream, 14 from abscesses, 10 from joints/bones, 4 from the urinary tract, and 1 each from the peritoneum and the thorax. P. agglomerans was most associated with penetrating trauma by vegetative material and catheter-related bacteremia.

Implementation of Goal-Directed Therapy for Children With Suspected Sepsis in the Emergency Department

BACKGROUND: Suboptimal care for children with septic shock includes delayed recognition and inadequate fluid resuscitation. OBJECTIVE: To describe the implementation of an emergency department (ED) protocol for the recognition of septic shock and facilitate adherence to national treatment guidelines. PATIENTS AND METHODS: Root-cause analyses and morbidity and mortality conferences identified system problems with sepsis recognition and management. A group of ED and critical care physicians met to identify barriers and create solutions. RESULTS: To facilitate sepsis recognition, a computerized triage system alarmed on abnormal vital signs, and then toxic-appearing children or children at high risk for invasive infection were placed in a resuscitation room. To facilitate timely delivery of interventions, additional nursing, respiratory therapy, and pharmacy personnel were recruited. Fluids were administered via syringe delivery; standardized laboratory studies and antibiotics were ordered and prioritized. Frequent vital-sign measurements and interventions were documented on a graphical flow sheet to facilitate interpretation of physiologic response to therapy. After protocol initiation, there were 191 encounters in 167 patients with suspected sepsis. When compared with children seen before the protocol, time from triage to first bolus decreased from a median of 56 to 22 minutes (P < .001) and triage to first antibiotics decreased from a median of 130 to 38 minutes (P < .001). CONCLUSIONS: The protocol resulted in earlier recognition of suspected sepsis and substantial reductions in both time to receipt of time-sensitive interventions and a decrement in treatment variation.

Evaluation of tuberculosis diagnostics in children: 2. Methodological issues for conducting and reporting research evaluations of tuberculosis diagnostics for intrathoracic tuberculosis in children. Consensus from an expert panel.

Confirming the diagnosis of childhood tuberculosis is a major challenge. However, research on childhood tuberculosis as it relates to better diagnostics is often neglected because of technical difficulties, such as the slow growth in culture, the difficulty of obtaining specimens, and the diverse and relatively nonspecific clinical presentation of tuberculosis in this age group. Researchers often use individually designed criteria for enrollment, diagnostic classifications, and reference standards, thereby hindering the interpretation and comparability of their findings. The development of standardized research approaches and definitions is therefore needed to strengthen the evaluation of new diagnostics for detection and confirmation of tuberculosis in children. In this article we present consensus statements on methodological issues for conducting research of Tuberculosis diagnostics among children, with a focus on intrathoracic tuberculosis. The statements are complementary to a clinical research case definition presented in an accompanying publication and suggest a phased approach to diagnostics evaluation; entry criteria for enrollment; methods for classification of disease certainty, including the rational use of culture within the case definition; age categories and comorbidities for reporting results; and the need to use standard operating procedures. Special consideration is given to the performance of microbiological culture in children and we also recommend for alternative methodological approaches to report findings in a standardized manner to overcome these limitations are made. This consensus statement is an important step toward ensuring greater rigor and comparability of pediatric tuberculosis diagnostic research, with the aim of realizing the full potential of better tests for children.

Comparing the Tuberculin Skin Test and T-SPOT.TB Blood Test in Children

BACKGROUND: Interferon-γ–release assays (IGRAs) have been developed for the diagnosis of tuberculosis infection, but few data are available for children. There currently is no reference standard for the diagnosis of tuberculosis infection. OBJECTIVE: To compare the performance of 1 IGRA, the T-SPOT.TB assay with the tuberculin skin test (TST) in children with different epidemiologic risk factors for tuberculosis. METHODS: We conducted a prospective study of 210 patients referred to 3 pediatric tuberculosis clinics, including those with no risk factors for tuberculosis (low risk, n = 27), risk factors but no identifiable source case (intermediate risk, n = 78), contact with a known source case (high risk, n = 74), and active disease (n = 31). Children were tested with TST and T-SPOT.TB. Concordance analyses were performed, and assay outcomes were modeled by multivariate logistic regression. RESULTS: For 13 children with culture-confirmed tuberculosis disease, sensitivity of TST and T-SPOT.TB was 77% and 92%, respectively, and concordance was 69%. For high-risk children, concordance was 94% for BCG-unimmunized children and 88% for BCG-immunized children. For intermediate-risk children, concordance was 74% for BCG-unimmunized children and 33% for BCG-immunized children. For low-risk children, concordance was 74% for BCG-unimmunized children and 20% for BCG-immunized children. Multivariate analysis revealed that contact with a source case was associated with T-SPOT.TB result, but age and BCG immunization were not. CONCLUSIONS: T-SPOT.TB is comparable to the TST in the diagnosis of tuberculosis disease and identification of high-risk children with tuberculosis infection and is more specific than the TST in children who have received the BCG vaccine.

Increasing adherence for latent tuberculosis infection therapy with health department-administered therapy.

Therapy is almost universally recommended for children with latent tuberculosis infection, but long courses of therapy can decrease adherence to drug therapy. The only variable positively associated with adherence to latent tuberculosis infection therapy in our population was health department–assisted administration of drugs (odds ratio, 7.2; 95% confidence interval, 3.8–13.8).

Detection of Mammalian Reovirus RNA by Using Reverse Transcription-PCR: Sequence Diversity within the λ3-Encoding L1 Gene

ABSTRACT Reoviruses infect virtually all mammalian species, and infection of humans is associated with mild gastrointestinal or upper respiratory illnesses. To improve reovirus detection strategies, we developed a reverse transcription-PCR technique to amplify a fragment of the reovirus L1 gene segment. This assay was capable of detecting 44 of 44 reovirus field isolate strains and was sufficiently sensitive to detect nearly a single viral particle (1.16 ± 0.13) per PCR of prototype strain type 3 Dearing. Pairwise comparisons of the 44 partial L1 gene sequences revealed that nucleotide variability ranged from 0 to 24.7%, with most of the nucleotide polymorphism occurring at synonymous positions. Phylogenetic trees generated from amplified L1 gene sequences suggest that multiple alleles of the L1 gene cocirculate in nature and that genetic diversity of the L1 gene is largely independent of the host species, geographic locale, or date of isolation. Phylogenetic trees constructed from the L1 gene sequences are distinct from those constructed from the four reovirus S-class gene segments, which supports the hypothesis that reovirus gene segments reassort in nature. This study establishes a new sensitive and specific technique for the identification of mammalian reoviruses and enhances our understanding of reovirus evolution.

Performance of a Rapid Influenza Test in Children During the H1N1 2009 Influenza A Outbreak

OBJECTIVE: To evaluate the performance of a rapid influenza diagnostic test (RIDT) in detecting H1N1 2009 influenza A virus in respiratory samples from pediatric patients in comparison to that of real-time reverse-transcriptase polymerase chain reaction (rRT-PCR) and viral culture. Methodology. This was a cross-sectional diagnostic-accuracy study conducted at a tertiary care childrens hospital. Patients for whom the RIDT (BinaxNOW [Binax, Inc, Portland, ME]), viral culture, and rRT-PCR results were known were included. Sensitivity, specificity, and likelihood ratios (LRs) were calculated. RESULTS: A total of 3030 specimens had RIDT results paired with both rRT-PCR and viral culture results. With rRT-PCR as the reference, overall test sensitivity was 45% (95% confidence interval [CI]: 43.3%–46.3%) and specificity was 98.6% (95% CI: 98.1%–99%). Positive and negative LRs were 32.9 (95% CI: 22.9–45.4) and 0.56 (95% CI: 0.54–0.58), respectively. RIDT sensitivity was significantly higher in young infants and children younger than 2 years than in older children. Using viral culture as the reference standard, RIDT sensitivity was 55.5% (95% CI: 51.9%–95.6%) and specificity was 95.6% (95% CI: 95%–96.1%). The positive and negative LRs were 12.6 and 0.47, respectively. CONCLUSIONS: The RIDT had relatively poor sensitivity but excellent specificity in this consecutive series of respiratory specimens obtained from pediatric patients. Although a positive RIDT result was highly accurate in predicting infection with influenza type A H1N1 2009 in children, a negative RIDT result did not preclude a child having H1N1. Therefore, for children at high risk with influenza-like illnesses during high-prevalence periods of influenza, empiric initiation of antiviral therapy should be considered for patients with a negative RIDT result.

Outside the Box and Into Thick Air: Implementation of an Exterior Mobile Pediatric Emergency Response Team for North American H1N1 (Swine) Influenza Virus in Houston, Texas

Study objective We describe the implementation of a mobile pediatric emergency response team for mildly ill children with influenza-like illnesses during the H1N1 swine influenza outbreak. Methods This was a descriptive quality improvement study conducted in the Texas Childrens Hospital (Houston, TX) pediatric emergency department (ED), covered, open-air parking lot from May 1, 2009, to May 7, 2009. Children aged 18 years or younger were screened for viral respiratory symptoms and sent to designated areas of the ED according to level of acuity, possibility of influenza-like illness, and the anticipated need for laboratory evaluation. Results The mobile pediatric emergency response team experienced 18% of the total ED volume, or a median of 48 patients daily, peaking at 83 patients treated on May 3, 2009. Although few children had positive rapid influenza assay results and the morbidity of disease in the community appeared to be minimal for the majority of children, anxiety about pandemic influenza drove a large number of ED visits, necessitating an increase in surge capacity. Surge capacity was augmented both through utilization of existing institutional resources and by creating a novel area in which to treat patients with potential airborne pathogens. Infection control procedures and patient safety were also maximized through patient cohorting and adaptation of social distancing measures to the ED setting. Conclusion The mobile pediatric emergency response team and screening and triage algorithms were able to safely and effectively identify a group of low-acuity patients who could be rapidly evaluated and discharged, alleviating ED volume and potentially preventing transmission of H1N1 influenza.

Development and validation of an ultrasound scoring system for children with suspected acute appendicitis

BackgroundTo facilitate consistent, reliable communication among providers, we developed a scoring system (Appy-Score) for reporting limited right lower quadrant ultrasound (US) exams performed for suspected pediatric appendicitis.ObjectiveThe purpose of this study was to evaluate implementation of this scoring system and its ability to risk-stratify children with suspected appendicitis.Materials and methodsIn this HIPAA compliant, Institutional Review Board-approved study, the Appy-Score was applied retrospectively to all limited abdominal US exams ordered for suspected pediatric appendicitis through our emergency department during a 5-month pre-implementation period (Jan 1, 2013, to May 31, 2013), and Appy-Score use was tracked prospectively post-implementation (July 1, 2013, to Sept. 30,2013). Appy-Score strata were: 1 = normal completely visualized appendix; 2 = normal partially visualized appendix; 3 = non-visualized appendix, 4 = equivocal, 5a = non-perforated appendicitis and 5b = perforated appendicitis. Appy-Score use, frequency of appendicitis by Appy-Score stratum, and diagnostic performance measures of US exams were computed using operative and clinical finding as reference standards. Secondary outcome measures included rates of CT imaging following US exams and negative appendectomy rates.ResultsWe identified 1,235 patients in the pre-implementation and 686 patients in the post-implementation groups. Appy-Score use increased from 24% (37/155) in July to 89% (226/254) in September (P < 0.001). Appendicitis frequency by Appy-Score stratum post-implementation was: 1 = 0.5%, 2 = 0%, 3 = 9.5%, 4 = 44%, 5a = 92.3%, and 5b = 100%. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 96.3% (287/298), 93.9% (880/937), 83.4% (287/344), and 98.8% (880/891) pre-implementation and 93.0% (200/215), 92.6% (436/471), 85.1% (200/235), and 96.7% (436/451) post-implementation – only NPV was statistically different (P = 0.012). CT imaging after US decreased by 31% between pre- and post-implementation, 8.6% (106/1235) vs. 6.0% (41/686); P = 0.048). Negative appendectomy rates did not change (4.4% vs. 4.1%, P = 0.8).ConclusionA scoring system and structured template for reporting US exam results for suspected pediatric appendicitis was successfully adopted by a pediatric radiology department at a large tertiary children’s hospital and stratifies risk for children based on their likelihood of appendicitis.

Performance of a Rapid Assay (Binax NOW) for Detection of Respiratory Syncytial Virus at a Children's Hospital over a 3-Year Period

ABSTRACT A rapid assay, Binax NOW RSV, was compared to viral culture for 14,756 pediatric respiratory specimens obtained from 2003 to 2006. There were 794 viral culture-confirmed respiratory syncytial virus infections. Sensitivity was 81%, and specificity was 93.2%. Sensitivity was greatest for neonates (91.1% versus 80.7% [P < 0.01]).