Anusha Ganeshalingham

Burden and outcomes of severe pertussis infection in critically ill infants

Objectives: Despite World Health Organization endorsed immunization schedules, Bordetella pertussis continues to cause severe infections, predominantly in infants. There is a lack of data on the frequency and outcome of severe pertussis infections in infants requiring ICU admission. We aimed to describe admission rates, severity, mortality, and costs of pertussis infections in critically ill infants. Design: Binational observational multicenter study. Setting: Ten PICUs and 19 general ICUs in Australia and New Zealand contributing to the Australian and New Zealand Paediatric Intensive Care Registry. Patients: Infants below 1 year of age, requiring intensive care due to pertussis infection in Australia and New Zealand between 2002 and 2014. Measurements and Main Results: During the study period, 416 of 42,958 (1.0%) infants admitted to the ICU were diagnosed with pertussis. The estimated population-based ICU admission rate due to pertussis ranged from 2.1/100,000 infants to 18.6/100,000 infants. Admission rates were the highest among infants less than 60 days old (p < 0.0001). Two hundred six infants (49.5%) required mechanical ventilation, including 20 (4.8%) treated with high-frequency oscillatory ventilation, 16 (3.8%) with inhaled nitric oxide, and 7 (1.7%) with extracorporeal membrane oxygenation. Twenty of the 416 children (4.8%) died. The need for mechanical ventilation, high-frequency oscillatory ventilation, nitric oxide, and extracorporeal membrane oxygenation were significantly associated with mortality (p < 0.01). Direct severe pertussis–related hospitalization costs were in excess of USD

Bacteroides fragilis concealed in an infant with Escherichia coli meningitis

1,000,000 per year. Conclusions: Pertussis continues to cause significant morbidity and mortality in infants, in particular during the first months of life. Improved strategies are required to reduce the significant healthcare costs and disease burden of this vaccine-preventable disease.

Porcelain lung: calcification in severe Bordetella pertussis infection

Anaerobic meningitis in infants is rare, therefore a high index of clinical suspicion is essential as routine methods for processing cerebrospinal fluid (CSF) do not detect anaerobes and specific antimicrobial therapy is required. We present an infant with Escherichia coli meningitis where treatment‐resistance developed in association with culture negative purulent CSF. These features should have alerted us to the presence of anaerobes, prompting a search for the causes of polymicrobial meningitis in infants.

Increasing Incidence of Life-threatening Pertussis: A Retrospective Cohort Study in New Zealand

An unimmunised 5-week-old, term male infant presented to the intensive care unit with cardiorespiratory failure and peripheral lymphocytosis. The infant deteriorated despite intubation, ventilation, vasoactive drug infusions and exchange transfusion. Venoarterial extracorporeal membrane oxygenation (ECMO) was started. Infection with Bordetella pertussis was subsequently confirmed. The lungs remained radiologically opacified and tidal volumes were poor despite lung recruitment manoeuvres, resulting in a prolonged …

Identifying Children at Risk of Malignant bordetella pertussis Infection

Background: Pertussis immunization programs aim to prevent severe infant disease. We investigated temporal trends in infant pertussis deaths and pediatric intensive care unit (PICU) admissions and associations of changes in disease detection and vaccines used with death and PICU admission rates. Methods: Using national data from New Zealand (NZ), we described infant pertussis deaths and PICU admissions from 1991 to 2013, over which time national immunization coverage at 2 years of age increased from <80% to 92%. In NZ, pertussis became a notifiable disease with polymerase chain reaction (PCR) diagnosis available in 1997 and acellular replaced whole-cell vaccine in 2000. We used Poisson regression to model temporal trends and compared rates in time intervals using rate ratios (RRs) with 95% confidence intervals (CIs). Results: There were 10 pertussis deaths and 159 infant PICU admissions with pertussis from 1991 to 2013. The annual number of infant pertussis PICU admissions increased from 1991 to 2013 (P = 0.02) but the number of pertussis deaths did not (P = 0.09). The risk of PICU admission during infancy with pertussis was increased in the notification/PCR versus the non-notification/PCR era (RR: 1.12; 95% CI: 1.02–1.19) and when acellular replaced whole-cell vaccine (RR: 1.19; 95% CI: 1.06–1.31). Median Pediatric Index of Mortality scores during 2001–2013 were lower than during 1991–1999 (P < 0.001). Conclusions: Infant PICU pertussis admission rates have increased in NZ despite improvements in immunization coverage. Higher rates have occurred since pertussis notification/PCR became available and since acellular replaced whole-cell vaccine. The severity of disease in infants admitted to PICU with pertussis has decreased in recent years.

Cerebral perfusion pressure-targeted therapy versus intracranial pressure-targeted therapy in acute meningitis.

Objective: To identify factors associated with malignant pertussis. Design: A retrospective case notes review from January 2003 to August 2013. Area under the receiver-operator characteristic curve was used to determine how well vital sign and white cell characteristics within 48 hours of hospital presentation identified children with malignant pertussis. Setting: The national children’s hospital in Auckland, New Zealand. Patients: One hundred fifty-two children with pertussis. Measurements and Main Results: There were 152 children with confirmed pertussis identified, including 11 children with malignant pertussis. The area under the receiver-operator characteristic curve was 0.88 (95% CI, 0.78–0.97) for maximum heart rate. The optimal cut-point was 180 beats/min, which predicted malignant pertussis with a sensitivity of 73% and a specificity of 91%. The area under the receiver-operator characteristic curve was 0.92 (95% CI, 0.81–1.0) for absolute neutrophil count, 0.85 (95% CI, 0.71–0.99) for total WBC count, 0.80 (95% CI, 0.63–0.96) for neutrophil-to-lymphocyte ratio, and 0.77 (95% CI, 0.58–0.92) for absolute lymphocyte count. All children with malignant pertussis had one or more of heart rate greater than 180 beats/min, total WBC count greater than 25 × 109/L, and neutrophil-to-lymphocyte ratio greater than 1.0 with an area under the receiver-operator characteristic curve of 0.96 (95% CI, 0.91–1.0) for a multivariate model that included these three variables. Conclusions: Clinical predictors of malignant pertussis are identifiable within 48 hours of hospital presentation. Early recognition of children at risk of malignant pertussis may facilitate early referral to a PICU for advanced life support and selection for trials of investigational therapies.

Severe Lactic Acidosis in an Amnesic Child

To the Editor: We read with interest a recent article published in Critical Care Medicine by Kumar et al (1). The authors make the following statements based on the results of a study published by Lindvall et al (2): “Reducing raised intracranial pressure (ICP) above 15 mm Hg increased the survival in children with bacterial meningitis” and “Lindvall et al solutions and benefit from Ringer’s acetate (5). Notably, saline has not improved survival-to-discharge in any study comparing fluid types in sepsis. Finally, we recently confirmed our observations regarding the potential risks of saline by noting the association between volume-adjusted chloride load and mortality among patients admitted with systemic inflammatory response syndrome (6). Supraphysiologic serum chloride concentration was associated with increased mortality and was also more likely to be a consequence of resuscitation with isotonic saline (6). Thus, until evidence from randomized controlled trials rejects our observations on the benefits of balanced crystalloid solutions, we suggest that the use of saline exclusively or in combination be restricted. There is certainly room for change as nearly all the patients in our large observational study had received some saline during resuscitation. Dr. Raghunathan’s institution received grant support from Baxter Healthcare. Dr. Konoske has disclosed that he does not have any potential conflicts of interest.

Isolated congenital mitral valve regurgitation presenting in the first year of life.

An 8-year-old boy presented to the emergency department after he was found unconscious outside his church on a rainy day. He had been seen by hismother 1 hour earlier and was previously fit and well and up to date with immunizations. An ambulancewas called and paramedics noted a reducedGlasgowComa Scale score of 3, trismuswithnormal respiratory effort, and a scalp hematomaon the left forehead.On arrival in theemergencydepartmenthewas afebrile, normotensivewith aheart rateof 120 beats/min, andhada respiratory rateof 20breaths/min.HisGlasgowComaScale scorehad improved to 14,buthehadno recollectionofevents.His left legwas flexed, andhe criedwhenever this limbwas examined.On closer inspection, his left footwaswarm, with generalizedmild erythema and swelling. Therewere bullae on the dorsumof the first and second toes and a cluster of painless, dry, black punctate lesions laterally (Figure, left). Similar, paler lesions were clustered symmetrically on the left (Figure, right) and right forearms. Venous blood gas analysis revealed severe lactic acidosis (pH, 6.9; PCO2, 4.9 kPa; PO2, 11.8 kPa; bicarbonate, 7.1 mEq/L; base excess, −26 mEq/L; and lactate, 171.17 mg/dL [19 mmol/L]). Values for serum glucose and ketones were 342.3 mg/dL (19 mmol/L) and 0 mmol/L, respectively. Other laboratory investigations were unremarkable apart from a creatinine kinase level of 3000 U/L (50.1 μkat/L) and a white blood cell count of 20 × 109 cells/L with lymphocytosis. Quiz at jama.com Figure.

Deep hypothermic circulatory arrest during the arterial switch operation is associated with reduction in cerebral oxygen extraction but no increase in white matter injury.

Aim:  Isolated congenital mitral regurgitation is rare and, when presenting in infancy, reflects severity of the malformation. The natural history is often fatal, and management during the first year of life remains a therapeutic challenge. These infants are poorly understood largely because of an absence of reporting in the medical literature and limited experience in each institution. We reviewed our own experience in order to add to the understanding of this condition.