Basim I. Asmar

An outbreak of carbapenem-resistant Acinetobacter baumannii infection in a neonatal intensive care unit: investigation and control.

OBJECTIVEnTo investigate the mode of transmission of and assess control measures for an outbreak of carbapenem-resistant (multidrug-resistant) Acinetobacter baumannii infection involving 6 premature infants.nnnDESIGNnAn outbreak investigation based on medical record review was performed for each neonate during the outbreak (from November 2008 through January 2009) in conjunction with an infection control investigation.nnnSETTINGnA 36-bed, level 3 neonatal intensive care unit in a university-affiliated teaching hospital in Detroit, Michigan.nnnINTERVENTIONSnSpecimens were obtained for surveillance cultures from all infants in the unit. In addition, geographic cohorting of affected infants and their nursing staff, contact isolation, re-emphasis of adherence to infection control practices, environmental cleaning, and use of educational modules were implemented to control the outbreak.nnnRESULTSnSix infants (age, 10-197 days) with multidrug-resistant A. baumannii infection were identified. All 6 infants were premature (gestational age, 23-30 weeks) and had extremely low birth weights (birth weight, 1000 g or less). Conditions included conjunctivitis (2 infants), pneumonia (4 infants), and bacteremia (1 infant). One infant died of causes not attributed to infection with the organism; the remaining 5 infants were discharged home. All surveillance cultures of unaffected infants yielded negative results.nnnCONCLUSIONSnThe spread of multidrug-resistant A. baumannii infection was suspected to be due to staff members who spread the pathogen through close contact with infants. Clinical staff recognition of the importance of multidrug-resistant A. baumannii recovery from neonatal intensive care unit patients, geographic cohorting of infected patients, enhanced infection control practices, and staff education resulted in control of the spread of the organism.

A Randomized Placebo-Controlled Trial of Massage Therapy on the Immune System of Preterm Infants

OBJECTIVES: The aim of this study was to investigate the effects of massage therapy (MT) on the immune system of preterm infants. The primary hypothesis was that MT compared with sham therapy (control) will enhance the immune system of stable premature infants by increasing the proportion of their natural killer (NK) cell numbers. METHODS: A randomized placebo-controlled trial of MT versus sham therapy (control) was conducted among stable premature infants in the NICU. Study intervention was provided 5 days per week until hospital discharge for a maximum of 4 weeks. Immunologic evaluations (absolute NK cells, T and B cells, T cell subsets, and NK cytotoxicity), weight, number of infections, and length of hospital stay were also evaluated. RESULTS: The study enrolled 120 infants (58 massage; 62 control). At the end of the study, absolute NK cells were not different between the 2 groups; however, NK cytotoxicity was higher in the massage group, particularly among those who received ≥5 consecutive days of study intervention compared with control (13.79 vs 10 lytic units, respectively; P = .04). Infants in the massage group were heavier at end of study and had greater daily weight gain compared with those in the control group; other immunologic parameters, number of infections, and length of stay were not different between the 2 groups. CONCLUSIONS: In this study, MT administered to stable preterm infants was associated with higher NK cytotoxicity and more daily weight gain. MT may improve the overall outcome of these infants. Larger studies are needed.

Nosocomial Infections and Multidrug-Resistant Bacterial Organisms in the Pediatric Intensive Care Unit

Nosocomial infections in Pediatric Intensive Care Units (PICUs) caused by multidrug-resistant bacterial organisms are increasing. This review attempts to report on significant findings in the current literature related to nosocomial infections in PICU settings with an international perspective. The types of nosocomial infections are addressed, including catheter-related bloodstream infections, ventilator-associated pneumonia, urinary tract infections, gastrointestinal infections and post-surgical wound infections. A review of emerging resistant bacterial pathogens includes methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus sp., Clostridium difficile, extended-spectrum β-lactamase producing Gram-negative organisms, Klebsiella pneumoniae carbapenemase-producing strains and multi-drug resistant Acinetobacter baumannii. Basic and enhanced infection control methods for the management and control of multidrug-resistant organisms are also summarized with an emphasis on prevention.

Increased Prevalence of G1P[4] Genotype among Children with Rotavirus-Associated Gastroenteritis in Metropolitan Detroit

ABSTRACT The G and P genotypes of rotavirus stool isolates from 100 children were determined by reverse transcription-PCR and nucleotide sequencing. G1P[4] was the most prevalent genotype(41%), followed by G1P[8] (16%) and G4P[4] (14%). The G genoypes detected were G1 (73%), G4 (17.4%), G9 (6.3%), and G2 (2.8%). The P genotypes were P[4] (71%) and P[8] (29%). Coinfection with more than one G genotype occurred in 12 patients, and coinfection with more than one P genotype occurred in 11 patients.

Increased prevalence of methicillin-resistant Staphylococcus aureus nasal colonization in household contacts of children with community acquired disease

BackgroundTo measure Methicillin-resistant Staphylococcus aureus (MRSA) nasal colonization prevalence in household contacts of children with current community associated (CA)-MRSA infections (study group) in comparison with a group of household contacts of children without suspected Staphylococcus aureus infection (a control group).MethodsThis is a cross sectional study. Cultures of the anterior nares were taken. Relatedness of isolated strains was tested using pulse field gel electrophoresis (PFGE).ResultsThe prevalence of MRSA colonization in the study group was significantly higher than in the control group (18/77 (23%) vs 3/77 (3.9%); p ≤ 0.001). The prevalence of SA colonization was 28/77 (36%) in the study group and 16/77 (21%) in the control group (p = 0.032). The prevalence of SA nasal colonization among patients was 6/24 (25%); one with methicillin-susceptible S. aureus (MSSA) and 5 with MRSA. In the study (patient) group, 14/24 (58%) families had at least one household member who was colonized with MRSA compared to 2/29 (6.9%) in the control group (p = 0.001). Of 69 total isolates tested by PFGE, 40 (58%) were related to USA300. Panton-Valetine leukocidin (PVL) genes were detected in 30/52 (58%) tested isolates. Among the families with ≥1 contact colonized with MRSA, similar PFGE profiles were found between the index patient and a contact in 10/14 families.ConclusionsPrevalence of asymptomatic nasal carriage of MRSA is higher among household contacts of patients with CA-MRSA disease than control group. Decolonizing such carriers may help prevent recurrent CA-MRSA infections.

Methicillin-resistant Staphylococcus aureus (MRSA) in hospitalized children: correlation of molecular analysis with clinical presentation and antibiotic susceptibility testing (ABST) results.

The molecular analysis of methicillin-resistant Staphylococcus aureus (MRSA) from 98 children admitted to the Children’s Hospital of Michigan, Detroit, MI, with serious MRSA infections during 2006–2007 was correlated with risk factors, clinical features, and antibiotic susceptibility testing (ABST) results. Isolates were characterized by staphylococcal cassette chromosome (SCC) mec type, the presence of Panton-Valentine leukocidin (PVL) genes, repetitive sequence (rep) polymerase chain reaction (PCR) and pulsed-field gel electrophoresis (PFGE), requirement for surgical intervention, antibiograms, and response to therapy. rep-PCR was more rapid than PFGE typing and correlated well. SCCmec type IV-containing isolates caused 92.8% of all infections, but the demographics and diseases associated with subtypes IVa and IVd differed. Subtype IVa (all PFGE type USA300 and PVL-positive) was identified in 81/93 (87.1%) of patients with community-onset (CO) MRSA, including 21/35 of those with risk factors for health care-associated (HA) infection. All other clones were PVL-negative. Subtype IVd (10 isolates; 9 USA800 and 1 eMRSA15) caused mainly HA-MRSA and no skin and soft tissue infections (SSTI). Seven classic HA-MRSA strains (SCCmec types II [6; 3 USA100 and 3 USA600] and III [1; USA200]) caused HA and hospital-onset (HO) infections. Surgical intervention was required in 68/81 patients infected with USA300 and 8/17 of the others. Most USA300 were susceptible (S) to clindamycin (CD) and patients were treated with CD alone or in combination. The other isolates were generally treated with vancomycin (VA) alone or in combination.

Asaia lannaensis bloodstream infection in a child with cancer and bone marrow transplantation

A 3-year-old Caucasian boy with medulloblastoma in relapse, who had received an autologous haematopoietic stem cell transplant (AHSCT), underwent chemotherapy and craniospinal radiation followed by a second AHSCT. The patient received a preparative chemotherapy regimen of carboplatin, etoposide and melphalan followed by the AHSCT at a CD34+ dose of 3.73610 cells kg. His post-transplant course was complicated by severe mucositis, pancytopenia and Clostridium difficile colitis diagnosed on day 6 post-transplantation (PT). He was successfully treated for the C. difficile colitis with metronidazole. On day 7, he developed hypertonia and spastic posturing. Magnetic resonance imaging of the brain showed an old subdural haematoma and possible radiation necrosis in the brainstem. He underwent craniotomy and drainage of the haematoma, and was treated with intravenous meropenem and vancomycin because of the neutropenia and mucositis. He improved and engrafted by day 12 PT. His antibiotic treatment was changed to intravenous cefepime. On day 14 PT, he developed tachycardia, hypotension and fever up to 40.1 uC. Blood cultures were obtained from both lumens of the CVC. Intravenous meropenem and vancomycin were restarted. Both blood cultures grew Gram-negative bacilli within 12–18 h. The patient remained febrile and hypotensive and tobramycin was added to his treatment regimen. Because the CVC was a possible source of infection, the catheter was locked with 70 % ethanol (the catheter volume plus 0.1 ml) according to our institutional protocol for sterilizing CVCs without removal. After 24 h, the catheter was flushed with normal saline (Dannenberg et al., 2003; Onland et al., 2006).

Neonatal Retropharyngeal Cellulitis Due to Group B Streptococcus

Two neonates who presented with histories of poor feeding, irritability and noisy breathing had group B streptococcal (GBS) bacteremia and retropharyngeal cellulitis. One infant also had submandibular cellulitis. Retropharyngeal cellulitis has not been recognized as a manifestation of GBS disease. Evaluation of the upper airway should be part of the workup of any sick infant with noisy breathing and/or grunting. Retropharyngeal tissue enlargement may be an early indicator of GBS disease.

Emergence of human rotavirus genotype G9 in metropolitan Detroit between 2007 and 2009

Between January 2007 and April 2009, rotavirus (RV)-positive stool samples from 238 children with acute gastroenteritis, seen at Childrens Hospital of Michigan in Detroit, USA, were collected and RV genotyping was performed. G and P genotypes were determined by RT-PCR and nucleotide sequencing was conducted on selected G9 and P[6] strains. Correlation between the severity of gastroenteritis episode and the infecting G genotype was done using a 14-point scoring system. The predominant G genotype was G9 (39.5u200a%), followed by G1 (35.3u200a%) and G4 (15.5u200a%), while P[8] was the most prevalent P genotype (66.5u200a%), followed by P[4] (21.9u200a%) and P[6] (11.2u200a%). The gene combinations G1P[8] and G9P[8] were the most prevalent (21.4u200a% and 20.6u200a%, respectively), followed by G4P[8] (13u200a%) and G9P[6] (8.8u200a%). Immunization data showed that only 17/238 (7.1u200a%) children received ≥one dose of RV vaccine (the pentavalent vaccine RotaTeq or the monovalent vaccine Rotarix) and that 10/17 were infected with G4P[8] strains. Severity of RV gastroenteritis episodes was not related to the infecting G genotype. Our results suggest a high proportion of genotype G9 strains in combination with P[8], P[6] and P[4] specificity circulating in the metropolitan Detroit area. While the protective efficacy of the RV vaccines has been demonstrated against G9P[8] strains, the level of cross-protection offered by the vaccines against G9 strains with P[6] and P[4] genotypes in the Detroit paediatric population remains to be determined.

Kawasaki Disease Hospitalizations in a Predominantly African-American Population

This is a descriptive study of the occurrence of Kawasaki disease (KD) in an urban population that was a majority of African Americans. Records of 189 children (mean age, 2.9 ± 2.2 years [range: 2 months to 11.1 years]) hospitalized for KD over 8 years (January 1, 1992 to December 31, 1999) were reviewed and data analyzed. One hundred thirty-six (72%) were African American (AA), 43 (23%) were white, and 9 (5%) children were “others.” The annual frequency was 15 for AA and 7.7 for white per 100,000 5-year-old children. Coronary artery abnormalities (CAA) were reported in 21 (11%) children (18 [13.2%] of 136 AA, and 3 [4.7%] of 43 whites [p=0.095]). AA children with CAA were older than their white counterparts (26 to 24 vs. 5 to 2.8 months, p=0.03). There was a higher occurrence in winter and spring (110 cases [58%] vs. 79 cases [42%]) compared to summer and fall. KD occurrence was positively associated with average monthly snowfall (r=0.35, p=0.004) and inversely associated with average monthly temperature (r= - 0.2, p=0.048). African-American children were more likely to be hospitalized for KD compared to white children. The association of KD with temperature and precipitation suggest that it is influenced by environmental factors.