Briony Hazelton

SEVERE ENCEPHALOPATHY WITH SWINE ORIGIN INFLUENZA A H1N1 INFECTION IN CHILDHOOD: CASE REPORTS

The potential for severe respiratory complications associated with swine origin influenza A H1N1 is well documented.1 Australia has seen a dramatic increase in the number of cases of H1N1 infection. H1N1 currently is responsible for >50% of all influenza cases in the Australian 2009 winter. Recently 4 children were reported with neurologic complications associated with swine origin influenza A H1N1.2 We report 2 previously well children who presented to our institution over a 2-week period with serious neurologic complications and focal changes on MRI associated with H1N1 2009 influenza infection. ### Case reports. Case 1 was a previously healthy 5-year-old girl who presented with 3 days of fever, right occipital headache, confusion, and drowsiness. She was febrile (38.5°C), agitated, and had a left hemiplegia. A brain MRI showed high signal and swelling of the right parieto-occipital cortex on T2-weighted images with diffusion restriction in the underlying subcortical white matter (figure, A). A nasopharyngeal swab specimen was positive for influenza A by direct immunofluorescence (IF), which was identified as influenza H1N1 of swine origin by real-time PCR.3 CSF RT-PCR was negative for H1N1 influenza virus. Treatment was started with oseltamivir within 24 hours of admission. She subsequently developed focal status epilepticus (clonic jerking of left hand and face) with right posterior spike and wave activity on EEG. …

Vitamin D and tuberculosis status in refugee children

Vitamin D deficiency and tuberculosis (TB) are associated in adults, but data in children are scarce. We screened refugee children routinely for vitamin D status and TB. Vitamin D values were significantly lower in latent TB (n = 81) and TB infection (n = 11) than in children without TB (n = 236). We conclude that refugee children with TB have reduced vitamin D levels.

Detection of influenza A and B with the Alere™ i Influenza A & B: a novel isothermal nucleic acid amplification assay

Rapid influenza diagnostic tests (RIDTs) have an important role in clinical decision‐making; however, the performances of currently available assays vary widely.

Assessment and management of obesity in childhood and adolescence

The increased prevalence of obesity in childhood and adolescence highlights the need for effective treatment approaches. Initial assessments of these patients should include taking a careful history (investigating comorbidities, family history and potentially modifiable behaviors) and physical examination with BMI plotted on a BMI-for-age chart. The degree of investigation is dependent on the patients age and severity of obesity, the findings on history and physical examination, and associated familial risk factors. There are several broad principles of conventional management: management of comorbidities; family involvement; taking a developmentally appropriate approach; the use of a range of behavior change techniques; long-term dietary change; increased physical activity; and decreased sedentary behaviors. Orlistat can be useful as an adjunct to lifestyle changes in severely obese adolescents and metformin can be used in older children and adolescents with clinical insulin resistance. Bariatric surgery should be considered in those who are severely obese, with recognition of the need for management in centers with multidisciplinary weight management teams and for surgery to be performed in tertiary institutions experienced in bariatric surgery. Finally, given the high prevalence and chronic nature of obesity, coordinated models of care for health-service delivery for the management of pediatric obesity are needed.

Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines

Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.

Perinatal outcomes of Australian buprenorphine‐exposed mothers and their newborn infants

To determine the short‐term outcomes of Australian buprenorphine‐exposed mother/infant dyads.

Nontuberculous Mycobacteria in Children: A Focus on Bloodstream Infections

Background: Nontuberculous mycobacteria (NTM) are ubiquitous organisms with variable disease-causing potential. Bloodstream infections caused by NTM in children are poorly described. Methods: We describe a retrospective case series of children with culture-confirmed mycobacterial disease managed at the Children’s Hospital at Westmead between July 2005 and June 2015. Results: Sixty-five patients had 149 positive NTM cultures; 55 (83.0%) episodes in 54 patients were considered clinically significant. Of the 54 children who met criteria for NTM disease, 25 (46.3%) had lymphadenitis, 13 (24.1%) lung disease, 8 (14.8%) had soft tissue infection or osteomyelitis and 8 (14.8%) had bacteremia. All children with bacteremia had a central venous catheter; those with pulmonary infection had underlying lung disease and all children with soft tissue infection or osteomyelitis had a history of recent penetrating injury. Disease caused by Mycobacterium avium–intracellulare complex was most common, accounting for 19 (76.0%) and 7 (53.8%) lymph node and lung infections, respectively. The most frequently isolated rapid growing mycobacteria were Mycobacterium fortuitum (8; 15%) and Mycobacterium abscessus (6; 11%), with M. fortuitum accounting for the majority (6; 75%) of bloodstream infections. Six (75%) patients with bacteremia had their intravenous catheter removed and all had a favorable outcome. A single disease relapse was reported in 1 of 2 patients with a retained catheter. Conclusion: Lymphadenitis was the most common NTM disease manifestation and not associated with comorbidity. NTM bacteremia was always associated with a central line and catheter removal with cure. We were unable to assess the added value of various antibiotic regimens.

Disseminated tuberculosis and tuberculous meningitis in Australian-born children; case reports and review of current epidemiology and management

We present two cases of tuberculous meningitis in Australian‐born children. We review the current literature surrounding management of paediatric tuberculosis and disseminated disease, emphasising the importance of prompt diagnosis and intervention. We discuss the epidemiology of tuberculosis in the Australian paediatric population and highlight the sentinel role of childhood infection in public health surveillance.

Epidural abscess in a neonate.

We report the case of a 16‐day‐old neonate who presented with fever and irritability. Blood and cerebrospinal fluid (CSF) samples collected on his admission grew methicillin sensitive Staphylococcus aureus on culture, prompting an urgent search for parameningeal collections or an occult sinus involving the central nervous system. Magnetic resonance imaging revealed a pyogenic collection within the epidural space extending from the upper cervical to lumbosacral level and multiple other deep tissue collections that required repeated surgical drainage. Central nervous system infections due to S. aureus are uncommon, particularly in the absence of an anatomical defect or prior neurosurgical instrumentation. This case demonstrates the importance of a timely and thorough search for parameningeal foci when CSF cultures are positive for unusual organisms such as S. aureus.

Shigella species epidemiology and antimicrobial susceptibility: the implications of emerging azithromycin resistance for guiding treatment, guidelines and breakpoints

Objectives To examine antimicrobial susceptibility patterns and predictors of resistance among Shigella isolates in New South Wales (NSW), Australia during 2013-14 with emphasis on azithromycin. Methods Cross-sectional analysis of all shigellosis cases (160) notified to public health authorities in NSW, Australia was performed. Results Among 160 Shigella isolates tested, 139 (86.9%) were susceptible to azithromycin, 104 (65.0%) to ciprofloxacin and 38 (23.7%) to co-trimoxazole. Ciprofloxacin resistance was 1.9 times more common in infections acquired in Australia compared with those acquired overseas, while azithromycin resistance was 8.5 times more common in males. Conclusions We recommend ongoing reconsideration of guidelines for the treatment of shigellosis based on emerging resistance patterns. First-line therapy may need to be reconsidered based on local resistance rates due to common resistance to co-trimoxazole and ciprofloxacin. We recommend culture and susceptibility testing for suspected and proven shigellosis. Azithromycin susceptibility breakpoints for Shigella species may need to be species specific.