Carlo Scolfaro

Nosocomial infections in pediatric cardiac surgery, Italy.

OBJECTIVE To evaluate the incidence of nosocomial infection (NI) in pediatric patients who received cardiothoracic surgery and to identify possible associated risk factors. DESIGN Prospective observational study. SETTING The cardiac surgery and cardiac intensive care units at the Regina Margherita Childrens Hospital, Turin, Italy. PATIENTS All patients who underwent surgery from July 20, 1998, to July 19, 1999, were enrolled, except patients with operative catheterization only. METHODS Clinical data were collected daily from July 20, 1998, to July 19, 1999. NIs were diagnosed according to US Centers for Disease Control and Prevention criteria. RESULTS 104 patients were included in the present study, 80 (76.9%) of whom underwent extracorporeal circulation. The NI ratio was 48.1% (50/104); the percentage of patients with NI was 30.8% (32/104): 23.1% developed one infection, 7.7% two or more. The rate of NI was 2.17 per 100 days of hospitalization (50/2,304). The most common pathogen was Pseudomonas aeruginosa. Important risk factors were length of preoperative admission >5 days, total length of admission >10 days, open chest during postoperative phase, and cyanotic heart disease. There was a significant association between sepsis and central venous catheterization for 3 days or more. Rate of sepsis was 19 per 1,000 catheter days (16/852). CONCLUSION NIs represent a frequent complication for children who undergo heart surgery. Based on our data, we suggest decreasing the preoperative stay as much as possible. The higher NI incidence in patients with an open chest postoperatively suggests that an alternative antibiotic strategy should be considered for these patients.

Vertically acquired hepatitis C virus infection: Correlates of transmission and disease progression

The worldwide prevalence of hepatitis C virus (HCV) infection in children is 0.05%-0.4% in developed countries and 2%-5% in resource-limited settings, where inadequately tested blood products or un-sterile medical injections still remain important routes of infection. After the screening of blood donors, mother-to-child transmission (MTCT) of HCV has become the leading cause of pediatric infection, at a rate of 5%. Maternal HIV co-infection is a significant risk factor for MTCT and anti-HIV therapy during pregnancy seemingly can reduce the transmission rate of both viruses. Conversely, a high maternal viral load is an important, but not preventable risk factor, because at present no anti-HCV treatment can be administered to pregnant women to block viral replication. Caution is needed in adopting obstetric procedures, such as amniocentesis or internal fetal monitoring, that can favor fetal exposure to HCV contaminated maternal blood, though evidence is lacking on the real risk of single obstetric practices. Mode of delivery and type of feeding do not represent significant risk factors for MTCT. Therefore, there is no reason to offer elective caesarean section or discourage breast-feeding to HCV infected parturients. Information on the natural history of vertical HCV infection is limited. The primary infection is asymptomatic in infants. At least one quarter of infected children shows a spontaneous viral clearance (SVC) that usually occurs within 6 years of life. IL-28B polymorphims and genotype 3 infection have been associated with greater chances of SVC. In general, HCV progression is mild or moderate in children with chronic infection who grow regularly, though cases with marked liver fibrosis or hepatic failure have been described. Non-organ specific autoantibodies and cryoglobulins are frequently found in children with chronic infection, but autoimmune diseases or HCV associated extrahepatic manifestations are rare.

Use of linezolid in infants and children: a retrospective multicentre study of the Italian Society for Paediatric Infectious Diseases

OBJECTIVES Because of the spread of drug-resistant Gram-positive bacteria, the use of linezolid for treating severe infections is increasing. However, clinical experience in the paediatric population is still limited. We undertook a multicentre study to analyse the use of linezolid in children. METHODS Hospitalized children treated with linezolid for a suspected or proven Gram-positive or mycobacterial infection were analysed retrospectively. Side effects were investigated, focusing on younger children and long-term treatments. RESULTS Seventy-five patients (mean age 6.8 years, range 7 days to 17 years) were studied. Mean ± SD linezolid treatment duration was 26.13 ± 17 days. Clinical cure was achieved in 74.7% of patients. The most frequent adverse events were diarrhoea and vomiting. Two patients had severe anaemia, two neutropenia and one thrombocytopenia. Two cases of grade 3 liver function test elevation and one case of pancreatitis were reported. The overall frequency of adverse events was similar between patients treated for >28 days and those receiving shorter treatments (30.8% versus 28.6%, P = 0.84). Children aged <2 years received linezolid for a shorter duration than older children (21.2 days versus 28.4 days, P = 0.05), whereas the frequency of adverse events was similar in the two age groups. CONCLUSIONS In our paediatric population, linezolid appeared safe and effective for the treatment of selected Gram-positive and mycobacterial infections. The adverse reactions encountered were reversible and appeared comparable to those reported in paediatric clinical trials. Nevertheless, the potential for haematological toxicity of linezolid in children means that careful monitoring is required during treatment.

Moxifloxacin for the treatment of pulmonary tuberculosis in children: A single center experience

To report our experience on the safety and tolerability of moxifloxacin for treating children affected by pulmonary TB.

Carbapenem-resistant Enterobacteriaceae Infections in Children: An Italian Retrospective Multicenter Study.

Background: The spread of carbapenem-resistant Enterobacteriaceae (CRE) is a health problem of major concern. CRE-related infections have significant morbidity and mortality, but data on CRE infection in pediatric population are limited. The aim of this study was to analyze epidemiologic and clinical characteristics, risk factors, therapeutic options and outcome of CRE infections in children in Italy. Methods: We performed a retrospective, multicenter, observational study of children with confirmed CRE infection or colonization admitted between January 1, 2011, and March 1, 2014, to 7 Italian pediatric centers. Results: Sixty-nine patients presenting 74 CRE infections and/or colonization were included. The most frequently isolated strain was Klebsiella pneumoniae carbapenemase-producing K. pneumoniae. Children with CRE infections had longer length of stay in hospital (P < 0.001), duration of disease (P = 0.001) and antimicrobial treatment (P < 0.001) than colonized children. Oncologic/immunosuppressive conditions are one of the factors significantly associated with a fatal outcome among children with CRE infections. Conclusions: Our study confirms that CRE infections affect mostly children with oncologic diseases and immunosuppression. Controlled studies in large cohorts are needed to evaluate the best therapeutic options and to assess further risk factors influencing outcomes and the survival of pediatric patients with infections caused by CRE.The spread of carbapenem-resistant Enterobacteriaceae (CRE) is a health problem of major concern. CRE-related infections have significant morbidity and mortality, but data on CRE infection in pediatric population are limited. The aim of this study was to analyze epidemiologic and clinical characteristics, risk factors, therapeutic options and outcome of CRE infections in children in Italy. We performed a retrospective, multicenter, observational study of children with confirmed CRE infection or colonization admitted between January 1, 2011, and March 1, 2014, to 7 Italian pediatric centers. Sixty-nine patients presenting 74 CRE infections and/or colonization were included. The most frequently isolated strain was Klebsiella pneumoniae carbapenemase-producing K. pneumoniae. Children with CRE infections had longer length of stay in hospital (P < 0.001), duration of disease (P = 0.001) and antimicrobial treatment (P < 0.001) than colonized children. Oncologic/immunosuppressive conditions are one of the factors significantly associated with a fatal outcome among children with CRE infections. Our study confirms that CRE infections affect mostly children with oncologic diseases and immunosuppression. Controlled studies in large cohorts are needed to evaluate the best therapeutic options and to assess further risk factors influencing outcomes and the survival of pediatric patients with infections caused by CRE.

An uncommon cause of seizures in children living in developed countries: neurocysticercosis -a case report

Neurocysticercosis represents an important cause of seizures in children in endemic countries, such as Latin America, Asia and sub-Saharan Africa, while in Europe, especially in Italy, the cases of neurocysticercosis are anectodal. We report the case of a 6 year old boy, born and lived for four years in Cameroon, who presented a right emiconvulsion. The diagnosis was neurocysticercosis. This case accentuates the need to consider neurocysticercosis in a child presenting with non febrile seizures, mainly if he emigrated from an area of high prevalence or if he had long-term stay in endemic regions.

The spread of drug-resistant tuberculosis in children: an Italian case series

Drug-resistant paediatric tuberculosis (TB) is an overlooked global problem. In Italy, the epidemiology of TB has recently changed and data regarding drug-resistant forms in the paediatric setting is scanty. The aim of this case series was to report the cases of drug-resistant TB, diagnosed between June 2006 and July 2010 in four Italian tertiary centres for paediatric infectious diseases, in children and adolescents living in Italy. Twenty-two children were enrolled, of these 17 were resistant to one or more drugs and five had multidrug-resistant TB. All but one child were either foreign born or had at least one foreign parent. Twenty-one patients completed their treatment without clinical or radiological signs of activity at the end of treatment, and one patient was lost to follow up. The outcomes were good, with few adverse effects using second-line anti-TB drugs. Although this series is limited, it might already reflect the worrisome increase of drug-resistant TB, even in childhood.

Etiological diagnosis of bloodstream infections through a multiplex real-time polymerase chain reaction test in pediatric patients: a case series from a tertiary Italian hospital

Abstract Background: The outcome of bloodstream infections (BSIs) is strongly related to microbiological diagnosis. Several factors may reduce blood culture (BC) diagnostic yield in pediatric BSIs, making the application of molecular methods quite promising. Methods: Multiplex real-time polymerase chain reaction (PCR) tests (the LightCycler Septifast Test MGRADE by Roche Diagnostics - LC-SF) performed in the tertiary centre of Regina Margherita Childrens Hospital (Turin, Italy) over a 3-year period were retrospectively evaluated. Results of the LC-SF test were compared with those of BC (Automated Bact/Alert 3D, Biomerieux) collected at a close time point. Results: 545 LC-SF tests were collected from 289 patients (183 males, median age 6.8 years, interquartile range (IQR) = 2.7–13.1); 163 had congenital or acquired immunodeficiency. In 515 cases (94.5%) the LC-SF test was performed with ongoing empirical antimicrobial therapy. Etiological definition was achieved in 111 BSI cases (20.4%). Both LC-SF and BC identified the responsible pathogen in 39 episodes. The LC-SF test alone gave a positive result in 29 septic episodes; BC alone permitted the etiological diagnosis in 43 episodes, but isolates were not included in the LC-SF master list in 10 cases. A 26% increase in bacterial identification chances due to the LC-SF test was documented. Cohens kappa test indicated a moderate strength of agreement (0.49) between LC-SF tests and BCs closely collected. Conclusions: BC remains the gold standard for the etiological diagnosis of BSIs, but PCR methods proved to be a valuable adjunctive diagnostic tool in pediatric BSIs, especially in children receiving empirical chemotherapy.

Carbapenemase-Producing Enterobacteriaceae (CPE) in the Pediatric Setting: Results from an 18-Month Survey

18-Month Survey Author(s): Sara Colombo, MD; Carlo Scolfaro, MD; Carmelina Calitri, MD; Marco Denina, MD; Francesca Carraro, MD; Gianfranco De Intinis, MD; Pier-Angelo Tovo, MD Source: Infection Control and Hospital Epidemiology, Vol. 35, No. 5 (May 2014), pp. 599-601 Published by: The University of Chicago Press on behalf of The Society for Healthcare Epidemiology of America Stable URL: http://www.jstor.org/stable/10.1086/675843 . Accessed: 24/06/2014 23:13

Primary sternal osteomyelitis in paediatric age: a case report with review of the literature

Osteomyelitis of the sternum is a rare clinical entity, mostly described in adults following cardiothoracic surgery, sternotomy, blunt chest traumas, intravenous line insertion and mediastinitis. When no predisposing factors can be demonstrated and no focus of infection other than sternal localization can be found, a diagnosis of primary sternal osteomyelitis (PSO) can be made. To date, slightly more than 20 cases of PSO have been documented in children: sternum ossification points are in their maximal activity phase in earlier paediatric age, representing a privileged area for bacterial growth after haematogenous bacterial spread. 1‐3 A healthy 15-month-old male came to our attention for midsternal swelling. He had a 20-day history of nocturnal awakening and weeping, with a febrile episode treated with paracethamol one week before hospital admission. Thenceforward he looked nervous and presented respiratory difficulties. No local traumas were reported. Upon examination, the child was afebrile, easily irritable and without apparent respiratory disturbances. An ill-defined midsternal swelling of 3 cm in diameter was palpable: it was tender, warm, painful, with reddening of the upper skin. White cell count was elevated (16.31610 3 /ml) with neutrophilia (53.7%, 8.76610 3 /ml); erythrocyte sedimentation rate and C-reactive protein were increased (120 mm/hour and 66.4 mg/l, respectively). No sternum alteration at X-rays was evident. Ultrasounds revealed a hypoecogen colliquating mass, with underlying cartilage and periosteum alterations. The magnetic resonance imaging (MRI) showed capsular exudate and synovial hyperplasia, with manubrium sterni joint’s arthritis and osteomyelitis of the underlying bone. As osteonecrosis and skeletal abnormalities were also sorted out, a diagnosis of PSO was made. Blood cultures performed at admission were sterile, even though the child had not been treated with antimicrobials. An increased antistaphylolysin titer (.8 U/ml, normal value ,2 U/ml) was documented, suggesting a possible staphylococcal infection. The child was given empiric antibiotic therapy with IV teicoplanin (10 mg/kg/day following a loading dose of 20 mg/kg/ day) and ceftriaxone (80 mg/kg/day), which lead to a prompt decrease in white cells, neutrophil count, inflammation indices and clinical improvement. Given the clinical and laboratory findings, fine needle aspiration of the mass was deemed unnecessary. After 10 days of antimicrobial therapy, due to the onset of a febrile maculopapular rash, teicoplanin and ceftriaxone were replaced by IV meropenem (60 mg/kg/day) and oral rifampicin (20 mg/kg/day). The child was discharged after 31 days in good general conditions, with a sensible reduction of the midsternal swelling. Oral rifampicin and trimethoprim/sulfamethoxazole (TMP/SMX, 10 mg/kg/day of TMP) were administered as outpatient for a total antibiotic course of 6 weeks. No relapses were found at follow-up: in particular, the MRI test of the sternum performed 3 months later showed complete bone resolution. In spite of its rarity, PSO should be considered in the differential diagnosis of sternal swelling in paediatric patients. Unfortunately, clinical symptoms are not specific, and history of trauma is absent in the majority of cases. Sickle cell disease is the sole predisposing condition clearly identified in paediatric age, 4 as these