Christa Relly

Risk factors for invasive reptile-associated salmonellosis in children.

Reptile-associated salmonellosis (RAS) in children has been reported primarily due to direct contact with turtles, but recently also due to indirect contact with more exotic reptiles, causing disease in infants. To evaluate risk factors for RAS, we reviewed the RAS cases published in the literature since 1965. A case was defined as a child ≤18 years of age with an epidemiological link by identification of Salmonella enterica in cultures from both the affected child and the exposed reptile. We identified a total of 177 otherwise healthy children (median age 1.0 years, range 2 days to 17.0 years). RAS manifested mainly with gastrointestinal disease, but 15% presented with invasive RAS, including septicemia, meningitis, and bone and joint infection. The children with invasive RAS were significantly younger than children with noninvasive disease (median age 0.17 and 2.0 years, p<0.0001). RAS is most frequently seen after exposure to turtles (42%). However, children with invasive RAS had been exposed more often (p≤0.001) to reptiles other than turtles, including iguanas, bearded dragons, snakes, chameleons, and geckos. Children exposed to those latter reptiles usually kept indoors were younger than children exposed to turtles mostly kept outdoors (p<0.0001). RAS in children is significantly associated with invasive disease at young age, in particular infants <6 months of age. Exposure to reptiles, other than turtles, kept indoors is associated with RAS at younger age and more invasive disease. This finding is helpful for recognizing or even preventing invasive RAS in young infants that are at highest risk.

Epidemiology of blood culture-proven bacterial sepsis in children in Switzerland: a population-based cohort study

BACKGROUND Sepsis is a leading cause of childhood mortality worldwide. We assessed population-based incidence and outcomes of blood culture-proven bacterial sepsis in children in Switzerland. METHODS We did a multicentre, prospective, cohort study at ten paediatric hospitals in Switzerland. We included neonates and children younger than 17 years with blood culture-proven bacterial sepsis. Children were eligible if they met criteria for systemic inflammatory response syndrome-according to 2005 paediatric consensus definition- at the time of blood culture sampling. Incidence was calculated by dividing the number of annual sepsis episodes in the study for the years 2012-15 by the end-of-year resident paediatric population in Switzerland. The primary outcome was in-hospital mortality in the first 30 days after sepsis onset. FINDINGS Between Sept 1, 2011, and Dec 31, 2015, we enrolled 1096 children to our study. Of 1181 episodes of blood culture-proven bacterial sepsis, 382 (32%) occurred in 379 previously healthy children, 402 (34%) in 391 neonates, and 397 (34%) in 341 children with comorbidities. Incidence was 25·1 cases per 100 000 (95% CI 23·8-26·4) in children and 146·0 cases per 100 000 (133·2-159·6) in neonates. Central line-associated bloodstream infections and primary bloodstream infections accounted for 569 (48%) of 1181 episodes, and organ dysfunction was present in 455 (39%) of 1181 episodes. Escherichia coli (242 of 1181 [20%]), Staphylococcus aureus (177 of 1181 [15%]), coagulase-negative staphylococci (135 of 1181 [11%]), and Streptococcus pneumoniae (118 of 1181 [10%]) were the most prevalent pathogens in our study, accounting for 57% of episodes. The overall case-fatality ratio was 7% (82 of 1181 episodes; 95% CI 5·6-8·6), and it was higher in neonates (11%, 45 of 402 episodes; 8·4-14·8; adjusted odds ratio [OR] 4·41, 95% CI 1·75-11·1) and children with comorbidities (7%, 27 of 397 episodes; 4·6-9·9; OR 4·97, 1·84-13·4) compared with previously healthy children (3%, ten of 382 episodes; 1·3-4·9). The case-fatality ratio was 1% (five of 726 episodes [95% CI 0·3-1·7]) for children without organ dysfunction, which increased to 17% (77 of 455 episodes [13·7-20·8]) when organ dysfunction was present (adjusted OR 4·84, 95% CI 1·40-16·7). INTERPRETATION The burden of blood culture-proven bacterial sepsis on child health remains considerable. We recorded key differences in predominant organisms, severity, and outcome between neonates, previously healthy children, and children with comorbidities. Although for most episodes of blood culture-proven bacterial sepsis, no organ dysfunction was seen, presence of organ dysfunction was strongly associated with mortality. FUNDING Swiss National Science Foundation, Swiss Society of Intensive Care, Bangerter Foundation, Vinetum and Borer Foundation, and Foundation for the Health of Children and Adolescents.

Incidence and Outcome of Group B Streptococcal Sepsis in Infants in Switzerland

The incidence and outcome of group B streptococcal (GBS) sepsis were assessed prospectively between September 2011 and February 2015 in all tertiary care pediatric hospitals of Switzerland. We describe a low incidence of GBS early-onset sepsis (0.12/1000 livebirths) and a predominance of GBS late-onset sepsis (0.36/1000 livebirths), a pattern that has not been reported in other countries.

Mycoplasma pneumoniae intrathecal antibody responses in Bickerstaff brain stem encephalitis.

The pathogenesis of Mycoplasma pneumoniae encephalitis is not established. We report, for the first time, the case of a patient with severe Bickerstaff brain stem encephalitis in whom we detected intrathecal production of M. pneumoniae-specific antibodies, contrasting the findings in another patient with less severe encephalitis in whom we detected intrathecal M. pneumoniae DNA but no specific antibodies. Our observations suggest that intrathecal M. pneumoniae-specific antibody responses may contribute to a more severe course of M. pneumoniae encephalitis.

Survey of macrolide-resistant Mycoplasma pneumoniae in children with community-acquired pneumonia in Switzerland.

Mycoplasma pneumoniae is a leading cause of communityacquired pneumonia (CAP) in children and macrolides are recommended for this entity [1]. Extensive macrolide use led to the rapid, worldwide emergence of macrolide-resistant M. pneumoniae (MRMP) [2] with rates of over 90% in Asia (China, 2012 [3]) and up to 26% in Europe (Italy, 2010 [4]). The first two cases of MRMP in Switzerland were reported in adults in 2012 [5]. We aimed to assess the presence of MRMP in children with CAP.

Unrecognized pediatric adult-type tuberculosis puts school contacts at risk.

Adolescents with an immigrant background who are from tuberculosis high-incidence regions were at highest risk to develop adult-type tuberculosis disease in a low-incidence region during a 20-year period. If diagnosis and treatment were delayed up to 6 months, latent tuberculosis infection was detected in almost half of the affected individuals’ school contacts.

Neonatal Sepsis of Early Onset, and Hospital-Acquired and Community-Acquired Late Onset: A Prospective Population-Based Cohort Study

Objective To assess the epidemiology of blood culture‐proven early‐ (EOS) and late‐onset neonatal sepsis (LOS). Study design All newborn infants admitted to tertiary care neonatal intensive care units in Switzerland and presenting with blood culture‐proven sepsis between September 2011 and December 2015 were included in the study. We defined EOS as infection occurring <3 days after birth, and LOS as infection ≥3 days after birth. Infants with LOS were classified as having community‐acquired LOS if onset of infection was ≤48 hours after admission, and hospital‐acquired LOS, if onset was >48 hours after admission. Incidence was estimated based on the number of livebirths in Switzerland and adjusted for the proportion of admissions at centers participating in the study. Results We identified 444 episodes of blood culture‐proven sepsis in 429 infants; 20% of cases were EOS, 62% hospital‐acquired LOS, and 18% community‐acquired LOS. The estimated national incidence of EOS, hospital‐acquired LOS, and community‐acquired LOS was 0.28 (95% CI 0.23‐0.35), 0.86 (0.76‐0.97), and 0.28 (0.23‐0.34) per 1000 livebirths. Compared with EOS, hospital‐acquired LOS occurred in infants of lower gestational age and was more frequently associated with comorbidities. Community‐acquired LOS was more common in term infants and in male infants. Mortality was 18%, 12%, and 0% in EOS, hospital‐acquired LOS, and community‐acquired LOS, and was higher in preterm infants, in infants with septic shock, and in those requiring mechanical ventilation. Conclusions We report a high burden of sepsis in neonates with considerable mortality and morbidity. EOS, hospital‐acquired LOS, and community‐acquired LOS affect specific patient subgroups and have distinct clinical presentation, pathogens and outcomes.

PS-212 Epidemiology Of Neonatal Sepsis In Switzerland – Results From The Swiss Paediatric Sepsis Study

Background and aims Neonatal infection is a major cause of morbidity and mortality. The ongoing Swiss Paediatric Sepsis Study prospectively evaluates the epidemiology of blood culture-proven sepsis in newborns and children in Switzerland. Methods Newborn infants admitted to nine Swiss neonatal intensive care units (NICUs) and presenting with culture-proven sepsis between 9.2011–2.2014 were prospectively enrolled. Early-onset sepsis (EOS) was defined as infection occurring. Results We identified 189 episodes of blood culture-proven sepsis in 186 patients. Thirty seven episodes were classified as EOS and 152 episodes were classified as LOS. Median gestational age at birth was 34 weeks for EOS, and 28 weeks for LOS. Mortality was 14% in EOS and 9% in LOS. Forty six percent of patients required mechanical ventilation during the sepsis episode, and 4% required catecholamine treatment for arterial hypotension. Group B Streptococcus (GBS) and Escherichia coli were the most frequently isolated pathogens in EOS, accounting for 35% and 16% of episodes. Coagulase-negative staphylococci were the leading pathogens in LOS (36%), followed by Staphylococcus aureus (18%), Escherichia coli (16%), and GBS (11%). The proportion of hospital-acquired LOS due to Coagulase-negative staphylococci, Staphylococcus aureus and Escherichia coli varied between 10–68%, 0–45% and 0–30% in different NICUs. Conclusions This national study confirms that neonatal sepsis continues to cause high morbidity and significant mortality. GBS is the most common cause of EOS. There are important differences in the aetiology of LOS in different institutions.

Time-to-Positivity of Blood Cultures in Children With Sepsis

Background: Blood cultures are essential for the diagnosis and further appropriate treatment in children with suspected sepsis. In most hospitals, children will be empirically treated or closely monitored for at least 48 h awaiting results of blood cultures. Several studies have challenged the optimal duration of empiric treatment in the era of continuously monitored blood culture systems. The aim of our study was to investigate time-to-positivity (TTP) of blood cultures in children with proven sepsis. Methods: The Swiss Pediatric Sepsis Study prospectively enrolled children 0–16 years of age with blood culture positive sepsis between September 2011 and October 2015. TTP was prospectively assessed in six participating academic pediatric hospitals by fully automated blood culture systems. Results: In 521 (93%) of 562 bacteremia episodes (493 children, median age 103 days, range 0 days−16.9 years) a valid TTP was available. Median TTP was 12 h (IQR 8–17 h, range 0–109 h). By 24, 36, and 48 h, 460 (88%), 498 (96%), and 510 (98%) blood cultures, respectively, were positive. TTP was independent of age, sex, presence of comorbidities, site of infection and severity of infection. Median TTP in all age groups combined was shortest for group B streptococcus (8.7 h) and longest for coagulase-negative staphylococci (16.2 h). Conclusion: Growth of bacteria in blood cultures is detectable within 24 h in 9 of 10 children with blood culture-proven sepsis. Therefore, a strict rule to observe or treat all children with suspected sepsis for at least 48 h is not justified.

Asymptomatic congenital tuberculosis: A case report

Rationale: Congenital tuberculosis (TB) is described as a rare, but severe disease. In contrast to the cases with severe symptoms reported so far, we describe a child with asymptomatic congenital TB. Patient concerns: An 8-week-old girl was investigated because of newly diagnosed TB in her mother, which complained about cough since 21 weeks gestation. Lung biopsy tissue specimens of the mother revealed necrotizing granuloma with a single acid-fast bacillus (AFB) and Mycobacterium tuberculosis (MTB) was detected by polymerase chain reaction. Bronchoalveolar lavage was negative for AFB smear and culture, arguing against postnatal transmission of MTB. TB contact investigations were negative. The child, at the age of 8 weeks at first assessment, was in an excellent general condition and diagnosed with congenital TB by culture-positive lung TB and exclusion of postnatal transmission. Diagnoses: The child fulfilled Cantwell criteria to diagnose congenital TB. Interventions: Ambulatory anti-tuberculosis treatment was initiated for 6 months. Outcomes: The 18 months follow-up was uneventful. Lessons: This case of asymptomatic congenital TB in a young child illustrates the diagnostic difficulties in congenital TB and raises the question whether congenital TB is underestimated.