Gabriela Maron

Voriconazole prophylaxis in children with cancer: changing outcomes and epidemiology of fungal infections.

Background: Invasive mould infections are a significant cause of morbidity and mortality in pediatric cancer patients, particularly in those undergoing aggressive myeloablative chemotherapy. Voriconazole has been described as an appropriate and effective prophylactic agent in adults with cancer. Methods: We compared the etiology, predisposing factors and outcomes of invasive mould infection in patients treated for acute myeloid leukemia before and after implementation of voriconazole prophylaxis in a pediatric cancer center. Results: We observed no difference in the number of invasive mould infection between groups. However, isolated organisms were markedly different, with a shift from aspergillosis to phaeohyphomycosis after the implementation of voriconazole prophylaxis. Survival at 90 days was improved in patients receiving voriconazole prophylaxis (P = 0.05). We did not identify a significant increase in the incidence of zygomycosis associated with routine use of voriconazole prophylaxis. Conclusions: Voriconazole prophylaxis was associated with improved survival in pediatric patients with acute myeloid leukemia, although other factors may be involved. Voriconazole prophylaxis was associated with a marked change in the pattern of mould infections, with a significant reduction in aspergillosis

A practical guide to alcohol-based hand hygiene infrastructure in a resource-poor pediatric hospital

BACKGROUND Resource-poor hospitals have many barriers to proper hand hygiene (HH). Alcohol-based HH can compensate for inadequate infrastructure and supplies. We describe the implementation of alcohol-based HH in five high-risk wards of a pediatric hospital in El Salvador. METHODS In 5 high-risk wards for nosocomial infections, we evaluated the accessibility, supplies, and cleanliness of the hand-washing sinks at 132 time points. We then installed gel dispensers, identified a local gel supplier, and trained nursing staff to maintain the dispensers. We evaluated user acceptance, costs, and the practice and technique of HH before and after installation. RESULTS Access and cleanliness were adequate at 18.9% and 11.3% of observation points, and towels and soap were available at 61.3% and 93.18% of points. Placement of 35 gel dispensers increased the ratio of HH stations to beds from 1:6.2 to 1:1.8. Alcohol gel was better tolerated than hand washing among 60 surveyed staff. Installation cost

Establishment of ethical oversight of human research in El Salvador: lessons learned

2558 (US) and the monthly gel supply,

Diagnostic value of routine chest radiography in febrile, neutropenic children for early detection of pneumonia and mould infections

731 (US). HH practice increased from 33.8% to 40.5%; use of correct technique increased from 73.8% to 95.2%. CONCLUSION Alcohol gel can address some of the barriers to effective HH at resource-poor institutions, and its cost may be offset by reduction of nosocomial infection.

Antiretroviral Therapy in Hiv-infected Infants and Children

Human research is necessary for establishing the best approaches to health care, and should be overseen by a functional research ethics committee. However, in most low-income countries these committees are inadequate in providing the guidelines needed to ensure that ethics remain a prominent feature of human research. We developed a model of interaction with key institutions in low-income countries that had an interest in improving the infrastructure of human participant research. As a result, a research ethics committee was established at three hospitals in El Salvador. The skills gained from developing these committees and the interest shown by the Salvadoran government in rigorous ethical oversight of research involving human participants has allowed the creation of a national ethics committee, which serves as an entity to establish norms and guidelines for further development of research ethics committees in El Salvador. This model of interaction can also be used by institutions in high-income countries to create and strengthen the capacity for ethics in human research in low-income countries.

A Multicenter Consortium to Define the Epidemiology and Outcomes of Inpatient Respiratory Viral Infections in Pediatric Hematopoietic Stem Cell Transplant Recipients.

BackgroundDespite recent studies failing to demonstrate the value of routine chest radiography (CXR) in the initial evaluation of the febrile neutropenic patient with cancer, this screening test is advocated by some experts. We evaluated the benefits of CXR for early diagnosis of pulmonary infection at St. Jude Children’s Research Hospital (SJCRH) with emphasis on early recognition of mould infections.Patients and methodsWe reviewed the courses of 200 consecutive febrile neutropenic pediatric patients to determine if routine CXR at initial evaluation was useful in the identification of clinically occult pneumonia. We also reviewed all cases of proven or probable mould infections from the opening of SJCRH in 1962 until 1998 when routine CXR was no longer practiced in our institution to identify cases that were first recognized by routine CXR.ResultsOf 200 febrile neutropenic patients, pulmonary abnormalities consistent with pneumonia were detected by routine CXR in only five patients without pulmonary signs or symptoms. In only one case was a change in management considered. Of the 70 patients with pulmonary mould infection identified from 1962 to 1998, routine CXR was performed in 45 patients at the onset of a febrile, neutropenic episode in which a mould infection was diagnosed. Routine CXR was pivotal in the recognition of the mould infection in only two cases over this 36-year period.ConclusionCXR is warranted in the evaluation of the newly febrile neutropenic pediatric oncology patient only when respiratory signs or symptoms are present.

Surgical lung biopsy in children after hematopoietic cell transplantation

Antiretroviral (ARV) therapy in human immunodeficiency virus(HIV)-infected infants and children has changed dramatically over the past several years, from monotherapy in the 1990s to the current use of combination regimens, including highly active ARV therapy (HAART). HAART has been associated with increased survival, reduction in opportunistic infections, improved growth and neurocognitive function, and improved quality of life. The goal of HAART is to achieve maximal suppression of viral replication to prevent disease progression, preserve immunologic function, and reduce the development of resistance while minimizing therapy-related side effects. A total of 16 ARV drugs have an approved pediatric treatment indication and are available as a pediatric formulation, tablet, or capsule size as of February 2009 (Table 1). ARV treatment options are continually being updated because of availability of new medications, formulations, and dosing recommendations. Although this review summarizes the current information, US readers should refer to the Working Group Guidelines on Antiretroviral Therapy and Medical Management of HIV-Infected Children for details, including the evidence basis for the treatment recommendations and future updates. International readers should refer to the World Health Organization and Pediatric European Network for Treatment of acquired immunodeficiency syndrome guidelines as well as locally applicable national and regional guidelines.

Care and Prevention of Infection

Abstract Background Respiratory virus infections (RVIs) pose a threat to children undergoing hematopoietic stem cell transplantation (HSCT). In this era of sensitive molecular diagnostics, the incidence and outcome of HSCT recipients who are hospitalized with RVI (H-RVI) are not well described. Methods A retrospective observational cohort of pediatric HSCT recipients (between January 2010 and June 2013) was assembled from 9 US pediatric transplant centers. Their medical charts were reviewed for H-RVI events within 1 year after their transplant. An H-RVI diagnosis required respiratory signs or symptoms plus viral detection (human rhinovirus/enterovirus, human metapneumovirus, influenza, parainfluenza, coronaviruses, and/or respiratory syncytial virus). The incidence of H-RVI was calculated, and the association of baseline HSCT factors with subsequent pulmonary complications and death was assessed. Results Among 1560 HSCT recipients, 259 (16.6%) acquired at least 1 H-RVI within 1 year after their transplant. The median age of the patients with an H-RVI was lower than that of patients without an H-RVI (4.8 vs 7.1 years; P < .001). Among the patients with a first H-RVI, 48% required some respiratory support, and 14% suffered significant pulmonary sequelae. The all-cause and attributable case-fatality rates within 3 months of H-RVI onset were 11% and 5.4%, respectively. Multivariate logistic regression revealed that H-RVI onset within 60 days of HSCT, steroid use in the 7 days before H-RVI onset, and the need for respiratory support at H-RVI onset were associated with subsequent morbidity or death. Conclusion Results of this multicenter cohort study suggest that H-RVIs are relatively common in pediatric HSCT recipients and contribute to significant morbidity and death. These data should help inform interventional studies specific to each viral pathogen.

Planning and implementation of an infection control training program for healthcare providers in Latin America.

BACKGROUND/PURPOSE Pulmonary complications are some of the leading causes of morbidity and mortality in immunocompromised pediatric patients. We sought to assess the value of surgical lung biopsy (SLB) in hematopoietic cell transplantation (HCT) pediatric patients. METHODS A retrospective review of patients who underwent SLB within one year of HCT between 1999 and 2015 was performed. RESULTS Twenty-nine patients (15 females, 14 males) with a median age of 10years (range, 0.6-23) were identified. Median interval between HCT and SLB was 114.8days (range, 16-302). At surgery, 11 (38%) patients were intubated, and 7 (24%) were receiving supplemental oxygen. The most common histological finding was cryptogenic organizing pneumonia in 8 cases (27%), followed by infection in 7 (24%). Perioperative complications (17%) included bronchopleural fistula (n=2), splenic laceration from a trocar injury (n=2), and hemothorax (n=1). Changes in therapy occurred in 25 patients (86%). Twenty-four (83%) patients survived more than 30days post SLB, and the overall survival rate was 41% with a median follow-up of 8.5years (range, 1-13). CONCLUSION SLB appears to be safe and informative in pediatric patients after HCT and led to changes in therapy in most patients. However, long-term survival after this procedure was <50%, reinforcing the fact that pulmonary complications are some of the leading causes of mortality in these patients. TYPE OF STUDY Retrospective analysis. LEVEL OF EVIDENCE Level IV.

Characterization of dengue shock syndrome in pediatric patients in El Salvador.

Infections are an important cause of morbidity and mortality in children with cancer who are at high risk for infections due to immunodeficiency. In these patients, a broad range of pathogens may affect all organ systems; the dissociation of severity with clinical presentation and rapid progression sum to the risk for unfavorable outcomes. Therefore, early recognition and treatment of infections are critical to reduce morbidity and increase survival. Prevention of infection is the key to reduce the risks of these patients.