Gilat Livni

Dexamethasone therapy for septic arthritis in children: results of a randomized double-blind placebo-controlled study.

Background We evaluated the effect of adding dexamethasone to antibiotic therapy in the clinical course of septic arthritis in children. Methods A randomized double-blind placebo-controlled trial was performed. The study group included 49 children with septicarthritis. In addition to antibiotic therapy given, patients were randomly assigned to receive intravenous dexamethasone 0.15 mg/kg every 6 hours for 4 days or placebo. The groups were compared for clinical and laboratory parameters, length of hospital stay, and late sequelae. Results Mean age was 33±42 months (range: 6 to 161 mo). There was no significant difference between the dexamethasone and placebo groups in age, duration of symptoms, joint affected, or levels of acute phase reactants. Bacteria were isolated from joint fluid in 17 patients (35%) and from blood in 4 patients. Compared with the placebo group, patients treated with dexamethasone had a significantly shorter duration of fever (P=0.021; mean first day without fever 1.68 vs 2.83) and local inflammatory signs (P=0.021; mean first day without pain 7.18 vs 10.76), lower levels of acute phase reactants (P=0.003; mean last day of erythrocyte sedimentation rate>25 mm/h 3.76 vs 8.40), shorter duration of parenteral antibiotic treatment (P=0.007; mean of 9.91 d vs 12.60 d), and shorter hospital stay. No side effects of treatment were recorded in either group. Conclusions A 4-day course of dexamethasone given at the start of antibiotic treatment in children with septic arthritis, is safe, and leads to a significantly more rapid clinical improvement, shortening duration of hospitalization compared with those treated with antibiotics alone. Level of Evidence I.

A RANDOMIZED, DOUBLE-BLIND STUDY EXAMINING THE COMPARATIVE EFFICACIES AND SAFETY OF INHALED EPINEPHRINE AND NASAL DECONGESTANT IN HOSPITALIZED INFANTS WITH ACUTE BRONCHIOLITIS

Optimal treatment of acute bronchiolitis is currently unclear. In a double-blind study, we found no significant differences between inhaled epinephrine and nasal decongestant in hospitalized infants with acute bronchiolitis regarding length of hospitalization, need for oxygen supplementation, or intravenous fluids and clinical score. Nasal decongestant is as effective as inhaled epinephrine in acute bronchiolitis.

Secondary Bacteremia After Rotavirus Gastroenteritis in Infancy

We describe 1 neonate and 3 infants with bacteremia secondary to rotavirus gastroenteritis. All had a typical course of an increase in temperature several days after admission. The causative organisms were Enterobacter cloacae and Klebsiella pneumoniae, both normal commensals of the small intestine. Pediatricians should be aware of this complication.

Concomitant administration of a virosome-adjuvanted hepatitis a vaccine with routine childhood vaccines at age twelve to fifteen months: a randomized controlled trial.

Background: The objectives of this trial were to test for noninferiority of a virosomal hepatitis A virus (HAV) vaccine (Epaxal) coadministered with routine childhood vaccines compared with Epaxal given alone and to an alum-adjuvanted HAV vaccine (Havrix Junior) coadministered with routine childhood vaccines. Methods: Healthy children 12- to 15-month-old were randomized to receive either a pediatric dose (0.25 mL) of Epaxal coadministered with DTPaHibIPV, oral polio vaccine, and measles-mumps-rubella vaccine (n = 109; group A), or Epaxal given alone (n = 105; group B), or Havrix Junior coadministered with DTPaHibIPV, oral polio vaccine, and measles-mumps-rubella vaccine (n = 108; group C). A booster dose was given 6 months later. Anti-HAV antibodies were tested before and 1 month after each vaccination. Safety was assessed for 1 month after each vaccination. Solicited adverse events were assessed for 4 days after each vaccination. Results: HAV seroprotection rates (≥20 mIU/mL) at 1 and 6 months after first dose were: A: 94.2% and 87.5%, B: 92.6% and 80.0%, C: 78.2% and 71.3%, respectively (A versus C: P < 0.001 and P = 0.017 at month 1 and 6, respectively). The respective geometric mean concentrations were: A: 51 and 64 mIU/mL, B: 49 and 59 mIU/mL, C: 33 and 37 mIU/mL (A versus C: P < 0.001 at both time points). All groups achieved 100% seroprotection after the booster dose. The geometric mean concentrations after the booster dose were 1758, 1662, and 1414, for groups A, B and C, respectively (A versus C: P = 0.15). No clinically significant reduction in immune response to all concomitant vaccine antigens was seen. All vaccines were well tolerated. Conclusions: Coadministration of pediatric Epaxal with routine childhood vaccines showed immunogenicity and safety equal to Epaxal alone as well as to Havrix Junior. After first dose, Epaxal was significantly more immunogenic than Havrix Junior.

The Association of Intrapartum Antibiotic Exposure With the Incidence and Antibiotic Resistance of Infantile Late-Onset Serious Bacterial Infections

Background. The widespread use of intrapartum antibiotics (IPA) has raised concerns regarding the adverse effects on the newborn. Objectives. To determine if IPA is associated with infantile late-onset serious bacterial infections (SBIs) and with antibiotic resistance. Patients and methods. From 2005 to 2009, data were prospectively collected for all infants born at our center, aged 7 to 90 days, who were hospitalized for fever. Cases included infants with culture-proven SBIs, and controls included infants without SBIs. Results. A total of 71 cases and 124 controls were included. IPA was documented in 11.3% of cases and in 7.3% of controls (P = .34). Among cases, ampicillin resistance was documented in 85% of antibiotic-exposed infants and in 63% of nonexposed infants (P = .19). Corresponding rates for first-generation cephalosporin resistance in urinary tract infection were 75% and 23.5% (P = .04). Conclusion. IPA is associated with a trend toward increased antibiotic resistance in late-onset SBIs. This should be taken into consideration in the selection of empirical therapy for febrile infants.

Increased susceptibility to varicella-zoster virus among Israeli physicians and nurses born in the Middle-East region.

Increased Susceptibility to Varicella‐Zoster Virus among Israeli Physicians and Nurses Born in the Middle‐East Region: Gabriel Chodick, et al. Sackler Faculty of Medicine, Tel‐Aviv University, Israel—Nosocomial transmission of varicella‐zoster virus (VZV) is recognized as a significant cause of morbidity in health care workers as well as in high‐risk patients. The current study aimed to investigate the presence of VZV antibodies among physicians and nurses, to assess the variables affecting it, and to compare it with previous international studies. Data were obtained by a questionnaire regarding sociodemographic and occupational characteristics and by determination of serum antibodies to varicella‐zoster. The seroprevalence of varicella‐zoster among the 335 study participants was 94.8% (95%CI: 91.9%–96.9%), with no significant difference between nurses (94%) and physicians (97%). Decreased risk for the virus was observed in workers who immigrated to Israel from the Asia or Africa (OR=0.15; 95% CI: 0.04–0.51). Reduced immunity among these workers remained significant in a multivariate model, which also included age, gender, years of education, number of siblings, and crowding at childhood. Our data suggest that in spite of the high immunity among Israeli physicians and nurses in general, the implementation of small‐scale vaccination programs aimed at workers from warmer and tropical areas, should be seriously considered.

Treatment of resistant bacterial infections in children: thinking inside and outside the box.

Antimicrobial resistance of bacteria causing pediatric infections has become more common and complicated in recent years. Although formerly confined to hospital settings, multi-drug resistant bacteria now also cause community-acquired infections. Treatment of infections caused by resistant pathogens is difficult, necessitating thinking both inside and outside the box. Determination of the precise minimal inhibitory concentration (MIC) is often crucial for selecting the most appropriate antibiotics, their doses, and use of prolonged infusions. For some multiply-resistant bacteria, off-label use of antibiotics, sometimes with no evidence from controlled studies (salvage therapy) is unavoidable.

Long-term Serologic Follow-up of Children Vaccinated with a Pediatric Formulation of Virosomal Hepatitis A Vaccine Administered With Routine Childhood Vaccines at 12-15 Months of Age.

Background : The aim of this open-label, active-controlled, parallel group, phase 2 follow-up study was to assess the long-term immunogenicity of Epaxal Junior, the pediatric dose of an aluminum-free virosomal inactivated hepatitis A virus (HAV) vaccine, in children receiving routine childhood vaccines (RCV). Methods: Healthy children (12–15 months old, ≥8u2009kg weight) were randomized (1:1:1) to group A: Epaxal Junior + RCV (day 1); group B: Epaxal Junior (day 1) + RCV (day 29) and group C: Havrix 720 + RCV (day 1). All 3 groups received 2 doses of HAV vaccines 6 months apart. Children who completed the primary study were followed up from 18 months to 7.5 years post booster. Results: Of 291/327 randomized children who had completed the primary study, 157 were followed for the 7.5-year analysis (group A: 50; group B: 54; and group C: 53). Of these, 152 children had protective levels of anti-HAV antibodies [≥10 mIU/mL; 98% (group A); 96.3% (group B); 96.2% (group C)]. Anti-HAV geometric mean concentrations were similar in groups A and B at all the time points (1.5-, 2.5-, 3.5-, 5.25- and 7.5-year time point) but slightly lower in group C. Predictions of the median duration of persistence of seroprotective antibody levels, using the linear mixed model were similar in all groups: (group A: 19.1 years, group B: 18.7 years, group C: 17.3 years). Conclusions: Immunization with Epaxal Junior administered with RCVs at 12 months elicited protective response beyond 7.5 years in almost all children. Assessing the kinetic of anti-HAV antibody titers decline over time, the moment to reach antibody concentrations below the accepted protective level may occur earlier than previously estimated.

Clinical Impact of β-Lactamase-producing Enterobacteriaceae in Sputum of Cystic Fibrosis Patients.

This case series describes 18 cystic fibrosis (CF) patients of a 135-patient CF center cohort with extended spectrum &bgr;-lactamase–producing Enterobacteriaceae, from 2003 to 2012. Four had chronic infection. Prevalence increased annually from 0 to 6.35%. Risk factors compared with the 2010 CF center cohort included continuous inhaled antibiotics (P = 0.014) and courses of intravenous antibiotics during the year before first isolation (P = 0.009). Hospitalization rates were 1.05/year and 0.47/year preinfection and postinfection, respectively (P = 0.02). Slope of forced expiratory volume at 1 second% predicted remained unchanged during 12 months.

Leukemoid reaction in the pediatric population: etiologies, outcome, and implications

Leukemoid reaction (WBC >u200930,000/μL) may indicate significant medical conditions, mostly infectious. Prompted by the lack of population-based data on the presentation, characteristics, and necessary workup in children with leukemoid reaction, we searched the database of a tertiary pediatric medical center for all children presented with at least one WBC count of ≥u200930,000/μL in 2009–2014. Demographic, clinical, and laboratory parameters were recorded. Children admitted with WBC <u200930,000/μL served as controls. Pneumonia was the most common diagnosis in the leukemoid reaction group, with a 5.5-fold higher prevalence of pleuropneumonia than in the control group. The leukemoid group had a longer average hospital stay (7.5 vs. 5.5xa0days). Patients with WBC ≥u200950,000/μL had a sixfold higher rate of leukemia than patients with a lower count. There was a significant association of leukemia with low platelet count, low levels of C-reactive protein, and high levels of uric acid and lactate dehydrogenase.Conclusion: Children presented with a leukemoid reaction are at high risk of pneumonia, especially pleuropneumonia, and a long hospital stay. Those with WBC ≥u200950,000/μL have a sixfold higher risk of leukemia. For prompt diagnosis, clinicians should be aware of the variables associated with leukemia.What is Known:• Leukemoid reaction has been associated with infectious diseases.• Leukemoid reaction at presentation in adults is correlated with high morbidity and mortality.What is New:• Children with leukemoid reaction are at high risk of pleuropneumonia.• We did not observe increased mortality in children with a leukemoid reaction.