İlker Devrim

Role of procalcitonin and CRP in differentiating a stable from a deteriorating clinical course in pediatric febrile neutropenia.

In clinical practice, when neutropenic-fever patients present with no microbiologically and clinically defined infection, the risk of underestimating an occult infection is of major concern, the clinicians have to make a decision on when to modify antibiotic therapy. Hence, a reliable, specific, and sensitive marker, which is regulated independently from the leukocyte count and the underlying disease, is needed for the early diagnosis of infections in cases of neutropenic fever. We have evaluated the diagnostic and follow-up value of procalcitonin (PCT) compared with C-reactive protein (CRP) and erythrocyte sedimentation rate in documenting the infection in neutropenic-fever patients undergoing intensive chemotherapy, as evidenced by the durational change in these parameters in the presence of defined infection. Forty-nine patients, who had 60 febrile episodes, and who were hospitalized in the Hacettepe University Ihsan Doğramacı Childrens Hospital between January 1, 2004 and January 1, 2005 were included in this prospective study. All patients had been diagnosed with neutropenic fever after intensive chemotherapy. In our study, PCT and CRP levels were significantly higher in neutropenic-fever patients (group I and group II separately) than in control patients (P<0.001) throughout the study period; but erythrocyte sedimentation rate levels did not show any significant difference (P>0.05). In sequential analyses of patients without documented infections, the median of PCT concentrations shows a tendency to fall after the 8th hour of onset of fever, whereas in patients with documented infections PCT concentrations fell after the 48th hour. In conclusion, our study suggests that PCT, when measured periodically, is a more useful diagnostic inflammation parameter in pediatric neutropenic-fever patients than CRP, both in estimating the severity of the infection and, the duration and origin of the fever. Hence, PCT might be helpful when deciding on initial therapy modification.

Measurement Accuracy of Fever by Tympanic and Axillary Thermometry

As the basic sciences develop, temperature measurement methods and devices were improved. For hundreds of years both in clinics and home, mercury-in-glass thermometer was the standard of human temperature measurements. In this study, we aimed to compare tympanic infrared thermometers with the conventional temperature option, mercury-in-glass thermometer, which is historical standard in the clinical conditions. Methods: A total of 102 randomly selected pediatric patients who admitted to our hospital were enrolled, and simultaneous temperature measurements were performed via axilla and external auditory canal with 3 different techniques. For external auditory recordings, infrared tympanic First Temp Genius for clinical use and Microlife IR 1DA1 for home usage were used. Classic mercury-in-glass thermometers were used for axillary recording. For each method, 886 measurements were performed. Results: The mean results of the axillary mercury-in-glass thermometers, infrared tympanic First Temp Genius, and Microlife IR 1DA1 were 36.8 ± 0.7, 37.5 ± 0.9, 36.9 ± 0.8, respectively. The Bland-Altman plot of differences suggests that 95% of the infrared tympanic clinical use thermometer readings were within the limits of agreement, which is +0.27 and −1.75°C range of mercury-in-glass thermometer. The Bland-Altman plot of differences suggests that 95% of the tympanic home-use thermometer readings were within the limits of agreement, which is +0.98 and −1.27°C range of mercury-in-glass thermometer. In our group, 15% of the patients were misdiagnosed as febrile with home-use tympanic thermometer, whereas this percentage was 4% with clinical tympanic thermometer. Also, 5% and 31% of febrile patients were misdiagnosed as afebrile with clinical tympanic and home-use tympanic thermometer, if axillary mercury-in-glass thermometer recording defines fever. Discussion: Our results showed that there is a significant difference in each recording with different thermometers, and this variance was present in both higher and lower readings. We recommend thathome-use infrared tympanic thermometer could be used for screening but must not be considered as a tool to decide patients follow-up.

Influenza Vaccine Adverse Event and Effect on Acceptability in Pediatric Residents

Despite the demonstrated benefits of influenza vaccinations, the coverage is lower than expected among health-care personnel (HCP). In this study we surveyed the attitudes of pediatric residents regarding influenza immunization and adverse reactions. Forty-five female and 35 male pediatric residents with ages ranging from 24 to 28 years were vaccinated with an influenza vaccine on 2 days in the 3rd week of September 2005 by the same nurse. Among our resident, 27 (33.7%) thought the vaccine unnecessary; their vaccine coverage was only 12% in the previous year. Thirteen residents (16%) had soreness at the vaccination site; 7 (8%) had other local reactions that did not interfere with everyday activities, and 16 (20%) had any systemic side effects. The overall rate of side effects from the vaccination was 36.5% (n=29). Twenty of the 29 vaccinees who experienced side effects stated they did not want to receive the vaccine the following year because of the side effects, while 13% in the group without side effects stated the same thing, mainly because of the cost of vaccination. We would like to recommend an influenza vaccination campaign for HCP by employers, but first we must plan to take steps to improve the acceptability of the influenza vaccine among HCP.C vaccine delivery methods for prevention of global childhood diseases carry a high risk for needle contamination, vaccine wastage, and transportation and storage difficulties. Aktiv-Dry LLC’s focus is on R&D of safe and effective microparticles of vaccines and pharmaceuticals for easier storage, greater thermal stability, and ease of use. We utilize our patented CO2-Assisted Nebulization with a Bubble Dryer® (CAN-BD) system to create stable dry microparticles of compounds for administration by needle-free aerosol inhalers, sublingual solid formulations, or safer unit-dose, all-in-one auto-reconstitution syringe devices. Recently, our work has focused on vaccine prevention of measles and hepatitis B. Aktiv-Dry has developed inhalable and sublingual vaccines for measles along with a human-powered, active dry powder inhaler called the PuffHaler® for intrapulmonary delivery of the dry powder measles vaccine. CAN-BD processed measles vaccine shelf-life stability has been shown for 4 years at 2-8oC, protective immunity after intrapulmonary delivery to rhesus macaques, and no serious adverse events reported to date during on-going clinical Phase I safety trials in 60 adult males in India. We have also demonstrated stability of CAN-BD processed and dried microparticles of hepatitis B vaccine for use in a preloaded, single-dose, field-reconstitution device for parenteral delivery. Aktiv-Dry-formulated hepatitis-B vaccine was stabilized with trehalose, processed, and determined to retain stability using in-house stability assays. Our immunogenicity results from intrapulmonary mucosal membrane delivery of measles vaccine dry powder aerosols and fundamental project goals may be extended to prevention and treatment (e.g., antibiotics and antivirals) of other pulmonary diseases (e.g., tuberculosis and influenza). Jessica M.H. Thrall et al., J Vaccines Vaccin 2013, 4:5 http://dx.doi.org/10.4172/2157-7560.S1.017

Secondary bacteremia in rotavirus gastroenteritis.

The aim of the study was to determine the frequency of secondary bacteremia in children with rotavirus gastroenteritis and persistence or reemergence of fever. We identified 376 children with a mean of age of 14.2 ± 10.1 months. A significant pathogen was isolated from blood cultures in 5 patients [Enterococcus faecium (n = 1), Klebsiella spp (n = 1), Staphylococcus aureus (n = 1), Raoultella planticola (n = 1), Candida albicans (n = 1); 1.3%]. The frequency of secondary bacteremia in children with rotavirus gastroenteritis is low, but it should be considered when there is fever lasting >48 hours or reemergence of fever.

Sphingomonas paucimobilis infections in children: 24 case reports.

Sphingomonas paucimobilis is a causative agent of infection in immunocompromised patients, and healthcare-associated infection. Although the infections associated with S.paucimobilis occurs rarely, it has been encountered with increasing frequency in clinical settings. In the current study we reported clinical features of the children with S.paucimobilis infection, and the antimicrobial susceptibilities of the isolated strains among the patients. This study was conducted in Dr. Behçet Uz Children’s Hospital, Turkey, during the period of January 2005 and December 2012. The medical records of pediatric patients with positive cultures for S.paucimobilis were reviewed. Sphingomonas paucimobilis isolates were recovered from 24 pediatric patients. The median age was 4 years (ranging from 3 days infant to 15 years) and 58,3% were male. Eight (33,3%) of the patients were under 1 months of age. Among the patients; 13 (54,2%) infections were community related however 11(45.8%) infections were nosocomial infection. The median duration of hospital stay was 7 days (ranging from 4 to 22 days). The most effective antibiotics were fluoroquinolones, carbapenems, and trimethoprim/sulfamethoxazole. This is the first largest study in children to evaluate the clinical features of S. paucimobilis infections. Sphingomonas paucimobilis may cause infections in both previously healthy and immunocompromised children. Although variable antimicrobial regimens were achieved to the patients, there was no attributable fatality due to S.paucimobilis infections due to the low virulence of the bacteria.

Bacterial agents causing meningitis during 2013–2014 in Turkey: A multi-center hospital-based prospective surveillance study

ABSTRACT This is an observational epidemiological study to describe causes of bacterial meningitis among persons between 1 month and 18 y of age who are hospitalized with suspected bacterial meningitis in 7 Turkish regions. covering 32% of the entire population of Turkey. We present here the results from 2013 and 2014. A clinical case with meningitis was defined according to followings: any sign of meningitis including fever, vomiting, headache, and meningeal irritation in children above one year of age and fever without any documented source, impaired consciousness, prostration and seizures in those < 1 y of age. Single tube multiplex PCR assay was performed for the simultaneous identification of bacterial agents. The specific gene targets were ctrA, bex, and ply for N. meningitidis, Hib, and S. pneumoniae, respectively. PCR positive samples were recorded as laboratory-confirmed acute bacterial meningitis. A total of 665 children were hospitalized for suspected acute meningitis. The annual incidences of acute laboratory-confirmed bacterial meningitis were 0.3 cases / 100,000 population in 2013 and 0.9 cases/100,000 in 2014. Of the 94 diagnosed cases of bacterial meningitis by PCR, 85 (90.4%) were meningococcal and 9 (9.6%) were pneumococcal. Hib was not detected in any of the patients. Among meningococcal meningitis, cases of serogroup Y, A, B and W-135 were 2.4% (n = 2), 3.5% (n = 3), 32.9% (n = 28), and 42.4% (n = 36). No serogroup C was detected among meningococcal cases. Successful vaccination policies for protection from bacterial meningitis are dependent on accurate determination of the etiology of bacterial meningitis. Additionally, the epidemiology of meningococcal disease is dynamic and close monitoring of serogroup distribution is comprehensively needed to assess the benefit of adding meningococcal vaccines to the routine immunization program.

Epidemic Adenoviral Keratoconjunctivitis Possibly Related to Ophthalmological Procedures in a Neonatal Intensive Care Unit: Lessons from an Outbreak

Purpose: Epidemic adenoviral keratoconjunctivitis can spread rapidly among preterm infants who frequently undergo ophthalmological examination. Here we present our experience on a nosocomial outbreak that affected 8 nursery staff members and 26 premature infants. We focus on the presentation and progress of the outbreak, the diagnosis of the disease and the measures taken for its control. Methods: Data were collected from patients’ files and records of the infection control team. Conjunctival swabs were collected to perform direct fluorescent assay (DFA) and viral culture. Diagnosis was made according to clinical evidence and/or detection of the virus. Statistical analysis was performed using SPSS 15.0 statistical software. Results: Infection was introduced to our unit after a laser photocoagulation procedure of a 28-week gestational infant and circulated rapidly within the unit due to direct transmission through contaminated medical equipment, fomites and hands of nursery staff members. Neither the patients, nor the nursery staff members developed systemic symptoms. While DFA tests were positive in seven infants, culture positivity could be demonstrated in only three infants. Contact and droplet precautions were implemented with the recommendation of the infection control team. No recurrence occurred after definition of the last case on the 32nd day. Conclusion: Ophthalmologic procedures continue to be a potential source of adenovirus outbreaks. However, negligence of contact measures during routine daily nursing care seems to be a more important contributing factor for rapid spread. Strict adherence to appropriate aseptic procedures is required to prevent this potentially hazardous infection in preterm infants.

Clinical and epidemiological features of Turkish children with 2009 pandemic influenza A (H1N1) infection: Experience from multiple tertiary paediatric centres in Turkey

Abstract Background: In April 2009 a novel strain of human influenza A, identified as H1N1 virus, rapidly spread worldwide, and in early June 2009 the World Health Organization raised the pandemic alert level to phase 6. Herein we present the largest series of children who were hospitalized due to pandemic H1N1 infection in Turkey. Methods: We conducted a retrospective multicentre analysis of case records involving children hospitalized with influenza-like illness, in whom 2009 H1N1 influenza was diagnosed by reverse-transcriptase polymerase chain reaction assay, at 17 different tertiary hospitals. Results: A total of 821 children with 2009 pandemic H1N1 were hospitalized. The majority of admitted children (56.9%) were younger than 5 y of age. Three hundred and seventy-six children (45.8%) had 1 or more pre-existing conditions. Respiratory complications including wheezing, pneumonia, pneumothorax, pneumomediastinum, and hypoxemia were seen in 272 (33.2%) children. Ninety of the patients (11.0%) were admitted or transferred to the paediatric intensive care units (PICU) and 52 (6.3%) received mechanical ventilation. Thirty-five children (4.3%) died. The mortality rate did not differ between age groups. Of the patients who died, 25.7% were healthy before the H1N1 virus infection. However, the death rate was significantly higher in patients with malignancy, chronic neurological disease, immunosuppressive therapy, at least 1 pre-existing condition, and respiratory complications. The most common causes of mortality were pneumonia and sepsis. Conclusions: In Turkey, 2009 H1N1 infection caused high mortality and PICU admission due to severe respiratory illness and complications, especially in children with an underlying condition.

Risk of vancomycin-resistant enterococci bloodstream infection among patients colonized with vancomycin-resistant enterococci

BACKGROUND Vancomycin-resistant enterococci colonization has been reported to increase the risk of developing infections, including bloodstream infections. AIM In this study, we aimed to share our experience with the vancomycin-resistant enterococci bloodstream infections following gastrointestinal vancomycin-resistant enterococci colonization in pediatric population during a period of 18 months. METHOD A retrospective cohort of children admitted to a 400-bed tertiary teaching hospital in Izmir, Turkey whose vancomycin-resistant enterococci colonization was newly detected during routine surveillances for gastrointestinal vancomycin-resistant enterococci colonization during the period of January 2009 and December 2012 were included in this study. All vancomycin-resistant enterococci isolates found within 18 months after initial detection were evaluated for evidence of infection. FINDINGS Two hundred and sixteen patients with vancomycin-resistant enterococci were included in the study. Vancomycin-resistant enterococci colonization was detected in 136 patients (62.3%) while they were hospitalized at intensive care units; while the remaining majority (33.0%) were hospitalized at hematology-oncology department. Vancomycin-resistant enterococci bacteremia was present only in three (1.55%) patients. All these patients were immunosuppressed due to human immunodeficiency virus (one patient) and intensive chemotherapy (two patients). CONCLUSION In conclusion, our study found that 1.55% of vancomycin-resistant enterococci-colonized children had developed vancomycin-resistant enterococci bloodstream infection among the pediatric intensive care unit and hematology/oncology patients; according to our findings, we suggest that immunosupression is the key point for developing vancomycin-resistant enterococci bloodstream infections.

Risk factors for isoniazid hepatotoxicity in children with latent TB and TB: difference from adults.

In an interesting article in CHEST (November 2007), Talmor and colleagues 1 demonstrate that recruitment maneuvers are well tolerated in ARDS, with no major hemodynamic or immunologic evidence of deterioration within the fi rst hour of a recruitment maneuver. However, certain aspects of this study are not clear from the article. In this study, eight out of the 26 patients had intraabdominal pathologic results wherein the pressures applied during the study may not be appropriate, because higher airway pressures are required to generate an equivalent transpulmonary pressure in the patient with increased intraabdominal pressure. 2 The use of bladder pressure measurements may help in determining the intraabdominal pressure and may help in this regard. Furthermore, stratifying the results into abdominal and extraabdominal categories may alter the results. Gattinoni et al 3 showed that patients with extrapulmonary ARDS (ARDSexp) have a greater response rate to recruitment maneuvers than those with pulmonary ARDS (ARDSp). Thus, patients with pneumonia may have a limited amount of recruitable lung tissue, and the higher pressure may overinfl ate normal lung rather than aerating the consolidated tissue. So, further separating the results into ARDSp and ARDSexp may lead to greater insight in the study. A series by Gattinoni et al 4 found that patients with ARDSp had a higher percentage of recruitable lung than patients with ARDSexp when using CT scanning of the whole lung to quantify recruitment. Thus, CT scanning should ideally be performed when evaluating the effects of recruitment maneuvers. Finally, two (7.69%) out of 26 patients in this study did show a hemodynamic compromise and early termination of the recruitment maneuver, which defi nitely puts a question mark on the safety of this maneuver in critically ill patients with ARDS.