Johanna Goldfarb

Cytomegalovirus Infection and HIV-1 Disease Progression in Infants Born to HIV-1–Infected Women

Background and Methods Cytomegalovirus (CMV) has been implicated as a cofactor in the progression of human immunodeficiency virus type 1 (HIV-1) disease. We assessed 440 infants (75 of whom were HIV-1–infected and 365 of whom were not) whose CMV status was known, who were born to HIV-1–infected women, and who were followed prospectively. HIV-1 disease progression was defined as the presence of class C symptoms (according to the criteria of the Centers for Disease Control and Prevention [CDC]) or CD4 counts of less than 750 cells per cubic millimeter by 1 year of age and less than 500 cells per cubic millimeter by 18 months of age.

The Decision to Breastfeed The Importance of Fathers' Approval

One hundred fifteen postpartum mothers who were within 24 hours of delivery completed a questionnaire to determine factors which may influence a mothers intention to breastfeed and to evaluate specifically the effect of working outside of the home. In our population of mostly middle-class married and insured women, working outside of the home was not significantly related to the decision to breastfeed (67.9% of working mothers, compared to 67.2% of those who did not plan to work postpartum, planned to at least partially breastfeed). The only factors that significantly related to breastfeeding intention pertained to the fathers level of education and to his approval of breastfeeding. Strong approval of breastfeeding by the father was associated with a high incidence of breastfeeding (98.1 %), compared to only 26.9% breastfeeding when the father was indifferent to feeding choice (P<0.001).

Knowledge and Awareness of Congenital Cytomegalovirus Among Women

Background. Congenital cytomegalovirus (CMV) infection is a leading cause of disabilities in children, yet the general public appears to have little awareness of CMV. Methods. Women were surveyed about newborn infections at 7 different geographic locations. Results. Of the 643 women surveyed, 142 (22%) had heard of congenital CMV. Awareness increased with increasing levels of education (P < .0001). Women who had worked as a healthcare professional had a higher prevalence of awareness of CMV than had other women (56% versus 16%, P < .0001). Women who were aware of CMV were most likely to have heard about it from a healthcare provider (54%), but most could not correctly identify modes of CMV transmission or prevention. Among common causes of birth defects and childhood illnesses, womens awareness of CMV ranked last. Conclusion. Despite its large public health burden, few women had heard of congenital CMV, and even fewer were aware of prevention strategies.

Outbreak of methicillin-resistant Staphylococcus aureus colonization and infection in a neonatal intensive care unit epidemiologically linked to a healthcare worker with chronic otitis.

OBJECTIVE To describe the investigation and interventions necessary to contain an outbreak of methicillin-resistant Staphylococcus aureus (MRSA) colonization and infection in a neonatal intensive care unit (NICU). DESIGN Retrospective case finding that involved prospective performance of surveillance cultures for detection of MRSA and molecular typing of MRSA by repetitive-sequence polymerase chain reaction (rep-PCR). SETTING Level III NICU in a tertiary care center. PARTICIPANTS Three neonates in a NICU were identified with MRSA bloodstream infection on April 16, 2004. A point prevalence survey identified 6 additional colonized neonates (attack rate, 75% [9 of 12 neonates]). The outbreak strain was phenotypically unusual. INTERVENTIONS Cohorting and mupirocin therapy were initiated for neonates who had acquired MRSA during the outbreak. Contact precautions were introduced in the NICU, and healthcare workers (HCWs) were retrained in cleaning and disinfection procedures and hand hygiene. Noncolonized neonates and newly admitted patients had surveillance cultures performed 3 times per week. RESULTS Two new colonized neonates were identified 1 month later. HCW X, who had worked in the NICU since June 2003, was identified as having chronic otitis. MRSA was isolated from cultures of swab specimens from HCW Xs ear canal and nares. HCW X was epidemiologically linked to the outbreak. Molecular typing (by rep-PCR) confirmed that the isolates from HCW X and from the neonates were more than 90% similar. Retrospective review of NICU isolates revealed that the outbreak strain was initially cultured from a neonate 2 months after HCW X began working on the unit. The epidemic strain was eradicated after removing HCW X from patient care in the NICU. CONCLUSION An outbreak of MRSA colonization and infection in a NICU was epidemiologically linked to a HCW with chronic otitis externa and nasal colonization with MRSA. Eradication was not achieved until removal of HCW X from the NICU. Routine surveillance for MRSA may have allowed earlier recognition of the outbreak and is now standard practice in our NICU.

Safety and tolerability of linezolid in children.

Background. Linezolid, an oxazolidinone, is effective in the treatment of adults and children with community-acquired and nosocomial pneumonia and uncomplicated and complicated skin and skin structure infections (SSSIs), including infections caused by Gram-positive resistant pathogens. Because of the increasing use of linezolid, it is important to review the common adverse events (AEs) associated with its use in children with the use of data from clinical trials. Objective. The safety and tolerability of linezolid in pediatric patients with Gram-positive infections were determined in four pediatric clinical studies. Study I included pediatric patients with community-acquired pneumonia; Study II included otitis media; Study III included SSSIs; and Study IV included complicated SSSIs, nosocomial pneumonia and bacteremia. Methods. Studies I and II had no comparator arm. Study III was randomized and compared linezolid with cefadroxil. Study IV also was randomized and compared linezolid with vancomycin. Patients <12 years of age received linezolid 10 mg/kg; patients age 12 years and older received 600 mg (intravenous/oral). Dosing frequency (two to three times daily) varied depending on age and clinical diagnosis. The primary safety endpoints were AEs, drug-related AEs, serious AEs and selected laboratory tests. Results. In the 4 studies 958 patients were included in the intent-to-treat analysis. In the linezolid vs. cefadroxil study (Study III), the most common AEs in patients treated with linezolid were diarrhea (7.8%), headache (6.5%) and upper respiratory tract infection (3.7%). In the linezolid vs. vancomycin study (Study IV), the most common AEs in the linezolid group were fever (14.1%), diarrhea (10.8%) and vomiting (9.4%). The most common drug-related AEs for linezolid in all 4 studies were diarrhea, vomiting, loose stools and nausea. None of these common AEs or drug-related AEs occurred more frequently in patients treated with linezolid than in those in the comparator group. Conclusions. Linezolid was safe and well-tolerated in pediatric patients with community-acquired pneumonia, otitis media, SSSIs and infections caused by Gram-positive resistant pathogens.

Mastitis Due to Mycobacterium abscessus after Body Piercing

We describe a patient with granulomatous mastitis due to Mycobacterium abscessus that presented as a mass lesion and was associated with a pierced nipple. To our knowledge, this is the first reported case of mastitis due to M. abscessus and the first association of this organism with body piercing.

Comparative study of the immunogenicity and safety of two dosing schedules of engerix-B® hepatitis B vaccine in neonates

A randomized multicenter study compared the routine hepatitis B vaccine schedule of 0, 1, 6 months with an accelerated schedule of 0, 1, 2 months in newborns. Two hundred ninety-nine infants whose mothers were seronegative for hepatitis B were enrolled in the study and randomized to either the routine or accelerated schedule. All infants had blood drawn for antibody titers to hepatitis B at 2, 3, 6 and 7 months of age. For 222 infants data were evaluable, at least for safety; 193 of these 22 had antibody titers that were evaluable. The infants vaccinated on the accelerated schedule developed seroprotective concentrations of antibody more quickly than the infants vaccinated on the routine schedule; 92.6% vs. 66.1% had seroprotective concentrations (> or = 10 mIU/ml) at 3 months of age (P < 0.001). However, infants in the accelerated schedule had lower geometric mean antibody titers at 7 months, 420.0 vs. 3141.8. We conclude that the accelerated vaccination schedule resulted in the more rapid development of seroprotective concentrations of antibody, but levels of antibodies were not as high as in the routinely vaccinated infants at 7 months. These data suggest that an accelerated vaccine schedule can be used in the newborn period. The effectiveness of the accelerated schedule in preventing perinatal infections compared to the standard schedule and the necessity for booster doses of vaccine remain to be studied.

Hand hygiene compliance rates after an educational intervention in a neonatal intensive care unit.

An observational study was performed at a level III neonatal intensive care unit to assess the impact of a hand hygiene promotion educational program on rates of compliance with hand hygiene on entrance into the unit. There was an initial improvement in the rate of compliance at 1 month after the intervention (from 89% [168 of 189 opportunities] to 100% [212 of 212 opportunities]; P<.001], but the rate decreased to the baseline rate at 3 months (89% [85 of 96 opportunities]).

Maternal and perinatal factors related to maternal-infant transmission of HIV-1 in the P2C2 HIV study : The role of EBV shedding

The association of maternal and perinatal factors with mother-infant transmission of HIV-1 was examined in a prospective multicenter cohort of singleton live births to 508 HIV-1-infected women with children of known HIV-1 infection status (91 [18%] HIV-1-infected, 417 [82%] uninfected). From multivariate logistic regression, independent predictors of HIV-1 transmission included maternal CD4 percentage (CD4%) (odds ratio [OR] per 10% increase in CD4% = 0.70; p = .003), ruptured membranes <24 hours (OR = 3.15; p = .02), and maternal bleeding (OR = 2.90; p = .03), whereas maternal zidovudine (ZDV) use was marginally associated (OR = 0.60; p = .08). The associations of maternal urinary cytomegalovirus (CMV) shedding, oropharyngeal Epstein-Barr virus (EBV) shedding, and serology profiles during pregnancy with HIV-1 transmission were examined in the subset of mothers in whom the CMV and EBV measurements were available. Maternal EBV seropositivity, CMV shedding, and CMV seropositivity were 100% (279 of 279), 7% (16 of 229), and 92% (270 of 274), respectively. These rates did not differ between transmitting and nontransmitting mothers. In univariate analyses, maternal EBV shedding was higher among transmitting than nontransmitting mothers (40 of 49 [82%] compared with 154 of 226 [68%]; p = .06) and was independently associated with transmission in multivariate logistic analyses adjusting for CD4%, ruptured membranes, and ZDV use, with an OR of 2.45 (95% confidence interval (CI), 1.03-5.84; p = .04). This permits the conclusion that EBV shedding is associated with maternal-infant HIV-1 transmission, independent of CD4%.

Lateral sinus thrombosis associated with mastoiditis and otitis media in children: a retrospective chart review and review of the literature.

The authors describe the clinical features and management of lateral sinus thrombosis associated with mastoiditis and otitis media in children. Of 475 patients with mastoiditis and otitis media, 13 (2.7%) had lateral sinus thrombosis identified by magnetic resonance imaging/magnetic resonance venography (n = 11) and angiography (n = 2). Clinical features included headache, vomiting, fever, diplopia, papilledema, sixth nerve palsy, seventh nerve palsy, and unilateral cerebellar ataxia. All patients received antibiotics for 1 to 8 weeks. Four patients underwent mastoidectomy alone, 5 mastoidectomy with concurrent myringotomy and ventilation tube, and 1 myringotomy with tube without mastoidectomy. Three underwent anticoagulation for 6 months (1 had heterozygous factor V Leiden mutation). All survived; deafness occurred in 5 patients (4 transient, 1 persistent). Magnetic resonance imaging/magnetic resonance venography should be obtained in any child with otitis media having features of raised intracranial pressure and/or focal neurodeficits to rule out lateral sinus thrombosis. Antibiotics and mastoidectomy are essential in management. A hypercoagulable state may predispose to lateral sinus thrombosis.