Jon S. Abramson

Prevention of respiratory syncytial virus infections: Indications for the use of palivizumab and update on the use of RSV-IGIV

The Food and Drug Administration recently approved the use of palivizumab (palē-vizhū-mäb), an intramuscularly administered monoclonal antibody preparation. Recommendations for its use are based on a large, randomized study demonstrating a 55% reduction in the risk of hospitalization attributable to respiratory syncytial virus (RSV) infections in high-risk pediatric patients. Infants and children with chronic lung disease (CLD), formerly designated bronchopulmonary dysplasia, as well as prematurely born infants without CLD experienced a reduced number of hospitalizations while receiving palivizumab compared with a placebo. Both palivizumab and respiratory syncytial virus immune globulin intravenous (RSV-IGIV) are available for protecting high-risk children against serious complications from RSV infections. Palivizumab is preferred for most high-risk children because of ease of administration (intramuscular), lack of interference with measles–mumps–rubella vaccine and varicella vaccine, and lack of complications associated with intravenous administration of human immune globulin products. RSV-IGIV, however, provides additional protection against other respiratory viral illnesses and may be preferred for selected high-risk children including those receiving replacement intravenous immune globulin because of underlying immune deficiency or human immuno-deficiency virus infection. For premature infants about to be discharged from hospitals during the RSV season, physicians could consider administering RSV-IGIV for the first month of prophylaxis. Most of the guidelines from the American Academy of Pediatrics for the selection of infants and children to receive RSV-prophylaxis remain unchanged. Palivizumab has been shown to provide benefit for infants who were 32 to 35 weeks of gestation at birth. RSV-IGIV is contraindicated and palivizumab is not recommended for children with cyanotic congenital heart disease. The number of patients with adverse events judged to be related to palivizumab was similar to that of the placebo group (11% vs 10%, respectively); discontinuation of injections for adverse events related to palivizumab was rare.

Varicella vaccine update

Recommendations for routine varicella vaccination were published by the American Academy of Pediatrics in May 1995, but many eligible children remain unimmunized. This update provides additional information on the varicella disease burden before the availability of varicella vaccine, potential barriers to immunization, efforts to increase the level of coverage, new safety data, and new recommendations for use of the varicella vaccine after exposure and in children with human immunodeficiency virus infections. Pediatricians are strongly encouraged to support public health officials in the development and implementation of varicella immunization requirements for child care and school entry.

Outbreak of Candida bloodstream infections associated with retrograde medication administration in a neonatal intensive care unit

An outbreak of candidemia involving five infants receiving total parenteral nutrition in the neonatal intensive care unit was investigated. Cultures of the intravenous fluids demonstrated that the retrograde medication syringe fluids were significantly more likely to be contaminated with Candida than were other fluids being administered to the infants (p less than 0.001). Candidemia was significantly associated with total parenteral nutrition (p = 0.04) and retrograde medication administration (p = 0.02). A survey of nursing practice found that reuse of the retrograde syringes was the most likely cause of contamination. Molecular typing showed that the strains of Candida albicans that were isolated from the bloodstream were also found in the retrograde syringes and that at least three strains of C. albicans and one strain each of Candida tropicalis and Candida parapsilosis were involved. In vitro growth curves demonstrated that Candida species had a selective growth advantage versus bacteria in the total parenteral nutrition fluid. An in vitro simulation of the retrograde medication administration system suggested that the outbreak probably developed after the frequency of changing intravenous tubing was decreased from every 24 hours to every 72 hours. The outbreak was terminated by using syringes only once and resuming intravenous tubing changes every 24 hours. Retrograde medication administration in association with total parenteral nutrition may increase the risk of Candida line infection.

Hepatitis C virus infection

Hepatitis C virus (HCV) has become the most significant cause of chronic liver disease of infectious etiology in the United States. The recognition that HCV can be transmitted perinatally or through blood transfusions warrants particular attention by the pediatrician. The American Academy of Pediatrics recommends screening infants born to HCV-infected mothers and persons with risk factors for HCV infection such as injection drug use, transfusion of ≥1 U of blood or blood products before 1992, or hemodialysis should be screened for anti-HCV. Also, persons who received clotting factor concentrates before 1987, when effective inactivation procedures were introduced, also should be screened. Guidelines for counseling families of HCV-infected children are provided.

Severe invasive group a streptococcal infections: A subject review

The course of severe invasive group A β-hemolytic streptococcal (GABHS) infections is often precipitous, requiring prompt diagnosis and rapid initiation of appropriate therapy. Therefore, physicians must have a high index of suspicion of this disease, particularly in patients at increased risk (eg, those with varicella or diabetes mellitus). Although a relationship between the use of nonsteroidal antiinflammatory drugs and severe invasive GABHS infections has been suggested, at present data on which to base a clinical decision about the use or restriction of nonsteroidal antiinflammatory drugs in children with varicella are insufficient. When necrotizing fasciitis is suspected, prompt surgical drainage, debridement, fasciotomy, or amputation often is necessary. Many experts recommend intravenously administered penicillin G and clindamycin for the treatment of invasive GABHS infections on the basis of animal studies. Some evidence exists that intravenous immunoglobulin given in addition to appropriate antimicrobial and surgical therapy may be beneficial. Although chemoprophylaxis for household contacts of persons with invasive GABHS infections has been considered by some experts, the limited available data indicate that the risk of secondary cases is low (2.9 per 1000) and data about the effectiveness of any drug are insufficient to make recommendations. Because of the low risk of secondary cases of invasive GABHS infections in schools or child care facilities, chemoprophylaxis is not indicated in these settings. Routine immunization of all healthy children against varicella is recommended and is an effective means to decrease the risk of invasive GABHS infections.

Prevention of lyme disease

Lyme disease is currently the most frequently reported vector-borne illness in the United States, accounting for more than 95% of such cases. The purpose of this report is to provide recommendations for preventing Lyme disease, including the use of Lyme disease vaccine. Individuals can reduce their risk of Lyme disease by avoiding tick-infested habitats when in endemic areas. If exposure to tick-infested habitats cannot be avoided, individuals may reduce their risk of infection by using repellents, wearing protective clothing, and regularly checking for and removing attached ticks. Morbidity from Lyme disease can be reduced significantly by detecting and treating the infection in its early stages; early and appropriate treatment almost always results in a prompt and uncomplicated cure. A Lyme disease vaccine (LYMErix, SmithKline Beecham, Collegeville, PA) was licensed by the US Food and Drug Administration on December 21, 1998, for persons 15 to 70 years of age. This vaccine seems to be safe and effective, but whether its use is cost-effective has yet to be clearly established. Use of this vaccine causes false-positive enzyme immunoassay results for Lyme disease. Lyme disease can be diagnosed in vaccinated persons by immunoblot testing. Decisions about the use of this vaccine should be based on an assessment of a persons risk as determined by activities and behaviors relating to tick exposure in endemic areas. This vaccine should be considered an adjunct to, not a replacement for, the practice of personal protective measures against tick exposure and the early diagnosis and treatment of Lyme disease.

Recommended adult immunization schedule: United States, October 2007-September 2008

The Advisory Committee on Immunization Practices (ACIP) annually reviews the recommended Adult Immunization Schedule to ensure that the schedule reflects current recommendations for the licensed vaccines. In June 2007, ACIP approved the Adult Immunization Schedule for October 2007September 2008. This schedule has also been approved by the American Academy of Family Physicians, American College of Obstetricians and Gynecologists, and American College of Physicians. Changes in the Schedule for October 2007September 2008 The 20072008 schedule differs from the previous schedule as follows: The yellow bar for varicella has been extended through all age groups on the age-based schedule (Figure top), indicating that varicella vaccine is recommended for all adults without evidence of immunity to varicella. Figure. Recommended Adult Immunization Schedule: United States, October 2007September 2008. 1. Tetanus, diphtheria, and acellular pertussis (Td/Tdap) vaccination Tdap should replace a single dose of Td for adults age <65 years who have not previously received a dose of Tdap (either in the primary series, as a booster, or for wound management). Only 1 of 2 Tdap products (Adacel, Sanofi Pasteur) is licensed for use in adults. Adults with uncertain histories of a complete primary vaccination series with diphtheria and tetanus toxoidcontaining vaccines should begin or complete a primary vaccination series. A primary series for adults is 3 doses: administer the first 2 doses at least 4 weeks apart and the third dose 6 to 12 months after the second dose. Administer a booster dose to adults who have completed a primary series and if the last vaccination was received 10 years previously. Tdap or Td vaccine may be used, as indicated. If the person is pregnant and received the last Td vaccination 10 years previously, administer Td during the second or third trimester; if the person received the last Td vaccination in <10 years, administer Tdap during the immediate postpartum period. A 1-time administration of 1 dose of Tdap with an interval as short as 2 years from a previous Td vaccination is recommended for postpartum women, close contacts of infants age <12 months, and all health care workers with direct patient contact. In certain situations, Td can be deferred during pregnancy and Tdap substituted in the immediate postpartum period, or Tdap can be given instead of Td to a pregnant woman after an informed discussion with the woman. Consult the ACIP statement for recommendations for administering Td as prophylaxis in wound management. 2. Human papillomavirus (HPV) vaccination Human papillomavirus vaccination is recommended for all women age 26 years who have not completed the vaccine series. History of genital warts, abnormal Papanicolaou test, or postive HPV DNA test is not evidence of prior infection with all vaccine HPV types; HPV vaccination is still recommended for these women. Ideally, vaccine should be administered before potential exposure to HPV through sexual activity; however, women who are sexually active should still be vaccinated. Sexually active women who have not been infected with any of the HPV vaccine types receive the full benefit of the vaccination. Vaccination is less beneficial for women who have already been infected with 1 or more of the HPV vaccine types. A complete series consists of 3 doses. The second dose should be administered 2 months after the first dose; the third dose should be administered 6 months after the first dose. Although HPV vaccination is not specifically recommended for females with the medical indications described in Figure (bottom), it can be administered because it is not a live-virus vaccine. However, immune response and vaccine efficacy might be less than that in persons who do not have the medical indications described or who are immunocompetent. 3. Measles, mumps, rubella (MMR) vaccination Measles component: Adults born before 1957 can be considered immune to measles. Adults born during or after 1957 should receive 1 dose of MMR unless they have a medical contraindication, documentation of 1 dose, history of measles based on health care provider diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who 1) have been recently exposed to measles or in an outbreak setting; 2) have been previously vaccinated with killed measles vaccine; 3) have been vaccinated with an unknown type of measles vaccine during 19631967; 4) are students in postsecondary educational institutions; 5) work in a health care facility; or 6) plan to travel internationally. Mumps component: Adults born before 1957 can generally be considered immune to mumps. Adults born during or after 1957 should receive 1 dose of MMR unless they have a medical contraindication, history of mumps based on health care provider diagnosis, or laboratory evidence of immunity. A second dose of MMR is recommended for adults who 1) are in an age group that is affected during a mumps outbreak; 2) are students in postsecondary educational institutions; 3) work in a health care facility; or 4) plan to travel internationally. For unvaccinated health care workers born before 1957 who do not have other evidence of mumps immunity, consider giving 1 dose on a routine basis and strongly consider giving a second dose during an outbreak. Rubella component: Administer 1 dose of MMR vaccine to women whose rubella vaccination history is unreliable or who lack laboratory evidence of immunity. For women of childbearing age, regardless of birth year, routinely determine rubella immunity and counsel women regarding congenital rubella syndrome. Women who do not have evidence of immunity should receive MMR vaccine upon completion or termination of pregnancy and before discharge from the health care facility. 4. Varicella vaccination All adults without evidence of immunity to varicella should receive 2 doses of single-antigen varicella vaccine unless they have a medical contraindication. Special consideration should be given to those who 1) have close contact with persons at high risk for severe disease (e.g., health care personnel and family contacts of immunocompromised persons) or 2) are at high risk for exposure or transmission (e.g., teachers; child care employees; residents and staff members of institutional settings, including correctional institutions; college students; military personnel; adolescents and adults living in households with children; nonpregnant women of childbearing age; and international travelers). Evidence of immunity to varicella in adults includes any of the following: 1) documentation of 2 doses of varicella vaccine at least 4 weeks apart; 2) U.S.-born before 1980 (although for health care personnel and pregnant women, birth before 1980 should not be considered evidence of immunity); 3) history of varicella based on diagnosis or verification of varicella by a health care provider (for a patient reporting a history of or presenting with an atypical case, a mild case, or both, health care providers should seek either an epidemiologic link with a typical varicella case or to a laboratory confirmed case or evidence of laboratory confirmation, if it was performed at the time of acute disease); 4) history of herpes zoster based on health care provider diagnosis; or 5) laboratory evidence of immunity or laboratory confirmation of disease. Assess pregnant women for evidence of varicella immunity. Women who do not have evidence of immunity should receive dose 1 of varicella vaccine upon completion or termination of pregnancy and before discharge from the health care facility. The second dose should be administered 4 to 8 weeks after the first dose. 5. Influenza vaccination Medical indications: Chronic disorders of the cardiovascular or pulmonary systems, including asthma; chronic metabolic diseases, including diabetes mellitus; renal or hepatic dysfunction; hemoglobinopathies; immunosuppression (including immunosuppression caused by medications or HIV); any condition that compromises respiratory function or the handling of respiratory secretions or that can increase the risk for aspiration (e.g., cognitive dysfunction, spinal cord injury, or seizure disorder or other neuromuscular disorder); and pregnancy during the influenza season. No data exist on the risk for severe or complicated influenza disease among persons with asplenia; however, influenza is a risk factor for secondary bacterial infections that can cause severe disease among persons with asplenia. Occupational indications: Health care personnel and employees of long-term care and assisted living facilities. Other indications: Residents of nursing homes and other long-term care and assisted living facilities; persons likely to transmit influenza to persons at high risk (e.g., in-home household contacts and caregivers of children age 0 to 59 months, or persons of all ages with high-risk conditions); and anyone who would like to be vaccinated. Healthy, nonpregnant adults age 49 years without high-risk medical conditions who are not contacts of severely immunocompromised persons in special care units can receive either intranasally administered influenza vaccine (FluMist, MedImmune Vaccines, Gaithersburg, Maryland) or inactivated vaccine. Other persons should receive the inactivated vaccine. 6. Pneumococcal polysaccharide vaccination Medical indications: Chronic pulmonary disease (excluding asthma); chronic cardiovascular diseases; diabetes mellitus; chronic liver diseases, including liver disease as a result of alcohol abuse (e.g., cirrhosis); chronic alcoholism, chronic renal failure, or nephrotic syndrome; functional or anatomic asplenia (e.g., sickle cell disease or splenectomy [if elective splenectomy is planned, vaccinate at least 2 weeks before surgery]); immunosuppressive conditions; and cochlear implants and cerebrospinal fluid leaks. Vaccinate as close to HIV diagnosis as possible. Other indications: Alaska Natives and c

Response to Haemophilus influenzae type bconjugate vaccine in chronically ill premature infants

Twenty-two premature infants with chronic lung disease (median gestational age 28 weeks) received polyribosylribitol phosphate-outer membrane protein conjugate Haemophilus vaccine at 2 and 4 months of chronologic age. The proportions with antibodies to polyribosylribitol phosphate at levels > 1 microgram/ml after doses 1 and 2 were 27% and 55%; geometric mean titers were 0.43 and 0.73 microgram/ml, significantly lower than values for term infants.

Antibody response to oral polio vaccine in premature infants.

APPROXIMATELY 50% OF TERM INFANTS will obtain protection to all three Serotypes of orally administered polio vaccine after a single dose at 2 months of age; multiple vaccine doses will increase the protection to 83% to 96% of children, v9 However, the optimal time to administer OPV to a child born prematurely has not been determined. The American Academy of Pediatrics recommends giving the first dose of OPV to a premature infant at 2 months of chronologic age if the child has been discharged from the hospital and is otherwise healthyJ ~ The Academy notes, however, that this recommendation is not based on adequate data. This study was undertaken to determine whether the antibody response in preterm infants to OPV given at 2 and 4 months of age is comparable to that in term infants.

Obturator internus muscle abscess in children.

The authors describe four cases of obturator internus muscle (OIM) abscess in children, including their clinical presentations and treatment. This was a retrospective chart review. Children and adolescents younger than 18 years discharged between July 1, 1985, and September 30, 1998, from Brenner Childrens Hospital with the diagnosis of muscle abscess or pelvic abscess were identified. A total of 56 patients were identified with the diagnosis of muscle abscess or pelvic abscess. OIM abscess was defined by radiologic findings of an inflammatory process with fluid collection in the OIM, along with the clinical findings suggestive of an OIM abscess. Four of the patients met the definition of OIM muscle abscess. The common presenting features were fever, limp, and hip pain. Computed tomography or magnetic resonance imaging was diagnostic in all four patients, and Staphylococcus aureus was the causative agent in each. All the patients recovered, one after surgical drainage and the other three after antimicrobial therapy alone or with needle aspiration. The presentation of OIM pyomyositis is similar to that of psoas muscle pyomyositis and other infectious processes of the pelvis and hip. The S. aureus is the most common etiologic agent but not the only one reported. Most patients can be managed without open surgical drainage, but needle aspirations may be helpful both therapeutically and diagnostically.