Kari A. Simonsen

Motavizumab treatment of infants hospitalized with respiratory syncytial virus infection does not decrease viral load or severity of illness

Background: This study was conducted to determine whether treatment with motavizumab, an anti-respiratory syncytial virus (RSV) monoclonal antibody, would decrease viral load and improve clinical outcomes in previously healthy term infants hospitalized with RSV lower respiratory tract infection. Methods: Infants hospitalized with lower respiratory tract infection and a positive RSV test performed locally were randomized to receive 1 intravenous dose of motavizumab (30 or 100 mg/kg) or placebo. Nasal wash samples were tested by real-time reverse transcriptase polymerase chain reaction at a central laboratory to determine viral load. Clinical data were collected during RSV hospitalization and at 12-month follow up. Results: Of 118 infants, 112 were confirmed RSV positive by real-time reverse transcriptase polymerase chain reaction. In each study group, median (range) RSV load (log10 copies/mL) decreased at a similar rate from baseline to study day 7 [motavizumab 30 mg/kg: 8.35 (2.5–9.5) to 5.03 (2.5–6.8); motavizumab 100 mg/kg: 8.22 (5.5–9.7) to 4.25 (2.5–8.0); placebo: 8.02 (6.7–9.8) to 5.17 (2.5–7.3)]. Median (range) duration of hospitalization was 3.05 (0.8–16.0), 2.99 (1.0–25.0) and 2.88 (0.8–11.7) days for the motavizumab 30 mg/kg, motavizumab 100 mg/kg and placebo groups, respectively. Six (8%) motavizumab and 0 placebo recipients were admitted to the intensive care unit and 4 required mechanical ventilation. The incidence of wheezing episodes during the 12-month follow up was comparable for all 3 groups. Conclusions: Motavizumab had no appreciable effect on RSV viral load measured in the upper respiratory tract of children hospitalized for RSV lower respiratory tract infection. No differences were observed for duration of hospitalization, severity of illness measures or wheezing episodes during 12-month follow up in children treated with motavizumab or placebo.

Powassan Encephalitis and Colorado Tick Fever

This article discusses two tick-borne illnesses: Powassan encephalitis, a rare cause of central nervous system infection caused by the Powassan virus, and Colorado tick fever, an acute febrile illness caused by the Colorado tick fever virus common to the Rocky Mountain region of North America.

Antigenemia, RNAemia, and innate immunity in children with acute rotavirus diarrhea

Antigenemia is commonly detected in children with acute rotavirus diarrhea, but the prevalence of viremia has not been clearly defined. We examined antigenemia in plasma and RNAemia in peripheral blood mononuclear cells (PBMC) of children with acute diarrhea by EIA, RT-PCR, and Southern hybridization, using primers and a probe specific to rotavirus NSP4 gene. We detected the presence of rotavirus antigen in 33.3% and almost full-length NSP4 gene in 70.8% of the acute-phase plasma and PBMC, respectively. In contrast, antigenemia and RNAemia were detected in 0% and 4.2% of the convalescent-phase plasma and PBMC, respectively, which were similar to antigenemia (0%) and RNAemia (7.7%) in healthy controls. We demonstrated an increase in the proportions of activated myeloid dendritic cells (mDC) and activated plasmacytoid DC (pDC) in acute-phase PBMC of patients when compared to those in convalescent phase of patients and in PBMC of healthy controls. The activation of mDC peaked on days 2-4 after illness onset, and the activation of acute-phase pDC appeared to correlate with levels of antigenemia. High prevalence of NSP4 gene in acute-phase PBMC indicates possible rotavirus replication in white blood cells, and extraintestinal spread and the activation of DC may have implications for the prevention of rotavirus disease in children.

Assessment of Initial Serum Vancomycin Trough Concentrations and Their Association with Initial Empirical Weight-Based Vancomycin Dosing and Development of Nephrotoxicity in Children: A Multicenter Retrospective Study

To determine whether a relationship exists between initial serum vancomycin trough concentrations and initial empirical vancomycin dose, patient weight, and patient age, and to determine the risks for vancomycin‐associated nephrotoxicity in pediatric patients stratified by hospital setting.

The effectiveness of e-learning in pediatric medical student education

Background Electronic learning allows individualized education and may improve student performance. This study assessed the impact of e-modules about infection control and congenital infections on medical knowledge. Methods A descriptive study was conducted involving third-year medical students on pediatric clerkship. e-Module content in three different formats was developed: a text monograph, a PowerPoint presentation, and a narrated PowerPoint lecture. Students’ use of the e-modules was tracked, as was participation in the infectious disease rotation and the order of pediatric rotation. Pre- and posttests specific to the e-module content and National Board of Medical Examiners (NBME) pediatric exam scores were recorded. Results Among 67 participants, 63% of them visited at least one e-module. Neither accessing any e-modules, timing of pediatric clerkship, nor assignment to ID rotation resulted in improved posttest nor NBME scores. Seventy percent of students rated the e-modules as satisfactory and reported usage improved their confidence with the congenital infections topic. Discussion e-Modules did not improve student performance on NBME or posttest; however, they were perceived as satisfactory and to have improved confidence among those who used them. This study underscores the importance of formally evaluating electronic and other innovative curricula when implemented within existing medical education frameworks.

A New Rapid Method for Clostridium difficile DNA Extraction and Detection in Stool: Toward Point-of-Care Diagnostic Testing

We describe a new method for the rapid diagnosis of Clostridium difficile infection, with stool sample preparation and DNA extraction by heat and physical disruption in a single-use lysis microreactor (LMR), followed by a rapid PCR amplification step. All steps can be accomplished in <20 minutes overall. Gel electrophoresis is currently used to detect the amplification product, pending real-time availability with an ultra-rapid thermocycler. Compared with the dual enzyme immunoassay (EIA) screening test (C. diff Quik Chek Complete; Techlab, Blacksburg, VA), the novel LMR/PCR assay showed complete concordance with all glutamate dehydrogenase (GDH) results (GDH(+)/toxin(+), n = 48; GDH(-)/toxin(-), n = 81). All 69 stool samples with discordant EIA results (GDH(+)/toxin(-)) were tested by both the LMR/PCR assay and the loop-mediated isothermal amplification test (LAMP) (Illumigene C. difficile; Meridian Bioscience, Cincinnati, OH). In 64/69 EIA-discordant samples, LAMP and LMR/PCR results matched (both positive in 29 sample and both negative in 35 samples); in the remaining 5 samples, results were discrepant between the LAMP assay (all five negative) and the LMR/PCR assay (all 5 positive). Overall, LMR/PCR testing matched the current algorithm of EIA and/or LAMP reflex testing in 193/198 (97.5%) samples. The present proof-of-concept study suggests that the novel LMR/PCR technique described here may be developed as an inexpensive, rapid, and reliable point-of-care diagnostic test for C. difficile infection and other infectious diseases.

Blood Cultures for Persistent Fever in Neutropenic Pediatric Patients Are of Low Diagnostic Yield

The incidence of bacteremia at the onset of pediatric febrile neutropenia (FN) at 2 academically linked institutions was 9.84%, and subsequent blood cultures performed for children with persistent FN yielded an incidence of 4.21%. Until the risk factors for new-onset bacteremia in patients being treated for FN can be identified and diagnostic methods can be improved, compliance with national guidelines is recommended.

Voluntary STD Testing and Treatment Program at a Metropolitan Correctional Facility: Evaluation of Test Acceptability and Associated Risk Factors

Few studies have addressed challenges of diagnosis and treatment of sexually transmitted diseases (STDs) within correctional facilities. Initiatives that screen all inmates can be cost-prohibitive, while symptom-based screening undoubtedly fails to recognize significant numbers of asymptomatically infected persons. This study discusses a voluntary STD screening and treatment program developed at the Douglas County (Nebraska) Department of Corrections where student volunteers interviewed, screened, and educated 456 inmates. Inmate urine samples and interview responses about risk behaviors and motivators for participation in the screening program were analyzed. The results support the ongoing project method to screen and treat inmates in the community correctional facility. Risk factor analysis suggests that targeted testing and treatment efforts may have a role in providing cost-effective care for STD among the incarcerated population.

A painful thigh lesion in an immunocompromised 11-year-old boy.

An 11-year-old boy with relapsed Ewing sarcoma complicated by pulmonary metastases was hospitalized in early September with fever, neutropenia, and worsening posterior thigh pain. He completed the most recent round of chemotherapy with topotecan, cyclophosphamide, and vincristine within 1 week before admission. Two days before admission, he began complaining of pain in his right upper posterior thigh. His father noted a small, less than 1 cm diameter, black, circular lesion in the area, thought to be a bruise. The patient denied recent trauma to his leg. Four days before hospitalization, he removed a small sliver from the sole of his left foot while visiting a local lake on the Iowa-Nebraska state borders. He waded, but did not swim in the lake. He also incurred mosquito bites on the lower extremities that day. On the day of admission, the patient had a fever of 38.6°C, pulse of 128/minute, respiratory rate of 20/minute, and blood pressure of 117/64 mm Hg. He was a wellappearing male with alopecia. Physical examination was notable for a loose primary lower left canine (#22) with a purple hue to the underlying gum, normal heart and lung examinations, an accessed port in his central chest that was clean and intact, a liver edge palpable just below the costal margin, and normal extremities. The skin examination revealed a mosquito bite on each of his anterior shins, a small puncture site at the location of the sliver he incurred in the sole of his left foot without any surrounding erythema, and a 1.5-cm gray-black macular lesion on his posterior superior right thigh. Laboratory findings revealed a white blood cell count of 270/ L with 20% neutrophils (absolute neutrophil count 50/ L), 72% lymphocytes, and 8% monocytes, hemoglobin 10.2 g/dL, hematocrit 29.5%, and platelets 45,000/ L. He was treated with cefepime and vancomycin empirically for fever and neutropenia. During the next 24 hours in the hospital, the posterior, medial, upper thigh lesion grew to 3 cm in diameter. It remained macular and developed central, target-like clearing surrounded by a gray inner ring and black outer ring. An additional 1.5-cm ring of erythema encircled the lesion. It was not ulcerated, necrotic, or fluctuant, and had no associated drainage or visible disruption of the superficial skin. The antimicrobial regimen was changed to liposomal amphotericin B, gentamicin, piperacillin-tazobactam, and vancomycin was continued. He underwent wide surgical excision of the lesion late on the second hospital day. Biopsy of the lesion and cultures were diagnostic (Fig., Supplemental Digital Content 1, http://links.lww.com/INF/A892). For denouement see p. 1017. Accepted for publication May 19, 2011. From the *Division of Pediatric Infectious Diseases, University of Nebraska Medical Center, 982162 University of Nebraska Medical Center Omaha, NE 68114–2162. E-mail: mahoffma@unmc.edu; and †Department of Pathology, Methodist Hospital and Children’s Hospital & Medical Center, Omaha, NE. The authors have no funding or conflicts of interest to disclose. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s Web site (www.pidj.com). Copyright

Comparison of Opt-In Versus Opt-Out Testing for Sexually Transmitted Infections Among Inmates in a County Jail.

A majority of jails in the United States rely on an opt-in (voluntary) rather than opt-out (universal) approach to testing for sexually transmitted infections (STIs). This study compares an opt-out approach at intake to opt-in testing during incarceration and estimates the prevalence of common STIs among jail inmates. Data derive from a universal intake pilot testing program (n = 298) and an established, student-led voluntary testing program (n = 1,963), respectively. The adjusted prevalence as well as the odds of testing positive for chlamydia were significantly higher in the opt-out program (p = .025 and .008, respectively) than the opt-in program but not for gonorrhea (p = .402 and .300, respectively). These results demonstrate the potential public health benefit of implementation of universal STI testing of jail inmates.