Marisol Fernandez

Candidal Meningitis in Neonates: A 10-Year Review

Candidal meningitis may complicate systemic candidiasis in the premature neonate. We conducted a 10-year retrospective review of 106 cases of systemic candidiasis in neonates to define the incidence, clinical features, laboratory findings, treatment, and outcome of candidal meningitis. Twenty-three of the 106 neonates had candidal meningitis (0.4% of admissions to the neonatal intensive care unit). The median gestational age was 26.2 weeks, the median birth weight was 820 g, and the median age at the onset of illness was 8 days. Clinical disease was severe and commonly was manifested by respiratory decompensation. Findings of cerebrospinal fluid (CSF) analyses varied: pleocytosis was inconsistent, hypoglycorrhachia was common, gram staining was uniformly negative, and Candida was isolated from 17 neonates (74%). Each infant was treated with amphotericin B (median cumulative dose, 30 mg/kg); 5 also received flucytosine therapy. In conclusion, initial clinical features of candidal meningitis are indistinguishable from those of other causes of systemic infection in premature neonates, and normal CSF parameters do not exclude meningitis. Timely initiation of amphotericin B monotherapy was associated with an excellent outcome.

Ophthalmologic, Visceral, and Cardiac Involvement in Neonates with Candidemia

A retrospective review of 86 neonates with candidemia hospitalized from January 1989 through June 1999 was conducted to determine the frequency of ophthalmologic, visceral, or cardiac involvement. Retinal abnormalities were observed in 4 (6%) of the 67 infants in whom indirect ophthalmoscopy examination was performed. Abdominal ultrasound abnormalities were detected in 5 (7.7%) of 65 infants. Echocardiogram revealed thrombi or vegetations in 11 (15.2%) of 72 infants. Age at onset, presence of central venous catheters, and species of Candida were not predictors for involvement at these sites. Infants with candidemia that lasted > or =5 days were more likely to demonstrate ophthalmologic, renal, or cardiac abnormalities than those with a shorter duration. Infants with involvement of these organs received larger cumulative doses of amphotericin B than those without detectable abnormalities. Because complication of disseminated candidiasis by eye, renal, or cardiac involvement has therapeutic implications, and because risk factors for candidemia inadequately predict these complications, evaluations are indicated for all neonates with candidemia.

Safety and Immunogenicity of a Bivalent Group B Streptococcal Conjugate Vaccine for Serotypes II and III

To determine whether 2 monovalent group B streptococcus (GBS) serotype II or III capsular polysaccharide (CPS)-tetanus toxoid (TT) conjugate vaccines combined in a single intramuscular dose would elicit immune responses comparable to those of monovalent vaccines, 75 healthy adults were randomized to receive GBS II-TT (3.6 micro g of CPS), GBS III-TT (12.5 micro g of CPS), or a bivalent mixture of GBS II-TT/III-TT vaccine (double-masked design). Vaccines were well tolerated. Four-fold or greater increases in GBS II or III CPS-specific IgG, respectively, were noted in postimmunization serum samples from 80%-90% of bivalent conjugate vaccine recipients, and these responses were similar to those of recipients of GBS II-TT or GBS III-TT monovalent vaccines. Immune serum samples promoted the opsonophagocytic killing of types II and III GBS in vitro. Unexpectedly, some recipients of these vaccines developed cross-reactive antibodies to the structurally similar heterologous polysaccharide. These results support the feasibility of a multivalent vaccine for the 5 prevalent invasive disease-causing GBS CPS serotypes.

A 5-Year Review of Recurrent Group B Streptococcal Disease: Lessons from Twin Infants

Recurrent invasive disease due to group B Streptococcus (GBS) in twin infants has not been reported. We report 2 cases of recurrent GBS afflicting both siblings of a set of dichorionic twin infants. The maternal and infant colonizing and invasive strains were identical by serotyping and pulsed-field gel electrophoresis (PFGE). Despite attempts at eradication with different antibiotic regimens, the infants remained colonized after treatment of the second episode. A 5-year review of recurrent invasive GBS disease in infants in our affiliated hospitals was undertaken, and 6 further cases were identified. Serotyping and PFGE of isolates from initial and second episodes were genotypically identical for each case. Three infants each had GBS serotype Ia or V disease and 2 had GBS serotype III disease. The exact pathogenesis of recurrent GBS disease remains unclear, but our data support the hypothesis that persistent mucosal colonization with the original GBS strain rather than new acquisition is a pivotal factor in disease recurrence.

Association of candidemia and retinopathy of prematurity in very low birthweight infants

OBJECTIVE To determine if the presence of candidemia in infants is associated with an increased incidence of threshold retinopathy of prematurity (ROP). DESIGN Retrospective, case-controlled study. PARTICIPANTS AND CONTROLS Forty-six infants admitted to the Texas Childrens Hospital Neonatal Intensive Care Unit between 1989 and 1999 with a birth weight 1500 g or less, estimated gestational age (EGA) 28 weeks or less, and in whom candidemia developed were matched to a control group of 46 infants based on corresponding birth weight, EGA, and year of birth. METHODS Records of each infant were reviewed to determine the presence and severity of ROP. MAIN OUTCOME MEASURES Development of threshold ROP, including retinal detachment. RESULTS Forty-three infants (93.5%) with candidemia and 39 (84.8%) without candidemia had ROP. Twenty-four infants (52.2%) with candidemia reached threshold and required surgical intervention, compared with 11 infants (23.9%) without candidemia (adjusted odds ratio [OR], 7.4; 95% confidence interval [CI], 1.7-32.1; P = 0.008). Retinal detachment developed in 10 of 24 candidemic infants (41.7%) who reached threshold ROP, compared with 2 of 11 infants (18.2%) without candidemia (OR, 4.4; 95% CI, 0.73-26.9; P = 0.1). CONCLUSIONS Candidemia is associated with increased risk of threshold ROP. Infants with Candida sepsis should be monitored closely for the development of ROP and progression after treatment.

Failure of rifampin to eradicate group B streptococcal colonization in infants.

Background. Mucous membrane colonization with group B streptococci (GBS) frequently persists in infants after treatment of invasive infection and may be associated with recurrent disease. Objective. To determine the frequency with which GBS colonization persists at mucous membrane sites after treatment of invasive early or late onset infection and to determine the efficacy of oral rifampin in eradicating colonization in these infants and their mothers. Methods. Cultures for isolation of GBS were obtained from infants and their mothers after completion of the infant’s parenteral therapy, 1 week later when rifampin therapy was initiated and at ∼1 and 4 weeks after completion of rifampin therapy. Rifampin was administered (10-mg/kg dose; maximum, 600 mg) twice daily for 4 days. Results. Ten of 21 infants (48%) and 13 (65%) of their 20 mothers were colonized with GBS at throat or rectal (infant) or vaginal, rectal or breast milk (mother) sites before rifampin was initiated. One week or less after rifampin treatment, 7 (70%) infants and 4 (31%) mothers remained colonized with GBS. At study completion 6 infants and 7 mothers had GBS colonization. Persistent colonization was not related to GBS serotype, to initial rifampin minimal inhibitory concentration or to the development of rifampin resistant strains. Conclusions. Rifampin treatment for four days utilized as a single agent after completion of parenteral therapy failed to reliably eradicate GBS colonization in infants.

Group B streptococcal infections

This review provides an overview of the scope, presentation, and management of group B streptococcal perinatal infections. Recently described information, including changes in the epidemiology, the emergence of serotype V, and the decline in early-onset infections after implementation of guidelines for maternal intrapartum chemoprophylaxis, is emphasized.

Carbapenem-Sparing Antibiotic Treatment Options in Children with Extended-Spectrum β-Lactamase (ESBL) Producing Bacteria

RESEARCH ARTICLE Carbapenem-Sparing Antibiotic Treatment Options in Children with Extended-Spectrum β-Lactamase (ESBL) Producing Bacteria Marisol Fernandez, Rachel D. Quick, Kathryn G. Merkel, Sarah Casey, Patrick Boswell, Ann Bailey and Sarmistha B. Hauger Pediatric Infectious Diseases, University of Texas at Austin Dell Medical School, Dell Children’s Medical Center of Central Texas, Austin, TX, USA Pediatric Infectious Diseases, Dell Children’s Medical Center of Central Texas, Austin, TX, USA Department of Pharmacy, Dell Children’s Medical Center of Central Texas, Austin, TX, USA Clinical Quality and Operational Effectiveness, Dell Children’s Medical Center of Central Texas, Austin, TX, USA Infection Control Preventionist, Dell Children’s Medical Center of Central Texas, Austin, TX, USA

Increasing Kingella Identification in Bone and Joint Infections in Young Children

Abstract Background Kingella kingae is an increasingly recognized pathogen among young children with bone and joint infections. Antibiotics given to cover methicillin-resistant Staphylococcus aureus are not effective against Kingella, and necessitate additional empiric antibiotics in this age group. Improving Kingella identification can narrow antibiotic choices and improve efficacy for long-term oral therapy. Methods We implemented a bone and joint infection guideline at a free standing children’s hospital that called for early imaging, focal sampling, and polymerase chain reaction (PCR) testing for culture-negative specimens. The goal was to increase identification of Kingella and other pathogens to improve targeted antimicrobial therapy. Children 6 to ≤ 60 months of age with uncomplicated acute hematogenous osteomyelitis or septic arthritis between January 1, 2009–December 31, 2016, were included in this study. Outcomes of bacterial identification were measured. Results Charts for 49 cases that met criteria were reviewed. Prior to the algorithm, we identified Kingella in 4% (1/25) of cases. Following routine use of updated sampling and testing techniques, including PCR testing, Kingella kingae identification increased to 29% of cases (7/24; P = 0.02) and, in fact, was the predominant pathogen identified in this age group. Conclusion Identification of Kingella was enhanced as a result of changes to sampling and testing, including PCR testing (Figure 1). Post-implementation, Kingella was more commonly identified than Staphylococcus aureus. Widespread availability of PCR testing in the future may allow for the use of narrowed antibiotic therapy and targeted transition to oral antibiotics in young children with bone or joint infection.Figure 1. Bacterial identification pre and post guideline among children aged 6–60 months. Disclosures All authors: No reported disclosures.

Decreasing Exposure to Radiation, Surgical Risk, and Costs for Pediatric Complicated Pneumonia: A Guideline Evaluation

OBJECTIVES This report describes the creation and successful implementation of a complicated pneumonia care algorithm at our institution. Outcomes are measured for specific goals of the algorithm: to decrease radiation exposure, surgical risk, and patient charges without adversely affecting clinical outcomes. METHODS We describe steps involved in algorithm creation and implementation at our institution. To depict outcomes of the algorithm, we completed a retrospective cohort study of hospitalized pediatric patients with a diagnosis of complicated pneumonia at a single institution between January 2010 and April 2016 who met criteria for the algorithm. Charts were manually reviewed and data were analyzed via Wilcoxon rank sum, χ2, and Fishers exact tests. RESULTS Throughout the algorithm creation process, our institution began to see a change in practice. We saw a statistically significant decrease in the number of patients who underwent a chest computed tomography scan and an increase in patients who underwent a chest ultrasound (P < .001). We also saw an increase in the use of chest tube placement with fibrinolytics and a decrease in the use of video-assisted thoracoscopic surgery as the initial chest procedure (P ≤ .001) after algorithm implementation. These interventions reduced related charges without significantly affecting length of stay, readmission rate, or other variables studied. CONCLUSIONS The collaborative creation and introduction of an algorithm for the management of complicated pneumonia at our institution, combined with an effort among physicians to incorporate evidence-based clinical care into practice, led to reduced radiation exposure, surgical risk, and cost to patient.