Meera Varman

Effects of Volume and Site of Blood Draw on Blood Culture Results

ABSTRACT Blood culture contamination greatly affects clinical decisions. Hence, it is of interest to assess the influence of factors such as the volume of blood drawn and the site of blood draw on the rates of blood culture contamination. In a retrospective study, blood cultures from infants and children up to 18 years of age who had at least one positive blood culture during the year 2006 were analyzed for their volume of blood drawn, patients weight, site of blood draw used, and blood culture results. Blood cultures were deemed adequate collections if they contained an appropriate weight-related volume of blood. Moreover, blood culture results were categorized as true pathogens, contaminants, and negative cultures; these were then compared and analyzed with respect to their volume and site of blood draw. A total of 5,023 blood cultures were collected during 2006, of which 843 were analyzed. There were 306 (36%) positive cultures among the 843 cultures analyzed. Of the 306 positive cultures, 98 (32%) were contaminants and 208 (68%) cultures grew significant pathogens. Thirty-five percent of the contaminant cultures had adequate volume compared to 60% in the true bacteremia group (P < 0.001). Also, of the 843 cultures, the rates of contamination among the different sites of blood draw were as follows: peripheral venipuncture, 36%; arterial, 10%; and central venous access, 7% (P = 0.155). The rate of contamination was higher with lower blood volumes, and there was no significant difference in the rates of contamination among the different sites of blood draw.

Encephalitis Associated with Influenza B Virus Infection in 2 Children and a Review of the Literature

Two children with influenza B-associated encephalitis (IBAE) presented to our hospital during the winter of 2000-2001, both of whom had cases notable for mutism in association with encephalitis. A review of the literature identified 13 additional reports consistent with IBAE that contained sufficient data for analysis. Eleven of 15 reported cases occurred in children aged <or=18 years; of these, more than one-half occurred in children <11 years of age. Neurologic symptoms appeared within the first 4 days of illness in 13 cases. Speech abnormalities were observed in 4 patients and consisted of mutism in 3. Although the majority of patients recovered fully, 3 were left with neurologic sequelae, and 1 died. These cases reveal the spectrum of IBAE and its potential for long-term sequelae. Clinicians caring for children should remain vigilant for this rare complication of influenza B virus infection.

Parotid abscess caused by Mycobacterium tuberculosis.

Tuberculosis of the parotid gland is rare. A 16-month-old US-born male infant with immigrant parents from Sudan presented to his primary care physician with periorbital cellulitis and preauricular lymphadenitis. He underwent incision and drainage of an abscess in the right intraparotid lymph node. The aspirate was positive for acid-fast bacilli by auramine-rhodamine stain and subsequently grew Mycobacterium tuberculosis. Antitubercular medications were started postoperatively.

Immunogenicity and Safety of two tetravalent (measles, mumps, rubella, varicella) vaccines coadministered with hepatitis a and pneumococcal conjugate vaccines to children twelve to fourteen months of age

Background: This study compared single-dose tetravalent measles, mumps, rubella, varicella vaccine, Priorix-Tetra, stored refrigerated (GSK+4C) or frozen (GSK-20C), with ProQuad (Merck-20C), when coadministered with hepatitis A vaccine (HAV) and 7-valent pneumococcal conjugate vaccine (PCV7). Methods: Multicenter, observer-blind phase 2 study in 1783 healthy 12–14 month olds randomized to: GSK+4C (n = 705), GSK-20C (n = 689) or Merck-20C (n = 389), administered concomitantly with HAV (Havrix) and PCV7 (Prevnar). Seroresponse rates and antibody geometric mean concentrations/titers were determined from enzyme-linked immunosorbent assay and neutralization assays. Reactogenicity and safety were assessed. Results: Seroresponse rates (day 42) were >97% for measles and rubella viruses and >92% for mumps virus, in all groups. Noninferiority of both GSK+4C and GSK-20C vaccines versus Merck-20C was demonstrated for seroresponse rates to measles, mumps and rubella viruses (lower 97.5% confidence interval above −5%, −10% and −5%, respectively). For varicella-zoster virus, seroresponse rates were 57.1%, 69.8% and 86.7% in the GSK+4C, GSK-20C and Merck-20C groups, respectively. Noninferiority was not shown for either GSK vaccine (lower 97.5% confidence intervals <−15%). Geometric mean concentration ratios for anti-varicella-zoster virus demonstrated noninferiority (lower 97.5% confidence interval ≥0.5) versus Merck-20C for GSK-20C only. Geometric mean concentration ratios for antibodies to HAV and to PCV7 pneumococcal serotypes also met criteria for noninferiority for both GSK groups compared with Merck-20C. GSK vaccine safety was observed comparable to Merck-20C. Localized but not generalized measles/rubella-like rash and grade 3 fever was reported slightly more frequently with GSK vaccines, but antipyretic use was similar. The incidence of subjects experiencing at least 1 serious adverse event was 2.0%, 2.9% and 1.8% in the GSK+4C, GSK-20C and Merck-20C groups, respectively. Conclusions: Noninferiority of both GSK measles, mumps, rubella, varicella vaccines versus Merck-20C was demonstrated for responses to measles, mumps and rubella viruses but was not fully demonstrated for varicella-zoster virus. The vaccines showed acceptable reactogenicity/safety when coadministered with HAV and PCV7.

Immunizations for patients with metabolic disorders.

Individuals with underlying metabolic disorders are a potential high-risk group for vaccine-preventable diseases. Newborn metabolic screening has provided a means of early identification and treatment for many of these disorders, whereas childhood immunization is one of the most effective means of decreasing the morbidity and mortality resulting from communicable diseases worldwide. There are very few contraindications to the routine administration of vaccines to the healthy, immunocompetent individual. In certain high-risk groups, such as immunocompromised patients, gravid females, and those with a history of previous anaphylactic reaction to a vaccine or its components, selective withholding of immunizations must be considered to decrease potential adverse events. A detailed analysis of the medical literature revealed few specific recommendations regarding appropriate immunization techniques for patients with metabolic disorders. In this review we detail the major metabolic disorder subtypes, elaborate on the available literature on immunizations for patients with these disorders, and provide suggested vaccine recommendations.

Isolation and characterization of an epidemic methicillin-resistant Staphylococcus aureus 15 variant in the central United States.

Epidemic methicillin-resistant Staphylococcus aureus 15 (EMRSA-15) and EMRSA-16 are pandemic MRSA strains which have received global attention due to their worldwide spread and increased prevalence. Both are primarily hospital-associated pathogens responsible for a myriad of diseases, ranging from

Identifying strategies to decrease infectious complications of gastroschisis repair

PURPOSE We describe the infectious complications of gastroschisis in order to identify modifiable factors to decrease these complications. METHODS Data from 155 gastroschisis patients (2001-2013) were reviewed. Complicated gastroschisis (intestinal atresia, necrotic bowel, or perforation) were excluded, leaving 129 patients for review. Patient demographics, surgical details, postoperative infections and complications, and length of stay were reviewed. We used CDC definitions of infectious complications. RESULTS The average gestational age of patients was 35.97weeks. Silos were used in 46% of patients (n=59) for an average of 7.4days. Thirty-one patients (24%) acquired an infection within the first 60days of life. Patients who developed an infection were born earlier in gestation (P=0.02), weighed less (P=0.01), required silos more often (P=0.01), and received a sutured repair (P=0.04). Length of stay of patients with an infection was longer than in patients without infection (P=0.01). CONCLUSIONS Infectious complications following gastroschisis repair are common. Subsets of gastroschisis patients at increased risk of infection include patients with silos, preterm delivery, low birth weight, and sutured repair. Based on our findings, our recommendation would be to carry gastroschisis patients to term and advocate against the routine use of silos, reserving their use for those cases when primary closure is not possible.

Status of the Prevention of Multidrug-Resistant Organisms in International Settings: A Survey of the Society for Healthcare Epidemiology of America Research Network.

OBJECTIVE To examine self-reported practices and policies to reduce infection and transmission of multidrug-resistant organisms (MDRO) in healthcare settings outside the United States. DESIGN Cross-sectional survey. PARTICIPANTS International members of the Society for Healthcare Epidemiology of America (SHEA) Research Network. METHODS Electronic survey of infection control and prevention practices, capabilities, and barriers outside the United States and Canada. Participants were stratified according to their countrys economic development status as defined by the World Bank as low-income, lower-middle-income, upper-middle-income, and high-income. RESULTS A total of 76 respondents (33%) of 229 SHEA members outside the United States and Canada completed the survey questionnaire, representing 30 countries. Forty (53%) were high-, 33 (43%) were middle-, and 1 (1%) was a low-income country. Country data were missing for 2 respondents (3%). Of the 76 respondents, 64 (84%) reported having a formal or informal antibiotic stewardship program at their institution. High-income countries were more likely than middle-income countries to have existing MDRO policies (39/64 [61%] vs 25/64 [39%], P=.003) and to place patients with MDRO in contact precautions (40/72 [56%] vs 31/72 [44%], P=.05). Major barriers to preventing MDRO transmission included constrained resources (infrastructure, supplies, and trained staff) and challenges in changing provider behavior. CONCLUSIONS In this survey, a substantial proportion of institutions reported encountering barriers to implementing key MDRO prevention strategies. Interventions to address capacity building internationally are urgently needed. Data on the infection prevention practices of low income countries are needed. Infect Control Hosp Epidemiol. 2016:1-8.

Characterization and mechanisms of resistance of group B streptococcal isolates obtained at a community hospital

Group B Streptococcus (GBS) (Streptococcus agalactiae) infection results in substantial morbidity and mortality among neonates due to vertical transmission [1]. While penicillin has been the drug of choice for maternal GBS prophylaxis, for penicillin-allergic patients, erythromycin and clindamycin are among the recommended alternatives, provided the isolate is susceptible [2]. GBS resistance to macrolides and lincosamides has been described to occur through two principle mechanisms: (i) active efflux of macrolides across the membrane by a hydrophobic mem-

Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS): A Quality Improvement Collaborative

Background Although many childrens hospitals have established antimicrobial stewardship programs (ASPs), data-driven benchmarks for optimizing antimicrobial use across centers are lacking. We developed a multicenter quality improvement collaborative focused on sharing data reports and benchmarking antimicrobial use to improve antimicrobial prescribing among hospitalized children. Methods A national antimicrobial stewardship collaborative among childrens hospitals, Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS), was established in 2013. Characteristics of the hospitals and their ASPs were obtained through a standardized survey. Antimicrobial-use data reports were developed on the basis of input from the participating hospitals. Collaborative learning opportunities were provided through monthly webinars and annual meetings. Results Since 2013, 36 US hospitals have participated in the SHARPS collaborative. The median full-time equivalent (pharmacist and physician) dedicated to 30 of these ASPs was 0.75 (interquartile range, 0.45-1.4). To date, the collaborative has developed 26 data reports that include benchmarking reports according to specific antimicrobial agents, indications, and clinical service lines. The collaborative has conducted 27 webinars and 3 in-person meetings to highlight the stewardship work being conducted in the hospitals. The data reports and learning opportunities have resulted in approximately 36 distinct stewardship interventions. Conclusion A pediatric antimicrobial stewardship collaborative has been successful in promoting the development of and innovation among pediatric ASPs. Additional research is needed to determine the impact of these efforts.