Michael Bolton

Pediatric Spinal Epidural Abscess: A 9-Year Institutional Review and Review of the Literature

Spinal epidural abscess (SEA) is a rare condition that requires prompt diagnosis and initiation of treatment for optimal outcome. Treatment generally consists of surgical intervention and systemic antibiotics. We present 1 of the largest cohorts of nontuberculous pediatric SEA in the English literature, emphasizing the outcomes of conservative (ie, nonoperative) management. We retrospectively identified 9 pediatric patients (≤18 years of age) with SEAs at Our Lady of the Lake Children’s Hospital from 2002 to 2011. Cases were reviewed for demographic, clinical, diagnostic, and treatment characteristics and outcomes. The diagnosis of SEA was made by MRI in all cases, and methicillin-resistant Staphylococcus aureus (MRSA) was the only identified pathogen, isolated via blood culture in 6 of 9 patients. Although every patient received systemic antibiotics, only 2 had neurosurgical intervention. Four of the 7 patients treated conservatively received computed tomography-guided needle drainage. All patients recovered without significant sequelae. SEA is a potentially fatal illness that necessitates a heightened clinical awareness for diagnosis and treatment. Although official recommendations regarding management in pediatrics are lacking, treatment has generally been surgical decompression and drainage in combination with antibiotics; recent reports have suggested that antibiotic therapy alone may be successful in select patient populations. Although the adult literature has suggested that such management can be trialed in specific situations, only a handful of cases in the pediatric literature have reported this nonoperative approach. We present one of the largest reviews in support of successfully treating SEA with nonsurgical therapy.

Trichomonas vaginalis Brain Abscess in a Neonate

We describe a case of cerebral trichomoniasis in a neonate in whom seizures and multiorgan failure developed during treatment for staphylococcal sepsis. Brain abscesses were identified with cranial sonography, and Trichomonas vaginalis was isolated from cerebrospinal fluid samples. The patient died despite metronidazole therapy.

An Improvement Approach to Integrate Teaching Teams in the Reporting of Safety Events

BACKGROUND AND OBJECTIVE: Patient safety events are underreported by physicians. Baseline data demonstrated that physicians submitted 3% of event reports at Our Lady of the Lake Children’s Hospital. Our aim was to increase the proportion of safety reports filed by residents and faculty to 6% of all reports within a 9-month period. METHODS: We used the Model for Improvement and serial Plan, Do, Study, Act cycles to test interventions we hypothesized would improve physician recognition and reporting of patient safety events. We tracked the percentage of Our Lady of the Lake Children’s Hospital event reports entered by residents or faculty over time as the primary outcome measure. Changes to teaching team processes included “patient safety rounds” prompted by text messages, an inpatient “superintendent” rotation with core patient safety responsibilities, and a “just-in-time” faculty development program called “QI on the Fly.” RESULTS: Physician-reported events increased to a monthly average of 24% of all events reported, an improvement that has been sustained over 17 months. Resident reporting accounted for most of the increase in physician reports. Increased physician reporting was temporally associated with implementation of the “superintendent” rotation. The total number of events reported increased as a result of increased physician reporting. CONCLUSIONS: Incorporating patient safety responsibilities into a teaching team’s workflow can increase physician safety event reporting. We plan additional Plan, Do, Study, Act cycles to spread this approach to other clinical settings and investigate the impact increased reporting might have on patient care.

An Atypical Case of Bartonella henselae Osteomyelitis and Hepatic Disease

Bartonella henselae is a Gram-negative bacterium and the causative agent of cat scratch disease (CSD). Atypical presentations of B. henselae that involve the musculoskeletal, hepatosplenic, cardiac, or neurologic systems are rare. In this case report, we describe a case of B. henselae osteomyelitis involving bilateral iliac bones complicated by hepatic lesions in a 12-year-old immunocompetent female patient. Although B. henselae is a rare cause of osteomyelitis, it should be considered when patients who present with fever, pain, and lymphadenopathy do not respond to routine osteomyelitis therapy.

Pediatric Tuberculosis in Nonimmigrants

Tuberculosis (TB), caused by Mycobacterium tuberculosis (MTB), is encountered more commonly in developing countries, though is becoming more frequent in industrialized nations. Despite this changing landscape, the majority of recent cases detailed in the United States are in patients of foreign descent. Disease burden is highest among older individuals and lowest among children younger than 14 years, though the latter tend to have a higher propensity for more invasive disease. This unique case series details the epidemiology of a local Louisiana outbreak of active tuberculosis in a Caucasian cohort with no known epidemiologic risk factors and where 3 of the patients described are younger than 2 years.

Late ELISA Testing in Infants Born to HIV-Positive Mothers

We present the case of a young boy who was born to a human immunodeficiency virus (HIV)-positive mother and originally found to be uninfected. Evidence-based guidelines were followed regarding the mother’s prenatal and infant’s postnatal care, including the avoidance of breast milk. HIV DNA polymerase chain reaction qualitative tests were obtained at birth, 6 weeks and 4 months, and were all negative. He also received 6 weeks of prophylactic zidovudine. Despite these measures, his health began to decline at 17 months of age and antibody and serology tests performed at this time confirmed HIV infection. Guidelines no longer recommend routine antibody testing at 18 months of age to confirm the absence of infection in exposed infants with a record of negative virology in the first year of life. Based on this case and others we propose that this test be added back to the national guidelines for the early detection and prompt treatment of HIV infection in infants born to HIV-positive mothers.