Mike Starr

Community-acquired methicillin-resistant Staphylococcus aureus causes severe disseminated infection and deep venous thrombosis in children : Literature review and recommendations for management

Abstract:  Community‐acquired methicillin‐resistant Staphylococcus aureus (CA‐MRSA) infection in children is increasingly common and can be associated with dissemination and life‐threatening complications. Empiric therapy for presumed severe Staphylococcus aureus infection should be reviewed. Four children with severe invasive CA‐MRSA infection causing osteomyelitis and pneumonia complicated by pulmonary embolus and deep venous thrombosis are described. The literature is reviewed and recommendations for management are provided.

Severe Bordetella holmesii Infection in a Previously Healthy Adolescent Confirmed by Gene Sequence Analysis

We describe an immunocompetent adolescent who presented with exceptionally severe Bordetella holmesii infection, including previously undescribed manifestations. Sequelae included a severe restrictive lung defect due to pulmonary fibrosis.

Antibiotic-resistant Gram-negative bacteremia in pediatric oncology patients--risk factors and outcomes.

Background: Infection with antibiotic-resistant (AR) Gram-negative (GN) bacteria is associated with increased morbidity and mortality. The aim of this study was to determine risk factors and outcomes associated with GN bacteremia with acquired resistance to antibiotics used in the empiric treatment of febrile neutropenia in pediatric oncology patients at our institution. Methods: All episodes of GN bacteremia in oncology patients at the Royal Children’s Hospital Melbourne, from 2003 to 2010 were retrospectively reviewed. Information regarding age, diagnosis, phase of treatment, inpatient status, previous AR GN infection, treatment with inotropes or ventilatory support, admission to intensive care unit, and hospital and intensive care unit length of stay were obtained from electronic records. Results: A total of 280 episodes of GN bacteremia in 210 patients were identified. Of these, 42 episodes in 35 patients were caused by an AR GN organism. Factors independently associated with AR GN bacteremia were high-intensity chemotherapy (odds ratio 3.7, 95% confidence interval: 1.2–11.4), hospital-acquired bacteremia (odds ratio 4.3, 95% confidence interval: 2.0–9.6) and isolation of AR GN bacteria from any site within the preceding 12 months (odds ratio 9.9, 95% confidence interval: 3.8–25.5). Episodes of AR GN bacteremia were associated with longer median hospital length of stay (23.5 days versus 14.0 days; P = 0.0007), longer median intensive care unit length of stay (3.8 days versus 1.6 days; P = 0.02) and a higher rate of invasive ventilation (15% versus 5.2%; P = 0.03). No significant difference in infection-related or all-cause mortality between the 2 groups was identified. Conclusions: In pediatric oncology patients, AR GN bacteremia is associated with an increased rate of adverse outcomes and is more likely in patients who have received high-intensity chemotherapy, have been in hospital beyond 48 hours and who have had previous AR GN infection or colonization.

All-Oral Antibiotic Treatment for Buruli Ulcer: A Report of Four Patients

1Department of Infectious Diseases, Austin Health, Melbourne, Australia, 2Department of Surgery, Box Hill Hospital, Melbourne, Australia, 3Department of Surgery,Monash University, Melbourne, Australia, 4Department of Anatomy and Developmental Biology, Monash University, Melbourne, Australia, 5WHO Collaborating Centrefor Mycobacterium ulcerans (Western Pacific Region) and Victorian Infectious Diseases Reference Laboratory, Melbourne, Australia, 6Department of AnatomicalPathology, Box Hill Hospital, Melbourne, Australia, 7Department of Infectious Diseases, Royal Children’s Hospital, Melbourne, Australia

Bickerstaff Brainstem Encephalitis Associated With Mycoplasma pneumoniae Infection

Bickerstaff brainstem encephalitis is a clinical syndrome of ophthalmoplegia, cerebellar ataxia, and central nervous system signs and is associated with the presence of anti-GQ1b antibodies. There is a clinical continuum between Bickerstaff brainstem encephalitis and Miller Fisher syndrome. We describe the case of an 11-year-old boy with encephalopathy, external ophthalmoplegia, brainstem signs, and ataxia with raised titers of anti-GQ1b antibodies. He presented following a respiratory illness and had laboratory evidence of recent infection with Mycoplasma pneumoniae. M pneumoniae infection has been associated with both Bickerstaff brainstem encephalitis and Miller Fisher syndrome. This is only the second case in the literature of Bickerstaff brainstem encephalitis with raised titers of anti-GQ1b antibodies described in association with M pneumoniae infection. The patient responded to intravenous immunoglobulin administration. (J Child Neurol 2006;21:533—534;

Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines

Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses or randomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.

Investigation of the rate of meningitis in association with urinary tract infection in infants 90 days of age or younger.

Objective:  To test the hypothesis that urinary tract infections (UTI) in young infants are rarely associated with meningitis.

Paediatric emergency medicine

Background: Intranasal (IN) fentanyl provides rapid and powerful non-parenteral analgesia in the ED. A concentrated solution of fentanyl (300 mg/mL) has been used in prior trials, yet many ED use the standard solution at a concentration of 50 mg/mL, which is widely available and of low cost. We set out to determine if this lower concentration of fentanyl is also efficacious. Methods: Prospective audit in children aged 5–18 years presenting with upper limb injuries. Patients received IN fentanyl (50 mg/mL) at 1.5 mg/kg. Patient assessed pain scores were collected 5, 10, 20, 30 and 60 min following IN fentanyl administration using a visual analogue scale or Bieri Faces – Revised scale. Parental scores were used if patients were unable to provide a score. Results: Of the 59 eligible patients, 36 were enrolled; median age was 6.8 years (range 5–15 years), and 89% (32/36) ultimately required fracture reduction. Median first dose of IN fentanyl was 1.4 mg/kg. Median pain scores dropped from 7 (interquartile range 5–10) pre-fentanyl to 5 (interquartile range 4–8) at 5 min and 2 (interquartile range 1–4) at 30 and 60 min. A total of 21 (58%) children did not require further analgesia in the ED. There were no adverse events. Conclusions: Standard i.v. concentration IN fentanyl (50 mg/mL) appears to have analgesic efficacy in children with upper limb injuries.

Formal infectious diseases consultations at a tertiary pediatric hospital: a 14-year review.

We analyzed the formal consultations seen by the infectious diseases service over a 14-year period at one of the largest pediatric hospitals in Australia. We highlight the increasing demand for pediatric infectious diseases expertise and the reasons for which consultations are sought. Our findings will help in planning and resource allocation in an era of increasingly complex patients.

Diagnostic yield of timing blood culture collection relative to fever

Background: Conventional practice involves obtaining a blood culture during or immediately after a fever to increase diagnostic yield. There are no data to support this practice in children. Methods: Retrospective single-center case-control study of children (0–18 years) who had blood cultures performed as part of routine care. Cases had an a priori defined pathogen isolated from blood culture (n = 410) and were age-matched with contemporaneous controls with a sterile blood culture (n = 410). The predictive value of fever (before and after blood culture), C-reactive protein and hematologic indices were analyzed by multivariate regression and area under the receiver operating characteristic curves (AUCs) in neonatal, general pediatric and pediatric oncology patients. Results: One thousand one hundred seventy-two (6.7%) of 17,607 blood cultures were positive, of which 410 (35%) cultured pathogen(s). Three hundred and twenty four (79%) cases and 275 (67.1%) controls had a fever (≥37.5°C) during the 12 hours pre- or post-collection. Fever 2–6 hours before a blood culture was neither sensitive nor specific for predicting bacteremia in neonatal or pediatric patients and marginally predictive in oncology patients (AUC 0.59–0.63). Cultures obtained 2–6 hours before fever were nonpredictive in neonates (AUC 0.56–0.59), marginally predictive in pediatric patients (AUC 0.64–0.67) and moderately predictive in oncology patients (AUC 0.70). C-reactive protein was marginally predictive in neonates (AUC 0.60). Hematologic indices were nonpredictive in all groups. Conclusions: Fever before obtaining blood culture was neither sensitive nor specific for culture positivity; timing of pediatric blood cultures relative to fever is unimportant. Bacteremia precedes a fever, but this is of limited clinical applicability.