Philip Toltzis

Frequency and risk factors for deep focus of infection in children with Staphylococcus aureus bacteremia.

Background: Staphylococcus aureus bacteremia (SAB) in children may be associated with development of deep-seated foci of infection, often prompting extensive diagnostic testing. The objective of this study was to establish the frequency and risk factors for deep foci of infection from SAB in pediatric patients. Methods: Medical charts of all children admitted with SAB to a tertiary-care center from January 1992 to June 2006 were reviewed. Study outcome was the presence of a deep focus of infection as documented by positive echocardiogram, bone imaging or abdominal imaging. Results: We studied 298 children, of whom 190 (64%) had echocardiograms, 116 (39%) had abdominal imaging, and 103 (35%) had bone imaging. Forty-seven subjects (16%) had symptoms of a deep focus of infection on discovery of SAB, which then was confirmed by 1 of the 3 tests. Eleven (3.7%) additional subjects had a clinically unsuspected deep focus identified before discharge. All children with an unsuspected deep focus of infection had either an underlying medical condition that potentially obscured the diagnosis or a central venous catheter. More than 1 day of positive blood cultures was associated with an unsuspected deep-seated infection (P < 0.01). Endocarditis was uncommon (2.7%), and occurred only in children with known congenital heart disease or with a central catheter. Conclusions: Deep-seated infections from SAB in children are most often clinically apparent at discovery of bacteremia. Unsuspected deep-seated infection is uncommon and confined to specific hosts. Routine diagnostic imaging is not indicated in all children with SAB.

Pitfalls in Diagnosis of Pediatric Clostridium difficile Infection

The incidence of Clostridium difficile infection (CDI) has risen among children and C difficile is increasingly recognized as an important cause of healthcare-associated diarrhea among pediatric patients. Still, increased identification of CDI in healthy children in the community and increased testing among infants requires cautious interpretation, given the high prevalence of asymptomatic colonization in young infants and frequent detection of viruses and other co-pathogens in stool specimens in these age groups. The significance of CDI among infants and the implications of positive C difficile testing among healthy children in the community are areas in need of further study.

Treatment and triage recommendations for pediatric emergency mass critical care.

Introduction: This paper will outline the Task Force recommendations regarding treatment during pediatric emergency mass critical care, issues related to the allocation of scarce resources, and current challenges in the development of pediatric triage guidelines. Methods: In May 2008, the Task Force for Mass Critical Care published guidance on provision of mass critical care to adults. Acknowledging that the critical care needs of children during disasters were unaddressed by this effort, a 17-member Steering Committee, assembled by the Oak Ridge Institute for Science and Education with guidance from members of the American Academy of Pediatrics, convened in April 2009 to determine priority topic areas for pediatric emergency mass critical care recommendations. Steering Committee members established subcommittees by topic area and performed literature reviews of MEDLINE and Ovid databases. The Steering Committee produced draft outlines through consensus-based study of the literature and convened October 6–7, 2009, in New York, NY, to review and revise each outline. Eight draft documents were subsequently developed from the revised outlines as well as through searches of MEDLINE updated through March 2010. The Pediatric Emergency Mass Critical Care Task Force, composed of 36 experts from diverse public health, medical, and disaster response fields, convened in Atlanta, GA, on March 29–30, 2010. Feedback on each manuscript was compiled and the Steering Committee revised each document to reflect expert input in addition to the most current medical literature. Task Force Recommendations: Recommendations are divided into three operational sections. The first section provides pediatric emergency mass critical care recommendations for hospitals that normally provide care to pediatric patients. The second section provides recommendations for pediatric emergency mass critical care at hospitals that do not routinely provide care to pediatric patients. The final section provides a discussion of issues related to developing triage algorithms and protocols and the allocation of scarce resources during pediatric emergency mass critical care.

Human Immunodeficiency Virus (HIV)-Related Risk-Taking Behaviors in Women Attending Inner-City Prenatal Clinics in the Mid-West

OBJECTIVE:Federal guidelines recommend the provision of human immunodeficiency virus education to all attendees of prenatal clinics. The current study was conducted to assess risk-taking behaviors among urban women voluntarily pursuing prenatal care.DESIGN AND SETTING:African American women attending urban prenatal clinics in Cleveland, Ohio were subjected to an extensive interview before receiving an experimental AIDS education curriculum. The interview sought detailed information regarding demographics, lifetime and recent sexual activity, condom use, and lifetime and recent illicit drug use.RESULTS:A total of 1017 women were interviewed; of these women, ∼73% were single. The majority had a monthly income of less than

Low Frequency of Endemic Patient-to-Patient Transmission of Antibiotic-Resistant Gram-Negative Bacilli in a Pediatric Intensive Care Unit

500. A total of 66% had only one partner in the past year, and almost 90% had ≤1 partner in the past 6 months. A total of 98% identified a main partner. Nearly all subjects were at least fairly certain that this partner did not use intravenous drugs, and 71% were at least fairly certain that he was monogamous. Only 19% used condoms most or all the time. Intravenous drug use among study subjects was very infrequent.CONCLUSION: These data indicate that inner-city Cleveland women seeking prenatal care are largely monogamous around the time of their gestation, and that a history of intravenous drug use is infrequent. They suggest that prenatal counseling in urban clinics will need to address women who largely are engaged in single-partner relationships at the time of the intervention.

Croup syndromes: Laryngotracheitis, epiglottitis, and bacterial tracheitis

We sought to determine the frequency of horizontal transmission of antibiotic-resistant gram-negative bacilli (ARGNB) in a pediatric intensive care unit during a nonoutbreak period. Among 5,300 admissions over 39 consecutive months, 13 ARGNB clusters involving 35 children were identified by pulsed-filed gel electrophoresis analysis, which suggests that person-to-person transmission was uncommon.

Zidovudine-Associated Embryonic Toxicity in Mice

This article examines the clinical presentation, evaluation, and treatment of the major infectious causes of upper airway obstruction in children. Several important changes have occurred in the management of laryngotracheitis (croup), the most frequent cause of upper airway obstruction in children. Specifically, several studies have documented that a subset of patients receiving a single administration of racemic epinephrine aerosol in the ambulatory setting can be discharged safely without the need for in-hospital observation. Moreover, several trials have established the effectiveness of steroids in ameliorating the severity of croup, although the role of steroids in children not requiring in-hospital management is still undefined. Epiglottitis and bacterial tracheitis, although much less common than croup, frequently lead to complete airway obstruction. Proper management of these two infections requires rapid recognition, expeditious evaluation, and establishment of an artificial airway. Once the airway has been secured, however, both diseases respond briskly to parenteral antibiotic therapy. Upper airway obstruction from infectious causes is encountered commonly in peiiatric practice. The major entities can be diagnosed readily on clinical and radiographic evidence. Effective management models have been well established to assure an uneventful recovery from these potentially life-threatening diseases.