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The American Academy of Pediatrics (AAP) is committed to the attainment of optimal physical, mental, and social health and well-being for all infants, children, adolescents and young adults.
Vaccine Studies: Examine the Evidence
Vaccine Studies: Examine the Evidence is a fact sheet produced by the American Academy of Pediatrics (AAP) that lists studies on vaccine safety, particulary in relation to autism.
Immunization Action Coalition
The Immunization Action Coalition (IAC) works to increase immunization rates and prevent disease by creating and distributing educational materials for health professionals and the public that enhance the delivery of safe and effective immunization services. IAC’s site provides free informational handouts and Vaccine Information Statements (VISs) published in the United States.
National Network for Immunization Information Update
Immunization Newsbriefs are a service provided by the National Network for Immunization Information Update (NNii), providing weekly summaries of recent articles about vaccines in the news media.
Vaccinate Your Baby
Vaccinate Your Baby is an awareness campaign that was launched by Every Child By Two. The site features news and information for parents who wish to learn about immunization and how best to protect their children from vaccine-preventable diseases.
Do Vaccines Cause That?
Do Vaccines Cause That? is a book written by Martin Myers, MD and Diego Pineda, M.S. The book is a guide designed to help evaluate vaccine safety concerns.
Hepatitis A, B and C Prevention Programs
Hepatitis A, B and C Prevention Programs showcases programs across the United States that work to prevent hepatitis A, B or C in people who are at risk for infection. The site also features general information on hepatitis B and hepatitis A vaccination, special topics related to viral hepatitis and links to other organization and resources.
Shot by Shot
Shot by Shot: Stories of Vaccine Preventable Diseases is a collection of stories from people who have been touched by vaccine-preventable diseases. Shot by Shot's storybank of real-life stories, told by survivors, family members, friends, and health care providers, brings first-hand experiences to new generations.
Virtual Mentor
Virtual Mentor is a bioethics journal published by the American Medical Association.
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Preserving the Future of Pediatric Infectious Diseases
Written by: Matthew Kronman, MD, MSCE
In the last cycle of the match for fellowship positions in Pediatric Infectious Diseases, there were approximately 80% as many applicants (55 total) as there were available fellowship positions [1]. Of these applicants, two-thirds had trained in US medical and osteopathic schools, while the other third had trained at foreign medical schools. The number of applicants was down from 76 in the prior year , and 65 two years ago. After the match, approximately 40% of the fellowship programs remained unfilled.
If you are reading this, you probably already know that a career in Pediatric Infectious Diseases provides a wealth of opportunity and satisfaction across the spectrum of activities in which we engage: from preserving and protecting the public health, to educating future clinicians, to discovering novel pathogens, to uttering the fun (and ever-changing) names of old ones such as Haemophilus aphrophilus (which now bears the much less Dr. Seuss-like name Aggregatibacter aphrophilus), to pursuing scientific inquiry of the highest caliber, and of course to curing children of disease.
So as we near the start of another fellowship applicant cycle, how can we continue to attract the best applicants and assure them of satisfying careers at the end of fellowship? What factors might affect resident interest in Infectious Diseases as a career?
One consideration, of course, is the potential concern that the supply of jobs at the end of fellowship might not match the societal demand. Many who pursue a career in Pediatric Infectious Diseases spend the majority of their time in biomedical research, yet some have argued that our current system of biomedical research is not sustainable, and has created a hypercompetitive environment for a dwindling pool of funding resources, resulting in more time spent on administrative tasks and grant resubmissions, while "today, time for reflection is a disappearing luxury for the scientific community"[2]. Others have even argued that grant funding should be awarded using a lottery system, given the difficulty faced by peer review study sections of selecting the best among multiple meritorious grant applications [3].
While funding climates and grant mechanisms might change, the need for excellent Infectious Diseases physicians will not. We will continue to face serious threats due to those epidemics that are already global and those that can spread quickly in our globalized world, due to emergence of new viral pathogens, ubiquitous increasing bacterial resistance, and antimicrobial overuse, to name a few. Furthermore, we in Infectious Diseases are fortunate that job opportunities outside clinical practice and research exist, including those in antimicrobial stewardship, infection prevention and control, domestic and international public health, advocacy, government service, and industry.
We in PIDS therefore have two important responsibilities. We must first ensure a robust pipeline supply of trainees by encouraging the best and brightest to join us in fighting the various threats we face, through reaching out to and mentoring trainees at all levels and revealing how wonderful a career in Infectious Diseases can be. And we must also work diligently to ensure societal demand – so that trainees will not need to worry that pursuing a career in Infectious Diseases will train them out of a job – by advocating for increased federal funding for biomedical research, improving the funding climate for young investigators, supporting the broad scope of job opportunities outlined above, and demonstrating our utility as a specialty to those around us, as our adult colleagues have begun to do [4,5].
References
http://www.nrmp.org/wp-content/uploads/2013/08/National-Resident-Matching-Program-NRMP-Results-and-Data-SMS-2014-Final.pdf, accessed 5/14/14
2. Rescuing US biomedical research from its systemic flaws. Alberts B, Kirschner MW, Tilghman S, Varmus H. PNAS 2014;111(16):5773-5777.
Taking the Powerball Approach to Funding Medical Research. Fang FC, Casadevall A. Wall Street Journal, April 14, 2014.
The Value of Infectious Diseases Specialists: Non-Patient Care Activities. McQuillen DP, Petrak RM, Wasserman RB, Nahass RG, Scull JA, Martinelli LP. Clin Infect Dis. 2008;47(8):1051-63. doi: 10.1086/592067.
Infectious Diseases Specialty Intervention Is Associated With Decreased Mortality and Lower Healthcare Costs. Schmitt S, McQuillen DP, Nahass R, Martinelli L, Rubin M, Schwebke K, Petrak R, Ritter JT, Chansolme D, Slama T, Drozd EM, Braithwaite SF, Johnsrud M, Hammelman E. Clin Infect Dis. 2014;58(1):22-8. doi: 10.1093/cid/cit610
JPIDS Article Review: The Safety and Immunogenicity of Rotavirus Vaccination in Infants with Intestinal Failure
Written by: Rebecca Wallihan, MD
Javid PJ, Sanchez SE, Jacob S, McNeal MM, Horslen SP, Englund JA. The Safety and Immunogenicity of Rotavirus Vaccination in Infants With Intestinal Failure. J Pediatric Infect Dis Soc. 2014 Mar;3(1):57-65
Summary
In the March 2014 issue of the Journal of the Pediatric Infectious Diseases Society, Javid and colleagues report the results of a trial of rotavirus vaccine in infants with intestinal failure. The authors examined the safety and immunogenicity of rotavirus vaccination in a cohort of infants 6-14 weeks of age with early intestinal failure who underwent surgery and required parenteral nutrition postoperatively. Subjects received two doses of monovalent rotavirus vaccine (RV1), with the exception of 2 infants who completed the series with pentavalent rotavirus vaccine (RV5). Safety data were assessed via survey daily for the first 5 days after each vaccine dose and collected information on fever, vomiting, diarrhea, generalized allergic reaction, or intussusception. Stool and serum samples were obtained at baseline and weeks 1 and 2 following each vaccine dose, with an additional stool sample at 4 weeks following each vaccine dose. Immunogenicity was defined as a 3-fold increase from baseline measurement in serum anti-rotavirus IgA antibody at least 4 weeks after the final vaccine dose. The authors evaluated stool shedding and serum antigenemia via an enzyme-linked immunosorbent assay. Six month follow-up data were collected during a telephone call to parents of subjects.
Of 15 infants enrolled in the study, 14 completed the vaccine series and 6-month follow-up data were available for 12. Irritability in the first 5 days after vaccination was the most common adverse event, developing in 9 (60%) subjects. Vomiting developed in 6 (40%) subjects, diarrhea in 5 (33%) subjects, and diaper rash in 2 (13%) subjects. None of these adverse events required alteration in a patient's feeding regimen. Additionally, no case of intussusception was reported during the study period. Results of serum anti-rotavirus IgA antibody measurement demonstrated seroconversion in 12 subjects. The remaining 2 infants had an elevated baseline IgA antibody to rotavirus prior to vaccination and did not demonstrate a 3-fold increase in antibody levels after vaccination. Overall, postvaccine stool shedding of rotavirus was seen in 7 (47%) infants with 1 subject shedding virus for more than 2 weeks following vaccination. Rotavirus antigen was not detected in the serum of any subjects.
Commentary
Due to inherent differences in intestinal anatomy, motility, and absorption, infants and children with intestinal failure are at higher risk for increased morbidity related to gastroenteritis, especially rotavirus [1,2]. Accordingly, the Advisory Committee on Immunization Practices (ACIP) from the Centers for Disease Control and Prevention (CDC) recommends administration of rotavirus vaccine to children with chronic gastrointestinal disorders, though it is listed as a precaution because of the lack of information regarding safety and efficacy [3]. In this paper, Javid and colleagues provide much needed data on the use of rotavirus vaccine in this patient population.
The first key area addressed is the safety of rotavirus vaccine in infants with intestinal failure. Previously, Fang et al [4] reported data from a case series of 9 infants with short bowel syndrome who received pentavalent rotavirus vaccine. In this retrospective study they found vaccination was well-tolerated by most infants. There were increased ileostomy losses on the day of or shortly after vaccine administration in 3 infants, though it was unclear if these were associated with vaccination or represented normal variability. No effects on weight gain, temperature, or urinary sodium were identified. The prospective nature and detailed data collection in the present paper by Javid et al provides even more evidence for the safety of rotavirus vaccine in this patient population. Irritability, vomiting, and diarrhea were the most common adverse events reported; however, no infants required hospitalization or changes to their nutritional regimen or medical management. Therefore, the clinical relevance of the reported symptoms appears to be minimal. Importantly, no cases of intussusception were observed during the study period. Further support for the mild nature of these symptoms is evidenced by parental agreement that the vaccine did not have any harmful effects. Serum antigenemia was not observed in any subject and viral shedding in the stool was similar to previously published data in healthy infants.
The second important point to emphasize is the immunogenicity of the rotavirus vaccine in this patient population. Given the variation in remaining bowel length and absorption, it was unknown how children with intestinal failure would process and respond to the vaccine. Seroconversion to rotavirus was detected in 86% of subjects who completed the vaccine series, similar to previously reported results from clinical trials of RV1 in healthy infants [3]. The remaining 2 infants both had elevated serum IgA antibody to rotavirus prior to receipt of the vaccine, with 1 of these infants having received a blood transfusion 1 week before antibody measurement. This study is the first published evidence to indicate that rotavirus vaccine appears to be immunogenic in children with intestinal failure. How this discovery correlates with efficacy in these children remains to be seen, as data are lacking on protection from rotavirus disease or health-care utilization.
Primary limitations of this study include small number of subjects and the inclusion of infants who were less severely affected (most had weaned from parenteral nutrition prior to discharge from their first inpatient admission). Despite these limitations, these results offer preliminary data to support the current ACIP recommendations for routine use of rotavirus vaccine in children with intestinal failure. The current study focused on RV1 so it remains unclear if the same results would be seen with RV5, though 2 of the enrolled infants did complete the series with RV5. It will be important to confirm these findings in larger patient populations, including in infants with more severe forms of intestinal failure. Future studies should also assess the long term impact of vaccination on health-care utilization in infants and children with chronic gastrointestinal disease.
References
Grosfeld JL, Rescorla FJ, West KW. Short bowel syndrome in infancy and childhood. Analysis of survival in 60 patients. Am J Surg. 1986 Jan;151(1):41-6.
Anagnostopoulos D, Valioulis J, Sfougaris D, Maliaropoulos N, Spyridakis J. Morbidity and mortality of short bowel syndrome in infancy and childhood. Eur J Pediatr Surg. 1991 Oct;1(5):273-6.
Centers for Disease Control and Prevention. Prevention of Rotavirus Gastroenteritis Among Infants and Children: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2009; 58(No. RR-2): 1-24.
Fang AY, Tingay DG. Early observations in the use of oral rotavirus vaccination in infants with functional short gut syndrome. J Paediatr Child Health. 2012 Jun;48(6):512-6.
MERS Update: Key Points – Middle East Respiratory Syndrome Coronavirus (MERS-CoV)- 5/12/2014
CDC has provided updated key points regarding the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), dated 5/12/2014. Updates include information about the second imported case of MERS in the United States.
For additional information regarding the MERS situation, please see:
CDC MERS Press Briefing Transcript (5/12/2014), http://www.cdc.gov/media/archives.htm
CDC MERS website: http://www.cdc.gov/coronavirus/mers/index.html
CDC MERS Feature Article: http://www.cdc.gov/features/novelcoronavirus/
CDC announces second imported case of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) infection in the United States
CDC and Florida Department of Health officials are investigating the second case of MERS-CoV infection in the United States. MERS-CoV, a virus relatively new to humans, was first reported in Saudi Arabia in 2012. On May 2, 2014 CDC reported the first case of MERS in the United States.
WHO:
Tom Frieden, M.D., M.P.H., Director, U.S. Centers for Disease Control and Prevention
Anne Schuchat, M.D. (RADM, USPHS) Assistant Surgeon General, United States Public Health Service; Director, National Center for Immunization and Respiratory Diseases
John H. Armstrong, MD, FACS, FCCP Florida's State Surgeon General and Secretary of Health
WHEN: Monday, May 12, 2014 at 2:00 p.m. ET
DIAL-IN:
Listen-only: 877-546-1574
Passcode: CDC MEDIA
Transcript:
A transcript of this media availability will be available following the briefing at the CDC web site at www.cdc.gov/media.
U.S. Department of Health and Human Services
CDC works 24/7 saving lives, protecting people from health threats, and saving money through prevention. Whether these threats are global or domestic, chronic or acute, curable or preventable, natural disaster or deliberate attack, CDC is the nation's health protection agency.
April 2014: JPIDS Article Review & Commentary
Written by: Christina Gagliardo, MD
Sammons JS, Gerber JS, Tamma PD, Sandora PD, Sandora TJ, Beekmann SE, Polgreen PM, Hersh AL. Diagnosis and Management of Clostridium difficile Infection by Pediatric Infectious Disease Physicians. J Pediatric Infect Dis Soc 2014 Mar; 3(1):43-48.
Summary:
In the March 2014 issue of the Journal of the Pediatric Infectious Disease Society, Sammons and colleagues report on practices for the diagnosis and management of mild, severe, and recurrent Clostridium difficile infection (CDI) by pediatric infectious disease (ID) physicians. They performed a web-based survey via the Emerging Infections Network (EIN) whose membership includes nearly one-quarter of all pediatric ID physicians who received board-certification since 1994. The survey was adapted and modified from an EIN survey of adult physicians on treatment of CDI and use of fecal microbiota transplantation. The survey included questions regarding diagnostic techniques and treatment strategies employed for CDI in children with clinical vignettes aimed to determine how treatment would differ based on clinical presentation (recurrent, severe, etc.), underlying chronic conditions, and patient age. They defined severe CDI as presence of WBC count >15,000 cells/µL, serum creatinine ≥ 1.5 times patient’s baseline, hypotension or shock, ileus, perforation, or megacolon. Recurrent CDI was defined as an episode occurring 8 weeks or less after the onset of a previous episode, provided symptoms had resolved from the previous episode.
Of 285 physicians surveyed, 145 (51%) responded and were included for analysis (twenty-two other respondents were excluded because they reported they had not managed patients with CDI in the past year). To diagnose CDI, 97 (67%) respondents used nucleic acid amplification assays alone or in combination with other laboratory methods, while 32 (22%) respondents used toxin enzyme immunoassay (EIA), and of these, over one-third used EIA alone. Forty respondents reported infant testing was restricted or required approval, with the majority reporting restrictions for below 12 months of age. Mild CDI in an immunocompetent host was managed with oral metronidazole in 100% of respondents, however oral metronidazole use varied and was less frequently preferred for patients with underlying comorbidities such as Crohn’s disease, renal transplant, and neutropenic AML patients. Oral vancomycin alone or in combination with at least one other agent was the preferred treatment for severe CDI by 65% of respondents. Oral vancomycin alone or in combination with another agent was used for treatment of a second recurrence by 131 (92%) respondents, with 16 of these respondents indicating they would initiate a vancomycin taper. For a third CDI recurrence and beyond, management varied greatly and included use of combination therapy or single agents including metronidazole, vancomycin, nitazoxanide, rifaximin, fidaxomicin, intravenous immunoglobulin, and fecal microbiota transplantation. Fecal microbiota transplantation was recommended most commonly for treatment of a third or later recurrence.
Commentary:
This study highlights the variability in practice among pediatric ID physicians in the diagnosis and management of recurrent and severe CDI. With regards to diagnosis, nearly 10% of respondents rely on toxin EIA only which has been shown to have poor sensitivity. Testing of infants < 12 months of age was not restricted at most institutions and some physicians felt CDI was a viable diagnosis in certain infants. The AAP 2013 Policy Statement [1] recommends that testing in infants < 12 months of age be limited to those with gastrointestinal motility disorders and outbreaks, and alternative diagnoses to be sought even in the event of a positive C. difficile test due to the high rate of colonization in infants [1]. The AAP also acknowledges the difficulty in test interpretation in the two and three year old age group. Wendt and colleagues recently reported results from a large community based epidemiologic surveillance study that young children from 1 to 3 years of age actually represent the highest CDI infection incidence and felt this young age group reflected true disease and not colonization [2]. This emphasizes the need for further study of CDI in this younger age group.
For treatment of mild CDI in immunocompetent children, oral metronidazole was unanimously the treatment of choice. For mild CDI in children with underlying chronic conditions, for severe CDI, and for recurrent CDI, treatment varied significantly. Although the AAP recommends oral vancomycin for severe CDI [1], this was not uniformly used by the respondents for severe disease. One recent study identified predictors of vancomycin use for CDI in children and identified significantly more vancomycin use in patients who were older, white, had private insurance, who had testing within 48 hours of admission, who were on antibiotic at the time of testing, or who had a gastrointestinal comorbidity [3]. Many respondents reported use of alternative agents such as fidaxomicin, which is not FDA approved in children, and use of fecal microbiota transplantation which demonstrated efficacy in a randomized controlled trial of adults [4]; pediatric data for both treatments are lacking.
Limitations of the study included use of EIN membership, which may not be generalizable to all pediatric ID physicians, clinical vignettes which may not reflect actual practice, and recall bias. The study highlights the important issue of variability in approach to management of severe and recurrent CDI, CDI in certain subpopulations of children, and the lack of comparative effectiveness studies for the optimal treatment of CDI in children. Finally, antibiotic overuse plays an important role in CDI and emphasizes the role for antimicrobial stewardship in the outpatient and inpatient settings. In short, less antibiotic use and more studies are needed for CDI in children.
References:
Schutze GE, Willoughby RE; Committee on Infectious Disease; American Academy of Pediatrics. Clostridium difficile infection in infants and children. Pediatrics 2013; 131(1):196-200.
Wendt JM, Cohen KA, Mu Y, et al. Clostridium difficile Infection Among Children Across Diverse US Geographic Locations. Pediatrics 2014; 133(4):651-8.
Schwenk HT, Graham DA, Sharma TS, et al. Vancomycin Use for Pediatric Clostridium difficile infection Is increasing and Associated with Specific Patient Characteristics. AAC 2013, 57(9):4307-13
van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile. NEJM 2013; 386(5): 407-15
A Call to Medical Billing Coding Greatness
Written by: Pui-Ying Iroh Tam, MD
Previous PIDS newsletters have included worthy and weighty communications on issues of profound importance, from vaccinations to antimicrobial stewardship. Certainly, part of the mission of PIDS is to 'care for children worldwide, through clinical care, education, research and advocacy,' and those are compelling problems that we hope to address and overcome in this generation. However, what has occupied my thoughts more recently have been more banal thoughts of billing codes.
Now, to be clear, I have never before had any interest in billing. I never received any orientation nor training on this as a medical student, resident, or fellow. To me this was the antithesis of why I went into medicine, something I regarded as another bureaucratic hurdle in order to complete my documentation.
However, I have developed a keen interest in the International Classification of Diseases, 10th Edition (ICD-10), which was scheduled to go into effect on 1st October, 2014, but has now been pushed back to 2015. With these codes, which include codes for new procedures and diagnoses that improve the information available for payment purposes, the healthcare delivery system will be transformed. As the secretary of the Department of Health and Human Services, Kathleen Sebelius, wrote, "ICD-10 is foundational for building a modernized health care system that will facilitate broader access to high quality care."
What has fascinated me most has been the new, expanded medical billing codes designed to provide greater detail in describing illnesses, injuries, and treatments. The 10th Edition was evaluated by a technical advisory panel in consultation with physician groups and clinical coders, and overseen by the World Health Organization. The main intent behind ICD-10 is to serve as a tool in classifying morbidity data for medical care review, indexing health records, and for basic health statistics; however, in the United States the codes are also used for billing purposes.
The uniqueness of some of the billing codes has captivated me. I have been enthralled by how one could have envisioned a use for a medical billing code for burn due to water skis on fire (V91.07XD) to being bitten by an Orca whale (W56.21XS – being struck by an Orca whale is a different code W56.22XS). What about a code for problems in relationship with spouse or partner (Z63.0)? Can I use it to bill myself when I've had a fight? It seems it would be difficult to outdo one of the earlier ICD classifications of 'visitation from God' as a cause for death; however, the ICD-10 code of 'asphyxiation as a result of encasement in a discarded refrigerator' (T71.231D) may have done just that.
Humor aside, these billing codes lead me to reflect on how the field of pediatric infectious diseases is recognized and remunerated. With the newest edition, 18,000 ICD codes have now expanded to around 140,000 codes, and one gets a sense from perusing this how much more weight is placed on surgical services. For balloon accidents and spacecraft injuries, there are 14 results each. There are 27 ICD-10 codes for various injuries to the nose, from abrasion to blister to contusion to puncture wound to laceration to nonvenomous insect bite. Conversely, when I typed in 'infection,' there were only 103 results. And not anything as exciting as involving chicken coops (Y92.72) or opera houses (Y92.253) or bunjee jumping (Y93.34). About half were infection billing codes associated with orthopedic procedures.
Therein lies the limitation of billing codes and the problematic orientation of insurance companies to our specialty as a whole. Why is there no billing code for severe infection caused by an esoteric organism that was identified by an astute physician? What about a billing code for quality of life improved and illness prevented due to immunization? Instead, we have a code for infection following immunization (T88.0XXS).
Given our specialty's relative adeptness at extracting details in the history, perhaps the ICD-10 codes are beckoning us to coding greatness. Whom else would be better able to identify whether an event occurred on the interstate highway (Y92.411), parkway (Y92.412), state road (Y92.413), sidewalk (Y92.480), parking lot (Y92.481), bike path (Y92.482) railroad track (Y92.85) or exit ramp (Y92.415)? Curiously, ICD-10 has 13 codes for immunization that were not administered because of various reasons, including due to patient refusal (Z28.21) and caregiver refusal (Z28.82). Billing for something that was not done? Perhaps that is progress.
References
Anna Wilde Mathews, Wall Street Journal, "Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way." 13th September, 2011.
US Department of Health and Human Services, News release. 24th August, 2012.
Erin McCann, Health IT news, "8 zaniest ICD-10 codes." 25th July, 2013.
Andrew Pollack, New York Times, "Roughed Up by an Orca? There's a Code for That." 29th December, 2013.
ICD-10 codes, http://www.cdc.gov/nchs/data/icd/Detailed%20List%20of%20Codes%20Exempt%20from%20POA.pdf accessed 4th February, 2014
Chris Dimick, Journal of AHIMA, "Senate passes ICD-10 delay bill." 31st March, 2014.
March 2014: JPIDS Article Review & Commentary
Written by: Matthew Kronman, MD, MSCE
Simon TD, Mayer-Hamblett N, Whitlock KB, Langley M, Kestle JRW, Riva-Cambrin J, Rosenfeld M, Thorell EA. Few Patient, Treatment, and Diagnostic or Microbiological Factors, Except Complications and Intermittent Negative Cerebrospinal Fluid (CSF) Cultures During First CSF Shunt Infection, Are Associated with Reinfection. J Pediatric Infect Dis Soc. 2014 Mar;3(1):15-22.
Summary
In the March 2014 issue of the Journal of the Pediatric Infectious Diseases Society, Simon and colleagues report the findings of their retrospective cohort study of children at Primary Children’s Medical Center with first ventricular shunt infection. The authors compiled an extensive dataset through meticulous chart review, gathering records on 118 children who had a first shunt placed between January 1, 1997 and October 12, 2006, and who developed a first shunt infection prior to December 31, 2006. The authors then collected patient, treatment, and surgical factors to evaluate which factors were associated with developing a second shunt infection prior to June 28, 2010. The overall median follow-up time was 5.7 years, and 31 (26%) subjects developed a shunt re-infection.
The authors evaluated numerous factors, but found only three factors associated with risk of re-infection in their adjusted multivariate model: use of ventriculoatrial shunts (adjusted hazard ratio [aHR] 4.0, 95% confidence interval [CI] 1.3-10.0) or complicated shunts, defined as shunts involving multiple reservoirs or connections (aHR 7.7, 95% CI 1.2-28.1); complications – including shunt malfunction, hemorrhage, and abdominal abscess – after first infection (aHR 3.1, 95% CI 1.2-7.0); and what the authors termed "intermittently negative CSF cultures" – i.e., having positive CSF cultures, followed by negative cultures, and then having further subsequent positive cultures (aHR 3.2, 95% CI 1.3-7.0). In a sensitivity analysis, higher white blood cell count in the CSF at first infection was also associated with re-infection. None of the many other variables that were evaluated - including pathogen isolated at first infection, duration of first infection treatment, concordance of antibiotics with pathogen identified, use of intrathecal antibiotics, or surgical approach - were associated with the risk of developing re-infection.
Commentary
Ventricular shunt infections are a common reason for inpatient Infectious Disease consultation. It can be difficult to know how intensively to evaluate for a shunt infection in patients with ventricular shunts who have only non-specific symptoms such as fever. Once identified, ventricular shunt infections often lead to substantial morbidity, including invasive surgery and prolonged hospitalization. While the 2004 IDSA meningitis guidelines mention ventricular shunt infections, there is little current guidance for Infectious Disease physicians to assist in treating these infections in children and preventing recurrences [Tice et al.].
This study builds upon our existing knowledge of factors associated with re-infection after a first ventricular shunt infection. Prior pediatric multicenter work has demonstrated a similar 26% rate of re-infection, and suggested that duration of antibiotic treatment is not associated with risk of ventricular shunt infections recurrence [Kestle et al.]. The rate of infection relapse or re-infection in children appears to be higher than that in adults [Conen et al.]. Retrospective studies to determine whether use of antibiotic-impregnated catheters can reduce the risk of subsequent shunt infection have had mixed results, with some studies demonstrating no benefit [Kan et al.], and others demonstrating a reduction in shunt infections [Parker et al.].
In the Simon et al. study, duration of antimicrobial therapy was not associated with re-infection risk, and the median duration was nearly identical between the groups that did (15 days) or did not (13 days) develop re-infection. Likewise, rates of intrathecal antibiotic and rifampin use were similar between the two groups but very low in both groups, limiting the ability to evaluate the impact of these factors. Future studies may elucidate whether there are patients who could safely receive a shorter duration of antibiotics without increasing the risk of re-infection, and whether intrathecal antibiotics or adjuvant rifampin decrease the risk of re-infection.
Notably, none of the factors associated with re-infection in this study were ones that Infectious Disease physicians might typically influence. The association of complex and ventriculoatrial shunts with re-infection seems logical, given the difficulty and likely increased operative time for these procedures; Infectious Disease physicians may be able to discuss these data with their neurosurgeon colleagues to help them determine what replacement shunt position is best after a first infection. It is not clear, however, why intermittent negative CSF cultures predict shunt re-infection. These intermittent negative cultures may simply suggest factors associated with a more difficult infection to clear, such as a larger burden of organism, more loculated and therefore intermittently draining collections, subtherapeutic antibiotic penetration and levels, or organisms that produce biofilms.
While more work needs to be done to illuminate the optimal treatment of ventricular shunt infections in children, a history of uncommon shunt types and prior complications or intermittently negative cultures with a prior infection should all increase the suspicion for shunt re-infection. After an infection of a ventriculoatrial shunt, it may also be worth placing the new shunt in a non-atrial position, if feasible.
References:
Simon TD, Mayer-Hamblett N, Whitlock KB, Langley M, Kestle JRW, Riva-Cambrin J, Rosenfeld M, Thorell EA. Few Patient, Treatment, and Diagnostic or Microbiological Factors, Except Complications and Intermittent Negative Cerebrospinal Fluid (CSF) Cultures During First CSF Shunt Infection, Are Associated with Reinfection. J Pediatric Infect Dis Soc. 2014 Mar;3(1):15-22.
Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis 2004 Jun 15;38(12):1651-72.
Kestle JR, Garton HJ, Whitehead WE, et al. Management of shunt infections: a multicenter pilot study. J Neurosurg 2006 Sep;105(3 Suppl):177-81.
Conen A, Walti LN, Merlo A, Fluckiger U, Battegay M, Trampuz A. Characteristics and treatment outcome of cerebrospinal fluid shunt-associated infections in adults: a retrospective analysis over an 11-year period. Clin Infect Dis 2008 Jul 1;47(1):73-82.
Kan P, Kestle J. Lack of efficacy of antibiotic-impregnated shunt systems in preventing shunt infections in children. Childs Nerv Syst 2007 Jul;23(7):773-7.
Parker SL, Attenello FJ, Sciubba DM, et al. Comparison of shunt infection incidence in high-risk subgroups receiving antibiotic-impregnated versus standard shunts. Childs Nerv Syst 2009 Jan;25(1):77-83.
Antibiotic Resistance, PIDS and You
By: Saul R. Hymes, MD
On September 16, 2013, the CDC issued a report on the extent of harm caused by antibiotic-resistant infections. While those of us in the infectious disease field have been aware of this growing problem, its extent was striking: 2,000,000 people sick every year with an antibiotic-resistant infection and 23,000 dead yearly from the same. The problem of antibiotic resistance, they said, "is one of our most serious health threats." Aside from the existing (and growing) number of infections and deaths, the CDC predicted "the loss of effective antibiotics will undermine our ability to fight infectious diseases and manage the infectious complications common in vulnerable patients." Complex infections would no longer be treatable due to complete antibiotic resistance, and thus procedures with known infectious complications like organ transplantation or cancer chemotherapy could become riskier or possibly abandoned altogether. Journalists envisioned this post-antibiotic era; the PBS series Frontline spent an hour of primetime TV on the subject; and in these reports and others, we doctors were labeled as part of the problem.
On March 4 of this year, the CDC released a report on the problem of antibiotic overuse in hospitalized patients. The report looks primarily at adult data, and found that 55.7% of patients discharged from 323 hospitals in 2010 received antibiotics while hospitalized; in more than a third of those patients, the antibiotic use was inappropriate and could have been improved upon. On the pediatrics side, we see similar findings: a recent study published in Infection Control and Hospital Epidemiology by Gerber et al (Gerber and 4 of his 6 coauthors are PIDS members) found that a majority of pediatric patients are similarly prescribed antibiotics while hospitalized. They found that just 4 conditions, representing only 1% of the diagnoses, contained 10% of the antibiotic use—and that use was highly inconsistent and often inappropriate. Our poor antibiotic prescribing practices in the past have now caught up to us—with a vengeance.
However, clichéd as it may be, we are not only part of the problem, but have been and can continue to be part of the solution. First and foremost, through the creation of inpatient antimicrobial stewardship programs (ASP’s), both adult and pediatric hospitals can gain control of their antibiotic use, standardize and minimize prescribing, and improve care as well as cut costs. PIDS and PIDS members have a number of ongoing efforts aimed at promoting ASP growth and research.
Every year for the past 4 years, PIDS has sponsored a conference on antimicrobial stewardship. Cosponsored by Children’s Mercy Hospital & Clinics, and led by Jason Newland, MD, MEd, the Director of Antimicrobial Stewardship there, the 5th annual conference will be occurring June 5–6, 2014, and offers the opportunity for PIDS members and nonmembers to learn more about starting an ASP, share their research and outcomes data, and learn from the work and research of others. Dr. Newland has also been instrumental in another broader effort around ASP research—the formation of the SHARPS group. A group made up of 7 children’s hospitals and their ASP’s, SHARPS was organized with the aim of conducting multi-center research on the benefits of pediatric ASP’s and where and how to implement strategies for improvement. To say the eventual results of their research are eagerly-awaited would be an understatement.
But most antibiotic prescribing goes on in the outpatient setting, far from the watchful eye of a traditional hospital-based ASP. Critical research by Theo Zaoutis, MD, MSCE, and others, has illustrated how we can perform outpatient stewardship to better ensure adherence to prescribing guidelines and use of narrower-spectrum antibiotics in the outpatient setting. This is an area many children’s hospitals, pediatric residencies, and infectious disease specialists have only begun to venture into and is one where we can make significant progress. Educational interventions through Grand Rounds and targeted lectures at practice sites, increased use of outpatient pediatric infectious disease care and phone consults to generalists, and, where feasible, active surveillance via prospective audit and feedback all have the potential to help improve antibiotic practices in this setting and are all areas where we as pediatric infectious disease practitioners can get involved.
The problem of antibiotic resistant infections is a daunting one, but it is one that PIDS members, pediatric infectious disease practitioners, and indeed all pediatricians and physicians can help combat. Think before you write a vancomycin order for one of your hospitalized patients. Do you really need to use that cephalosporin for ambulatory treatment of pneumonia, otitis or a UTI? On an individual level, every little bit helps, and on a larger scale, every institution and multi-institution group that can work on antimicrobial stewardship can make a real difference. Will we reach a post-antibiotic era? Some practitioners, for some patients and some infections, are already effectively working within it, though I certainly hope to never see its full arrival. Through improving our antimicrobial stewardship—in all settings—we have the best chance of delaying it as long as possible.
Among U.S. Children, More Infections Caused by Drug-Resistant Bacteria
Infections caused by a concerning type of antibiotic-resistant bacteria are on the rise in U.S. children, according to a new study published in the Journal of the Pediatric Infectious Diseases Society and available online. Although still uncommon, the bacteria are increasingly found in children of all ages, especially those 1-5 years old, raising concerns about dwindling treatment options.
Researchers led by Latania K. Logan, MD, of Rush University Medical Center in Chicago, analyzed resistance patterns in approximately 370,000 clinical isolates from pediatric patients, collected nationwide between 1999 and 2011. Specifically, they determined the prevalence of a resistant type of Gram-negative bacteria, Enterobacteriaceae, that produces a key enzyme, extended-spectrum beta-lactamase (ESBL). The enzyme thwarts many strong antibiotics. Another indicator of ESBL prevalence, susceptibility to third-generation cephalosporins—an important class of antibiotics used to treat many infections—was also measured.
The prevalence of ESBL-producing bacteria increased from 0.28 percent to 0.92 percent from 1999 to 2011; resistance to third-generation cephalosporins increased from 1.4 percent to 3.0 percent. ESBLs were found in children across the country of all ages, but slightly more than half of the isolates with this resistance were from those 1-5 years old. Nearly three-quarters (74.4 percent) of these bacteria were resistant to multiple classes of antibiotics.
"These antibiotic-resistant bacteria have traditionally been found in health care settings but are increasingly being found in the community, in people who have not had a significant history of health care exposure," Dr. Logan said. "In our study, though previous medical histories of the subjects were unknown, 51.3 percent of the children presented in the outpatient or ambulatory setting."
While the overall rate of these infections in children is still low, ESBL-producing bacteria can spread rapidly and have been linked to longer hospital stays, higher health care costs, and increased mortality, the study authors noted. In a 2013 report, the Centers for Disease Control and Prevention called ESBLs a "serious concern" and a significant threat to public health.
Physicians should obtain cultures for suspected bacterial infections to help determine which antibiotics are best, Dr. Logan said. "Some infections in children that have typically been treated with oral antibiotics in the past may now require hospitalization, treatment with intravenous drugs, or both, as there may not be an oral option available."
More research is needed to define risk factors for these infections in children, their prevalence in different settings, and their molecular epidemiology, Dr. Logan said. A companion study by several of the same researchers, also now available online in the Journal of the Pediatric Infectious Diseases Society, suggests that children with neurologic conditions are at higher risk for infections caused by ESBL-producing bacteria.
Additional drug development, keeping younger patients in mind, is also needed. "The overwhelming majority of current research for new pharmaceuticals against antibiotic-resistant organisms are in adults," Dr. Logan said. "New drug options will need to be available for young children."
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Published quarterly, the Journal of the Pediatric Infectious Diseases Society represents the spectrum of peer-reviewed, scientific and clinical information on perinatal, childhood, and adolescent infectious diseases. The journal is a publication of the Pediatric Infectious Diseases Society (PIDS), the world's largest professional organization of experts in the care and prevention of infectious diseases in children.
PIDS membership encompasses leaders across the global scientific and public health spectrum, including clinical care, advocacy, academics, government, and the pharmaceutical industry. From fellowship training to continuing medical education, research, regulatory issues and guideline development, PIDS members are the core professionals advocating for the improved health of children with infectious diseases both nationally and around the world, participating in critical public health and medical professional advisory committees that determine the treatment and prevention of infectious diseases, immunization practices in children, and the education of pediatricians.
President's Corner
As we embark on a new year, PIDS activities continue to build on the goals and objectives identified in the Strategic Planning meeting that the PIDS Council (now Board of Directors) undertook last May. Over the next several months, we will focus on membership development, education, and training. The Communications Committee has revamped the Society’s newsletter to include news and important updates related to pediatric infectious diseases and patient care, as well as promote articles published in JPIDS and other mainstream media. The Membership Committee assisted in the development of the Fellow of the Pediatric Infectious Diseases Society (FPIDS) membership category and brochure. We are now seeking applications for 2014 candidates (click here to view the criteria and deadline to submit an application). The newly formed Pediatric Transplant ID Working Group developed the first Pediatric Transplant ID Course. This course will be held in front of the St. Jude/PIDS Pediatric Infectious Diseases Research Conference and will provide trainees and junior faculty an overview of the state of the art in Transplant ID including research gaps and new research areas. The St. Jude/PIDS Pediatric Infectious Diseases Conference features a "Frontiers in Infectious Diseases" symposium, with presentations from leading investigators in infectious diseases and microbiology and a series of career development workshops that will focus on writing and ethical issues in research and academia. Thank you goes to the Research Affairs Committee for developing another superb program. The Program and Meetings Committee has developed more outstanding programs for the Pediatric Academic Societies’ Meeting, May 3-6, in Vancouver, British Columbia, Canada and the 30th Annual Meeting of the European Society for Paediatric Infectious Diseases, May 6-10, in Dublin, Ireland. Planning also is underway for the Pediatric Antimicrobial Stewardship Conference, to be held June 5-6 in Kansas City, Missouri, with joint sponsorship with Children’s Mercy Hospitals and Clinics. I encourage members to attend, if possible, at least one of these conferences. More information can be found on the PIDS website (www.pids.org).
The 2014 Spring Election will be held in March. PIDS is now accepting nominations for Board Members to serve a four-year term. If you are interested in nominating yourself or a colleague to serve as a Board Member, please click here to view the nomination form and instructions for submission. In addition, PIDS staff recently sent out the second dues reminder to all PIDS members. Your membership and active participation in the Society is what makes PIDS strong and vibrant. If you have not received your 2014 PIDS dues invoice, please contact the PIDS Headquarters at pids@idsociety.org. Along with dues, we are asking members to consider making a contribution to the PIDS Education and Research Foundation to ensure continuation of the PIDS Fellowship and Research Awards and educational programs. As a reminder, the deadline for applications for the PIDS awards, including the PIDS and PIDS-St. Jude Fellowship Awards, the Young Investigator Award, and the Distinguished Physician Award is fast approaching. Links to award applications and submission deadlines can be found in this newsletter. Or, you may visit the PIDS website at www.pids.org. I encourage you to nominate a colleague or trainee for an award. Your questions, concerns, and suggestions are always welcomed. Please contact the PIDS Headquarters office at (703) 299-6764 and speak with Christy or Faith.
Here’s to another productive year!
CDC Flu Update
The CDC has released updated key messages for the 2013-14 influenza season, and also the CDC/Influenza Division Weekly Influenza Surveillance Report FluView (http://www.cdc.gov/flu/weekly/) for Week 4 and the January 31, 2014 seasonal influenza key points. Also listed below are key points related to recent human infections with avian influenza A (H7N9) virus in China.
2013-14 Influenza Season Key Points
January 31, 2014 Key Points
FluView - January 25, 2014
Avian Influenza A (H7N9) Key Points
CDC Letter to Health Care Providers
The CDC has addressed a letter to health care providers emphasizing that a vaccine recommendation made by a provider is key in a patient's decision to get vaccinated.
Please click here to view the letter from the CDC.
New IAC Guidebook Helps Birthing Institutions Give birth to the end of Hep B
St. Paul, Minnesota – The Immunization Action Coalition (IAC) is urging hospitals and birthing centers to Give birth to the end of Hep B with the launch of its new comprehensive guidebook “Hepatitis B: What Hospitals Need to Do to Protect Newborns.” Endorsed by the American Academy of Family Physicians, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, and the Centers for Disease Control and Prevention, this resource breaks new ground as a policy and best practice guide for newborn hepatitis B immunization.
Read more: New IAC Guidebook Helps Birthing Institutions Give birth to the end of Hep B
CDC Avian Influenza A H7N9 Virus Key Points
Click here to view the CDC's key points as of May 31, 2013 related to the recent human infections with avian influenza A (H7N9) in China.
CDC will provide updated information as it becomes available at http://www.cdc.gov/flu/avianflu/h7n9-virus.htm.
Aditional information related to these cases is updated by the World Health Organization (WHO) at http://www.who.int/csr/don/en.
Dr. Pickering Congratulates Janet Englund, President of PIDS
Dr. Larry Pickering congratulating Janet Englund, President of PIDS, on their new seat on the advisory group of ACIP at the Feb. 2013 meeting.
Read more: Dr. Pickering Congratulates Janet Englund, President of PIDS
MMWR Update
The CDC has just released the MMWR update early release, please click here to view the complete document.
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