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Objective: To investigate the safety, tolerability, and pharmacokinetics of the anti-tumor necrosis factor-alpha monoclonal antibody infliximab in subjects with intravenous immunoglobulin (IVIG)-resistant Kawasaki disease (KD).Study Design: We conducted a multicenter, randomized, prospective trial of second IVIG infusion (2 g/kg) versus infliximab (5 mg/kg) in 24 children with acute KD and fever after initial treatment with IVIG. Primary outcome measures were the safety, tolerability, and pharmacokinetics of infliximab. Secondary outcome measures were duration of fever and changes in markers of inflammation.Results: Study drug infusions were associated with cessation of fever within 24 hours in 11 of 12 subjects treated with infliximab and in 8 of 12 subjects retreated with IVIG. No infusion reactions or serious adverse events were attributed to either study drug. No significant differences were observed between treatment groups in the change from baseline for laboratory variables, fever, or echocardiographic assessment of coronary arteries.Conclusions: Both infliximab and a second IVIG infusion were safe and well tolerated in the subjects with KD who were resistant to standard IVIG treatment. The optimal management of patients resistant to IVIG remains to be determined. [ABSTRACT FROM AUTHOR]

Background: We noted a recent increase in cases of infective endocarditis (IE) at our institution. The purpose of the study is to examine the incidence, risk factors, microbiology and outcome of IE in our pediatric population., Methods: Retrospective review of IE cases during 2002-2020 at Children's Hospital of Michigan, Detroit., Results: 68 patients with IE were identified. There was a 2-fold increase in incidence during the 2012-2020 (late period) compared to the 2002-2011 (early period). The most common predisposing conditions were congenital heart disease (CHD) in 39 (57.4%) and central venous catheter (CVC) in 19 (27.9%). CHD was more frequent in the late period (29/43, 67.4%) compared to early period (10/25, 40.0%) (p = 0.042). In CHD patients, palliative or corrective cardiac surgery was performed prior to IE diagnosis in 4/25 (16%) in early period and 23/43 (53.5%) in the late period (p = 0.004). S. aureus was the most common causative organism (35.3%) followed by streptococci (22.1%). Valve replacement or valvuloplasty was performed in 22.1% of patients. Complications occurred in 20 (29.4%). Mortality occurred in 7 (10.3%): 3 had CHD, 3 had CVC and underlying conditions and 1 had fulminant MRSA infection., Conclusion(s): The higher incidence of IE during the late period is likely due to an increase in patients with CHD who had undergone prior cardiac surgery. S. aureus was the predominant pathogen in all patients including those with CHD, followed by streptococci. IE in children continues to be associated with high rates of morbidity and mortality., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Competing Interests: The authors have no funding or conflicts of interest to disclose.

Objective: To assess the incidence rate of S. aureus colonization at baseline along with the mupirocin susceptibility (or resistance) rate in patients in a neonatal intensive care unit (NICU) and a pediatric intensive care unit (PICU) in conjunction with the implementation of universal decolonization as the standard of care., Design: Prospective cohort study., Setting: Children's Hospital of Michigan (CHM) inpatient intensive care units (ICUs)., Participants: Newly admitted pediatric patients to the CHM NICU or PICU aged between 1 day and ≤21 years., Interventions: Baseline and follow-up S. aureus screening cultures were obtained before patients underwent universal decolonization with mupirocin 2% antibiotic ointment (intranasal and umbilical) and chlorhexidine baths as standard of care to reduce CLABSI rates., Results: Baseline S. aureus colonization rates of new admissions to the CHM NICU and PICU were high at 32% and 29%, respectively. Baseline mupirocin susceptibility to any S. aureus growth was 98.4%. All baseline culture isolates whether positive for MRSA or MSSA, with one exception, had minimum inhibitory concentrations (MICs) of ≤0.19 µg/mL. All follow-up study cultures after universal decolonization at 7 days or beyond with any S. aureus growth had mupirocin MICs of ≤0.125 µg/mL., Conclusions: Baseline S. aureus colonization rates of new admissions to the CHM ICUs were high as was baseline mupirocin susceptibility. Follow-up cultures, albeit limited in number, did not detect increasing mupirocin MICs over 1 year, despite broad mupirocin exposure due to the implementation of universal decolonization.

Central line associated blood stream infections (CLABSIs) in infants and children with intestinal failure due to short bowel syndrome may be caused by different organisms due to intestinal translocation and skin contamination. We report what we believe the first case of candidemia in an infant with short bowel syndrome caused by the environmental yeast Candida sojae that was initially misidentified as Candida tropicalis . We discuss its possible sources including a central venous catheter (CVC) and gut translocation and the differences between the two Candida species., Competing Interests: The authors report no conflict of interest., (© 2022 The Authors.)

Introduction: Neonates and young infants with invasive candidiasis are particularly at increased risk of dissemination including hematogenous Candida meningoencephalitis. The echinocandins including micafungin have emerged as a preferred agent in most cases of candidemia and invasive candidiasis but data in pediatric patients under 4 months of age are limited., Areas Covered: In this report, we review the micafungin use in infants younger than 4 months of age. Animal studies as well as clinical data that support its use in neonatal candidiasis are reviewed. In addition, the status of FDA approval and the rationale of micafungin dosing recommendations in infants <4 months are discussed., Expert Opinion: A dose of 4 mg/kg was approved for treatment of candidemia, Candida peritonitis and abscesses excluding meningoencephalitis or ocular involvement in patients younger than 4 months of age. However, because of the risk of central nervous system dissemination as well as the difficulty in establishing this diagnosis, this dose is inadequate to treat ill infants with candidemia. More studies are needed to establish the safety and efficacy of micafungin daily dose of at least 10 mg/kg in infants younger than 4 months of age when hematogenous Candida meningoencephalitis or ocular involvement cannot be excluded.

Global mobility has been steadily increasing in recent years. The assessment of the febrile child returning from international travel is a diagnostic challenge. The COVID-19 pandemic has profoundly affected international travel and made evaluation and management of the sick returned traveler more challenging. Children visiting friends and relatives abroad remain at higher risk of infection compared to tourists. This review presents a guidance on the initial assessment of a traveling febrile child including interpretation of medical history, physical examination, and laboratory findings. Important clues to etiology include exposure to different infectious agents, incubation periods of pathogens, and prophylaxis regimens and vaccines received. Early identification of potentially life-threatening and highly contagious infections is essential. In this article, we discuss the epidemiology, evaluation, and management of specific travel related infections such as malaria, typhoid fever, dengue fever, viral hemorrhagic fever, rickettsiosis, leptospirosis, schistosomiasis, gastrointestinal, and respiratory infections., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2021.)

This study was conducted to assess the clinical spectrum, management, and outcome of SARS-CoV-2-related multisystem inflammatory syndrome in children (MIS-C). We reviewed medical records of children with MIS-C diagnosis seen at the Children's Hospital of Michigan in Detroit between April and June 2020. Thirty-three children were identified including 22 who required critical care (group 1) and 11 with less intense inflammation (group 2). Children in group 1 were older (median 7.0 years) than those in group 2 (median 2.0 years). Abdominal pain was present in 68% of patients in group 1. Hypotension or shock was present in 17/22 patients in group 1. Thirteen (39.4%) had Kawasaki disease (KD)-like manifestations. Five developed coronary artery dilatation; All resolved on follow-up. Intravenous immunoglobulin (IVIG) was given to all patients in group 1 and 7/11 in group 2. Second-line therapy was needed in 13/22 (group 1) for persisting inflammation or myocardial dysfunction; 12 received infliximab. All patients recovered.Conclusion: MIS-C clinical manifestations may overlap with KD; however, MIS-C is likely a distinct inflammatory process characterized by reversible myocardial dysfunction and rarely coronary artery dilatation. Supportive care, IVIG, and second-line therapy with infliximab were associated with a favorable outcome. What is Known: • Multisystem inflammatory syndrome in children (MIS-C) manifestations include fever, gastrointestinal symptoms, shock, and occasional features of Kawasaki disease (KD). • Treatment includes immunomodulatory agents, most commonly IVIG and corticosteroids. What is New: • Spectrum of MIS-C varies from mild to severe inflammation and coronary artery dilatation occurred in 5/22 (23%) critically ill patients. • IVIG and infliximab therapy were associated with a favorable outcome including resolution of coronary dilatation; only 2/33 received corticosteroids.

We conducted a study to determine the rate of bacterial colonization of stethoscopes, coats, and pagers of residents at a pediatric residency training program as compared to that of badges, sleeves, and pagers of non-patient care staff (control group). Among 213 cultures obtained from 71 residents, 27 potential pathogens were isolated from 22 residents (27/213, 12.7%) as compared to 10 potential pathogens out of 162 samples obtained from 54 control participants (10/162, 6.2%) ( P = .0375). The most common pathogen isolated from residents and control participants was methicillin sensitive Staphylococcus aureus (MSSA). The source of positive cultures among the residents was the stethoscope (8/22, 36.3%), pager (8/22, 36.3%), and coat sleeve (11/22, 50%). The rates of colonization with potential pathogens were higher among residents than control participants and about 12% of residents' stethoscopes, coats and pagers were colonized with bacterial pathogens. These are potential sources of nosocomial transmission of pathogenic organisms., Competing Interests: Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article., (© The Author(s) 2020.)

We noted a recent increase in number of immunocompromised children with CMV viremia at our institution. The purpose of this study was to determine the frequency of CMV viremia in this population and evaluate factors associated with drug-resistant mutations. A retrospective review of immunocompromised hosts, 0-21 years of age, who had CMV viremia during 2007-2017. CMV viremia was detected using PCR assays. Genetic mutation assays were performed using PCR sequencing of the phosophotransferase UL 97 gene and the polymerase UL54 gene of CMV using Quest Diagnostics (San Juan Capistrano, CA, USA) or ARUP Labs (Salt Lake City, UT, USA). Thirty-one patients were identified, including 10 (32%) during the last 2 years. Of the 31 patients, 18 had hematopoietic stem cell transplantation (HSCT), 5 had primary immunodeficiency, 4 had malignancies, 3 had heart transplantation and 1 had new Human Immunodeficiency virus (HIV) infection. Antiviral resistance testing was performed on isolates from seven patients: five with persistent viremia (>1 mo), and two prior to starting antiviral therapy. Resistance was identified in three patients' isolates: two with common variable immunodeficiency (CVID) and one with recurrent Hodgkin's lymphoma who had undergone autologous HSCT. The two patients with CVID had chronic diarrhea and malabsorption and had received prolonged oral valganciclovir courses prior to emergence of resistance. The patient with Hodgkin's lymphoma had received a prolonged IV ganciclovir course. All three tested positive for UL97 mutation and two had both UL97 and UL54 gene mutations. Majority of our patients (21/31) with CMV viremia were transplant recipients and ganciclovir resistance developed in 10%. Two had intestinal malabsorption. Treatment with oral valganciclovir should be avoided in patients with poor gut absorption as that may increase the risk of resistance.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

Background: We noted a recent increase in cases of urinary tract infection due to community-acquired ESBL-producing Escherichia coli in children treated at our institution. Risk factors of urinary tract infection due to ESBL-producing E. coli in children in the USA remain unclear. Methods: A single center retrospective case control study of UTI due to CA-ESBL-producing E. coli during a 5-year period (2012-2016). Control cases with non-ESBL-producing E. coli urinary tract infection were matched by age, gender and year of infection. Results: A total of 111 patients with ESBL-producing E coli urinary tract infection and 103 controls were included. The proportion of ESBL-producing E coli urinary tract infection ranged from 7% to 15% of all UTI cases. The distribution of ESBL cases per year: 27 in 2012; 18 in 2013; 22 in 2014; 15 in 2015 and 29 in 2016. Median age was 4 years with female predominance (84%). The ESBL group was predominantly African American (32%) followed by individuals of Middle Eastern ethnic background (31%). Risk factors by univariate analysis were vesicoureteral reflux: (20.9 ESBL group vs 6% controls; p  = .002), prior antibiotic usage in the last 3 months (including β-lactams), prior UTI (last 3 months), recent hospitalization (last 3 months) and Middle Eastern ethnic background. However, multivariate analysis showed that only prior antibiotic usage ( p  = .001) and Middle Eastern ethnic background ( p  < .001) were independent risk factors. ESBL-producing strains were more frequently resistant to trimethoprim-sulfamethoxazole (72% vs 25%) and ciprofloxacin (73% vs 5%) than strains not producing ESBL. Conclusion: Risk factors for community-acquired ESBL-producing E coli urinary tract in our pediatric patient population were antibiotic usage within the previous 3 months and Middle Eastern ethnic background. This may be related to increased risk of intestinal colonization with resistant bacterial strains.

Objective: The study was undertaken to determine the etiology, review management, and outcome in children diagnosed with acute pericarditis during 11 years at tertiary pediatric institution., Methods: Retrospective chart review of children diagnosed between 2004 and 2014. Patients with postsurgical pericardial effusions were excluded., Results: Thirty-two children were identified (median age 10yr/11mo). Pericardiocentesis was performed in 24/32 (75%) patients. The most common cause of pericarditis was infection in 11/32 (34%), followed by inflammatory disorders in 9 (28%). Purulent pericarditis occurred in 5 children including 4 due to Staphylococcus aureus : 2 were methicillin resistant (MRSA). All patients with purulent pericarditis had concomitant infection including soft tissue, bone, or lung infection; all had pericardial drain placement and 2 required pericardiotomy and mediastinal exploration. Other infections were due to Histoplasma capsulatum (2), Mycoplasma pneumoniae (2), Influenza A (1), and Enterovirus (1). Pericarditis/pericardial effusion was the initial presentation in 4 children with systemic lupus erythematosus including one who presented with tamponade and in 2 children who were diagnosed with systemic onset juvenile inflammatory arthritis. Tumors were diagnosed in 2 patients. Five children had recurrent pericarditis. Systemic antibiotics were used in 21/32 (66%) and prednisone was used in 11/32 (34%) patients., Conclusion: Infections remain an important cause of pericarditis in children. Purulent pericarditis is most commonly caused by Staphylococcus aureus and is associated with significant morbidity, need of surgical intervention, and prolonged antibiotic therapy. Echocardiography-guided thoracocentesis remains the preferred diagnostic and therapeutic approach. However, pericardiotomy and drainage are needed when appropriate clinical response is not achieved with percutaneous drainage.

FilmArray Meningitis/Encephalitis (ME) polymerase chain reaction (PCR) panel was tested on 62 cerebrospinal fluid (CSF) samples from young infants (0-3 months) with suspected meningitis and compared with CSF cultures. Twelve CSF samples from 9 infants were positive by ME PCR panel (10 Group B Streptococcus (GBS) and 2 Escherichia coli) of which only 5 were positive by culture. The 7 CSF samples that were positive only by ME PCR panel were obtained from infants who had received prior antibiotic treatment. The ME PCR panel can be a useful tool in the rapid diagnosis of bacterial meningitis in pretreated young infants.

After a sharp drop of rotavirus (RV) infections at Children's Hospital of Michigan, Detroit, USA in 2010 season, we noted an increase in the number of cases during the 2011 season including some RV vaccine (RVV) recipients. This study was conducted to determine the circulating genotypes during 2011 season and whether the increase in RV diarrhea was caused by replacement genotypes. G and P genotypes were determined by RT PCR and nucleotide sequencing of selected strains was performed. The vaccination rate among study patients was 24 %. RV strains from 68 stool samples were genotyped including 18 from vaccinated children and 50 from unvaccinated children. The predominant G genotype was G1 (58.8 %) followed by G9 (17.7 %) and G4 (15.5 %). P[8] was the predominant P genotype (68 %) followed by P[6] (17.6 %) and P[4] (3 %). All G9 strains were associated with P[6]. The most prevalent G-P combination was G1P[8] (56 %), followed by G9P[6] (17.6 %). Similar proportions of RV genotypes were found among vaccinated and unvaccinated children. Our local data suggest that 5 years after the introduction of RVV there has been no genotype replacement. Although a small increase in G9P[6] frequency was noted, G1P[8] remained the predominant strain of RV in our inner city community in the Midwestern USA.

Background: Salmonella gastroenteritis, usually self- limited, can result in bacteremia and focal disease. This study was undertaken to determine the role of age and infecting Salmonella serotype on the risk of bacteremia in children., Methods: This was a review of medical records of children with positive nontyphoidal Salmonella cultures seen in an urban setting at the Children's Hospital of Michigan in Detroit between July 1993 and December 2007., Results: Isolates recovered from 633 patients, representing 50 serotypes, included 594 positive stool cultures and 72 (11.4% of all patients) positive blood cultures. Salmonella serotype Typhimurium was the most common serotype, accounting for 29.4% (186/633) of isolates, of which only 3 (1.6%) were recovered from blood. The most common serotype recovered from blood was serotype Heidelberg (40/120 of patients with Heidelberg serotype) accounting for 55.5% (40/72) of positive blood cultures. The patients' age range was 2 weeks to 20 years, with a median of 7 months (interquartile range, IQR = 4-23 months). Bacteremic patients (n = 72) had a median age of 6.5 months (IQR = 4-11 months) and were comparable in age to non-bacteremic patients (n = 266), who had a median age of 5.5 months (IQR = 3-11 months) (p = 0.24). The odds ratio (OR) for bacteremia in patients infected with serotype Typhimurium was 0.21 and in patients with serotype Heidelberg was 4.0. Patients with serotype Heidelberg infection in the age groups < 3 months, 3-6 months, 6-12 months, and > 12 months had an OR for bacteremia of 9.2, 2.5, 3.2, and 6.0, respectively., Conclusion: In our patient population, children with Salmonella serotype Heidelberg infection are at higher risk of bacteremia than children infected with other Salmonella serotypes. The risk is highest during the first 3 months of life.

Infective endocarditis is extremely rare in children with structurally normal hearts. The most common etiological agents are staphylococcal and streptococcal species. Nutritionally variant streptococci also classified as Abiotrophia species are a group of fastidious organisms that account for only 5% to 6% of all cases of culture-negative infective endocarditis. Only seven cases of Abiotrophia infective endocarditis have been previously reported in children with no underlying structural heart disease. We report two cases of Abiotrophia infective endocarditis in children without any predisposing factors. Both patients presented with nonspecific symptoms leading to delay in diagnosis. While bacteriological clearance was achieved in both cases, both had a complicated course including development of brain mycotic aneurysms, splenic infarction, renal failure, and irreversible damage to the mitral valve. Both patients required surgical removal of the native mitral valve and replacement. We also present review of seven cases with similar diagnosis published previously in literature and highlight important differences. Our cases highlight special challenges in management of Abiotrophia endocarditis in pediatric patients. As the organism may not be isolated in routine culture media, may present with atypical clinical symptoms and may have a complicated course even without antibiotic failure, a high index of suspicion should be maintained in children with subacute symptoms even with no underlying structural cardiac disease., (© 2013 Wiley Periodicals, Inc.)

Objectives: Pentavalent rotavirus vaccine (RV5) has been shown to be well-tolerated and efficacious in preventing rotavirus gastroenteritis in healthy infants. Safety and immunogenicity of RV5 in infants with surgical gastrointestinal disease have not been studied. The aim of the present study was to evaluate the safety and immunogenicity of RV5 in infants with a history of congenital or acquired intestinal disease requiring resection compared with healthy infants., Methods: Infants with intestinal resection were matched by gestational age and chronological age to healthy infants (controls). Dose 1 of RV5 was given at 10 to 12 weeks of chronological age. Doses 2 and 3 were given at intervals of 4 to 10 weeks, with all 3 doses given by 32 weeks. All infants were monitored for adverse events (AEs) by telephone calls, clinic visits, and parental written reports during the first 42 days after each dose and monthly thereafter by telephone for 12 months. Serum anti-rotavirus immunoglobulin A (IgA) titers were measured prevaccination and 2 weeks after dose 3., Results: A total of 5 infants with surgical gastrointestinal disease and 3 control subjects were enrolled. All participants (100%) mounted a 3-fold increase in serum anti-rotavirus IgA geometric mean titer postvaccination. RV5 administration to surgical infants was well tolerated with a majority of AEs being attributed to the underlying medical condition., Conclusions: Postvaccination serum anti-rotavirus IgA levels indicate that RV5 is immunogenic in infants with a history of bowel resection, despite varying lengths of residual bowel. RV5 was well tolerated with few vaccine-related AEs.

Objectives: The aim of this study was to investigate the effects of massage therapy (MT) on the immune system of preterm infants. The primary hypothesis was that MT compared with sham therapy (control) will enhance the immune system of stable premature infants by increasing the proportion of their natural killer (NK) cell numbers., Methods: A randomized placebo-controlled trial of MT versus sham therapy (control) was conducted among stable premature infants in the NICU. Study intervention was provided 5 days per week until hospital discharge for a maximum of 4 weeks. Immunologic evaluations (absolute NK cells, T and B cells, T cell subsets, and NK cytotoxicity), weight, number of infections, and length of hospital stay were also evaluated., Results: The study enrolled 120 infants (58 massage; 62 control). At the end of the study, absolute NK cells were not different between the 2 groups; however, NK cytotoxicity was higher in the massage group, particularly among those who received ≥5 consecutive days of study intervention compared with control (13.79 vs 10 lytic units, respectively; P = .04). Infants in the massage group were heavier at end of study and had greater daily weight gain compared with those in the control group; other immunologic parameters, number of infections, and length of stay were not different between the 2 groups., Conclusions: In this study, MT administered to stable preterm infants was associated with higher NK cytotoxicity and more daily weight gain. MT may improve the overall outcome of these infants. Larger studies are needed.

Background: Because of a recent upsurge in retropharyngeal abscess (RPA) cases due to community-associated methicillin-resistant Staphylococcus aureus (MRSA), we reevaluated the microbiology, clinical manifestations and treatment outcome of RPA over the past 6 years (2004 to 2010). Findings were compared with those of a previous 11-year study (1993 to 2003) period., Methods: A retrospective review of medical records of children with RPA., Results: One hundred fourteen children (61 males) with RPA were identified representing a 2.8-fold increase in incidence (per 10,000 admissions) over the previous 11-year period. Abscess drainage was performed in 74 (65%). A total of 116 isolates (93 aerobes, 23 anaerobes) were recovered from 66 specimens. S. aureus was recovered from 25 (38%) of the 66 specimens compared with 2 (4.9%) of 41 in the previous 11 years; 16 (64%) of 25 were MRSA compared with none in the previous 11 years. Children whose abscess grew MRSA were younger (mean 11 months) than the others (mean 62 months) (P<0.001) and required longer duration of hospitalization (mean 8.8 days) than the rest (mean 4.5 days) (P=0.002). Five children had mediastinitis; all caused by MRSA. All MRSA isolates were susceptible to clindamycin. Ceftriaxone plus clindamycin was the most common treatment regimen. All patients had resolution of their abscesses., Conclusions: RPA has increased in frequency in our pediatric population with an associated increase of Staphylococcus aureus, mainly community-associated MRSA. This is likely due to the overall increase in community-associated MRSA infections in our pediatric patients. Treatment with ceftriaxone and clindamycin in addition to surgical drainage was effective.

When 13 of 13 nasal wash specimens from a single pediatrician's office tested positive for low quantities of Bordetella pertussis DNA, we suspected prelaboratory contamination. Investigation revealed that Pentacel and Adacel vaccines contain high copy numbers of B. pertussis DNA, which can be aerosolized, causing false-positive B. pertussis PCR results.

We describe the case of a previously healthy 7-month-old male infant with urinary tract infection due to Staphylococcus epidermidis grown from two separate urine cultures. Further evaluation showed severe bilateral vesicoureteral reflux. Physicians should not assume that S. epidermidis is always a contaminant in urine cultures.

Between January 2007 and April 2009, rotavirus (RV)-positive stool samples from 238 children with acute gastroenteritis, seen at Children's Hospital of Michigan in Detroit, USA, were collected and RV genotyping was performed. G and P genotypes were determined by RT-PCR and nucleotide sequencing was conducted on selected G9 and P[6] strains. Correlation between the severity of gastroenteritis episode and the infecting G genotype was done using a 14-point scoring system. The predominant G genotype was G9 (39.5 %), followed by G1 (35.3 %) and G4 (15.5 %), while P[8] was the most prevalent P genotype (66.5 %), followed by P[4] (21.9 %) and P[6] (11.2 %). The gene combinations G1P[8] and G9P[8] were the most prevalent (21.4 % and 20.6 %, respectively), followed by G4P[8] (13 %) and G9P[6] (8.8 %). Immunization data showed that only 17/238 (7.1 %) children received ≥one dose of RV vaccine (the pentavalent vaccine RotaTeq or the monovalent vaccine Rotarix) and that 10/17 were infected with G4P[8] strains. Severity of RV gastroenteritis episodes was not related to the infecting G genotype. Our results suggest a high proportion of genotype G9 strains in combination with P[8], P[6] and P[4] specificity circulating in the metropolitan Detroit area. While the protective efficacy of the RV vaccines has been demonstrated against G9P[8] strains, the level of cross-protection offered by the vaccines against G9 strains with P[6] and P[4] genotypes in the Detroit paediatric population remains to be determined.

Nosocomial infections in Pediatric Intensive Care Units (PICUs) caused by multidrug-resistant bacterial organisms are increasing. This review attempts to report on significant findings in the current literature related to nosocomial infections in PICU settings with an international perspective. The types of nosocomial infections are addressed, including catheter-related bloodstream infections, ventilator-associated pneumonia, urinary tract infections, gastrointestinal infections and post-surgical wound infections. A review of emerging resistant bacterial pathogens includes methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus sp., Clostridium difficile, extended-spectrum β-lactamase producing Gram-negative organisms, Klebsiella pneumoniae carbapenemase-producing strains and multi-drug resistant Acinetobacter baumannii. Basic and enhanced infection control methods for the management and control of multidrug-resistant organisms are also summarized with an emphasis on prevention.

We have sufficient knowledge and unprecedented access to global resources to dramatically reduce the transmission of HIV-1 from mother to children worldwide. Most transmission occurs during delivery and after birth through breastfeeding. For this reason, efforts to interrupt transmission have focused on peripartum period and safe infant feeding. This includes the use of antiretroviral therapy, elective cesarean section, avoidance of breastfeeding, and exclusive breastfeeding. This review summarizes recent studies and new international development on the prevention of mother-to-child HIV transmission. Prevention of mother-to-child transmission of HIV should now be integrated as part of basic maternal and child health services.

Objective: To investigate the mode of transmission of and assess control measures for an outbreak of carbapenem-resistant (multidrug-resistant) Acinetobacter baumannii infection involving 6 premature infants., Design: An outbreak investigation based on medical record review was performed for each neonate during the outbreak (from November 2008 through January 2009) in conjunction with an infection control investigation., Setting: A 36-bed, level 3 neonatal intensive care unit in a university-affiliated teaching hospital in Detroit, Michigan., Interventions: Specimens were obtained for surveillance cultures from all infants in the unit. In addition, geographic cohorting of affected infants and their nursing staff, contact isolation, re-emphasis of adherence to infection control practices, environmental cleaning, and use of educational modules were implemented to control the outbreak., Results: Six infants (age, 10-197 days) with multidrug-resistant A. baumannii infection were identified. All 6 infants were premature (gestational age, 23-30 weeks) and had extremely low birth weights (birth weight, 1000 g or less). Conditions included conjunctivitis (2 infants), pneumonia (4 infants), and bacteremia (1 infant). One infant died of causes not attributed to infection with the organism; the remaining 5 infants were discharged home. All surveillance cultures of unaffected infants yielded negative results., Conclusions: The spread of multidrug-resistant A. baumannii infection was suspected to be due to staff members who spread the pathogen through close contact with infants. Clinical staff recognition of the importance of multidrug-resistant A. baumannii recovery from neonatal intensive care unit patients, geographic cohorting of infected patients, enhanced infection control practices, and staff education resulted in control of the spread of the organism.

During April-May 2009, a novel H1N1 influenza virus was determined to be the cause of influenza outbreaks in North America. By June 2009, widespread infections were recorded all over the world and an ongoing pandemic was declared. The clinical manifestations ranged from a self limited illness to fatal disease. Current clinical data suggest that the highest infection rates and complications occur in children and young adults. In contrast to seasonal influenza, the rates of hospitalization and death in adults 65 years or older were low. Risk factors for severe disease are similar to those of seasonal influenza and include diverse medical conditions. However, pregnant women and children with neurodevelopmental disorders or chronic pulmonary conditions are at highest risk of developing severe disease. Rapid antigen detection tests have variable and suboptimal sensitivity for diagnosis of novel H1N1 influenza. Diagnosis is confirmed by real-time reverse transcriptase polymerase chain reaction or by virus isolation in cell culture. Treatment is recommended with oral oseltamivir or inhaled zanamavir for patients who are at risk of complications as well as those who are worsening clinically or have evidence of lower respiratory tract infection. Treatment with intravenous peramivir can be used in special situations when oral or inhaled antiviral therapy is not tolerated or considered inadequate. Inactivated and live attenuated vaccines are available. Current vaccination recommendations and infection control measures are discussed.

The molecular analysis of methicillin-resistant Staphylococcus aureus (MRSA) from 98 children admitted to the Children's Hospital of Michigan, Detroit, MI, with serious MRSA infections during 2006-2007 was correlated with risk factors, clinical features, and antibiotic susceptibility testing (ABST) results. Isolates were characterized by staphylococcal cassette chromosome (SCC) mec type, the presence of Panton-Valentine leukocidin (PVL) genes, repetitive sequence (rep) polymerase chain reaction (PCR) and pulsed-field gel electrophoresis (PFGE), requirement for surgical intervention, antibiograms, and response to therapy. rep-PCR was more rapid than PFGE typing and correlated well. SCCmec type IV-containing isolates caused 92.8% of all infections, but the demographics and diseases associated with subtypes IVa and IVd differed. Subtype IVa (all PFGE type USA300 and PVL-positive) was identified in 81/93 (87.1%) of patients with community-onset (CO) MRSA, including 21/35 of those with risk factors for health care-associated (HA) infection. All other clones were PVL-negative. Subtype IVd (10 isolates; 9 USA800 and 1 eMRSA15) caused mainly HA-MRSA and no skin and soft tissue infections (SSTI). Seven classic HA-MRSA strains (SCCmec types II [6; 3 USA100 and 3 USA600] and III [1; USA200]) caused HA and hospital-onset (HO) infections. Surgical intervention was required in 68/81 patients infected with USA300 and 8/17 of the others. Most USA300 were susceptible (S) to clindamycin (CD) and patients were treated with CD alone or in combination. The other isolates were generally treated with vancomycin (VA) alone or in combination.

Multidrug-resistant viridans group streptococcus (MDRVS) strains have emerged as important pathogens. Treatment of MDRVS infections is problematic. The use of fluoroquinolones for treatment of MDRVS osteomyelitis has not been established. We present the first case of MDRVS osteomyelitis of the mandible successfully treated with sequential intravenous then oral moxifloxacin, and review the literature on the subject.

Chryseobacterium indologenes central nervous system infection has not been reported. We present a case of lumboperitoneal shunt infection caused by C. indologenes successfully treated with trimethoprim-sulfamethoxazole and rifampin in a pediatric patient. Forty-three additional cases of C. indologenes non-central nervous system infections reported in the English medical literature were reviewed. Risk factors for C. indologenes infections include underlying medical illnesses, underlying immunocompromising conditions and presence of indwelling intravascular devices.

New pathogens have emerged that now complicate the management of community-acquired pneumonia (CAP). Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a potential cause of CAP, particularly complicated CAP. In this literature review, the incidence, invasiveness, and antimicrobial management of CA-MRSA is discussed. Based on existing data and the rising incidence of CA-MRSA, we recommend a change in antibiotic selection for complicated CAP.

An 11-y-old boy developed a liver abscess 3 weeks following blunt abdominal trauma. Abscess culture yielded pure growth of Clostridium novyi type B, not previously reported as a cause of human infection. The patient was managed successfully with antibiotic therapy and continuous percutaneous drainage. Clostridial liver abscess following blunt abdominal trauma may occur as a delayed complication and may be managed without resectional debridement.

Antibiotic susceptibility testing by the microdilution technique was performed on 184 Yersinia enterocolitica isolates recovered from children with gastroenteritis in the Detroit area during a 12-year period. The majority of isolates were resistant to ampicillin, ticarcillin and cefazolin. The most active agents were cefotaxime, ceftriaxone, cefepime, gentamicin, tobramycin, sulphamethoxazole/trimethoprim, imipenem and ciprofloxacin. Cefotaxime and ceftriaxone were effective in the treatment of bacteraemia in 12 patients.

Objective: Although the use of complementary and alternative medicine (CAM) in children is increasing, little is known about its use in children with human immunodeficiency virus (HIV) infection. This study investigated the use of CAM by parents of children with HIV infection (H), children with asthma (A), and well children (W). Our hypothesis was that parents of the H group are more likely to use CAM than parents of the W or A group because of the nature and severity of the illness., Materials and Methods: Parents of 152 subjects [H (n = 46), A (n = 53), and W (n = 53)] were interviewed on the use of CAM for their children, types of CAM, reasons for use/nonuse, methods of payment, and perceived benefits for their children., Results: Compared with parents of the W and A groups, parents of the H group were less likely to be employed, were less likely to have private insurance, were less likely to have a high school or college education, and were more likely to be black. Interestingly, 38% of the W parents used CAM in their children compared with 22% in the H group and 25% in the A group. More than 80% of all three groups paid out of pocket for their use of CAM in their children. Within these groups, H parents were more likely to want CAM as part of their child's medical care (H = 91% vs W = 75% and A = 67%, P = 0.02) and were more likely to believe that CAM was expensive (H = 78% vs W = 57% and A = 60%, P < 0.01)., Conclusions: Our study revealed a relatively high rate of CAM usage by parents of all three study groups. Although parents of children with HIV infection were more likely to want CAM as part of their children's medical care, their rate of CAM usage was not higher than that in well children. This may be related to their socioeconomic factors. A larger and more diverse study population may provide more information on factors contributing to CAM usage in chronically ill and well children.

Objective: To assess the effect of using 2 throat swabs vs 1 on rapid detection of group A streptococcus by the STREP A OIA MAX (hereafter, OIA MAX) test., Methods: Children aged 5 to 18 years with acute pharyngitis were randomized to 1 of 2 study groups. In group 1, one throat swab was obtained, streaked first on sheep blood agar, and then used for OIA MAX testing. In group 2, two throat swabs were obtained simultaneously. One swab was streaked first on sheep blood agar and then joined with the other swab for OIA MAX testing. In both groups, the pledgets in the collection-transport tube were incubated in Todd-Hewitt broth. A positive group A streptococcus culture either by sheep blood agar or Todd-Hewitt broth was confirmed by a latex agglutination test., Results: Three hundred sixty-three patients were enrolled, 177 in group 1 and 186 in group 2. Cultures were positive for group A streptococcus in 154 (42.4%) of 363 patients. The sensitivity and specificity of OIA MAX testing were 94.7% and 100.0%, respectively, in group 1, and 92.4% and 96.3%, respectively, in group 2. There was no statistical difference between the sensitivity, the specificity, and the predictive values of the OIA MAX test performed with 1 swab compared with those performed with 2 swabs (P>.10). There was no association between OIA MAX test sensitivity and the severity of pharyngitis as measured by the modified Centor criterion (history of fever, absence of cough, presence of pharyngeal or tonsillar exudates, and presence of cervical lymphadenopathy) scores., Conclusions: The OIA MAX test yielded comparable sensitivity and specificity in both study groups. The use of 2 throat swabs instead of 1 swab did not increase the sensitivity of the OIA MAX test. The performance of the OIA MAX test did not depend on the severity of pharyngitis.

Gastrointestinal cytomegalovirus infection is a common opportunistic infection in immunocompromised patients. It is a rare cause of enterocolitis in immunocompetent hosts. We present a case of severe cytomegalovirus enterocolitis causing intractable diarrhea in a previously healthy infant. The child was successfully treated with intravenous ganciclovir.

Resistance to antimicrobial agents, which was recognized more than 50 years, continues to be a major cause of increased morbidity, mortality and health care cost. Overuse of antibiotics is considered the major contributing factor; however, poor implementation of infection control measures, prolonged hospitalization, admission to intensive care units and the use of invasive procedures are other contributing factors. The authors review the epidemiology, mechanism of resistance, treatment options and prevention measures of infections caused multi-drug resistant S. pneumoniae, methicillin-resistant S. aureus (MRSA), macrolide-resistant S. pyogenes and vancomycin-resistant enterococci (VRE) in pediatric patients. Antibacterial resistance among Gram-negative organisms, including extended spectrum beta-lactamase (ESBL) producing enteric bacteria, and the management and prevention of infections caused by these organisms are also discussed.

Advances have been made in the understanding of the pathogenesis of mother-to-child transmission of human immunodeficiency virus (HIV). Most transmission occurs during delivery and after birth throught breastfeeding. For this reason, efforts to interrupt transmission have focused on peripartum period and infant feeding. This includes the use of antiretroviral therapy, elective cesarean section and avoidance of breastfeeding. This review summarizes recent major studies and new development on the prevention of mother-to-child HIV transmission. The application and the impact of such interventions in developing world is discussed. Prevention of mother-to-child transmission of HIV should now be integrated as part of basic maternal and child health services in developing countries.

Human herpes virus-6 was first reported in 1986 and is the sixth member of the herpes virus family. HHV-6 consists of two closely related variants HHV-6A and HHV-6B. The majority of infections occur in healthy infants with most infections caused by HHV-6B. The virus preferentially infects CD4+T-lymphocytes and the surface marker CD46 acts as a co-receptor. Infection is followed by persistence and latency in different cells and organs including monocytes/macrophages, salivary glands, the brain and the kidneys. In this article we will discuss the clinical manifestations of HHV-6 infection in healthy children and the syndromes associated with HHV-6 reactivation in immunocompromised patients. Evidence of association between HHV-6 infection and different clinical entities such as multiple sclerosis, malignancy, infectious momononucleosis, drug hypersensitivity syndromes and skin eruptions is discussed. Published data on the use and efficacy of antiviral agents in complicated infections and infections in immunocompromised patients is presented.

A 4 1/2-month-old, 26-week premature infant with multiple complications of prematurity required a central venous catheter for venous access and antibiotic treatment of bacterial nosocomial infections. He developed tricuspid valve endocarditis with vegetation caused by Enterococcus faecium resistant to ampicillin, vancomycin and quinupristin-dalfopristin but susceptible to linezolid. He was successfully treated with linezolid intravenously (7 weeks) and then orally (2 weeks).

The G and P genotypes of rotavirus stool isolates from 100 children were determined by reverse transcription-PCR and nucleotide sequencing. G1P[4] was the most prevalent genotype(41%), followed by G1P[8] (16%) and G4P[4] (14%). The G genoypes detected were G1 (73%), G4 (17.4%), G9 (6.3%), and G2 (2.8%). The P genotypes were P[4] (71%) and P[8] (29%). Coinfection with more than one G genotype occurred in 12 patients, and coinfection with more than one P genotype occurred in 11 patients.