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The Ebola virus disease (Ebola) outbreak in West Africa (2014-2015) prompted domestic planning to address the scenario in which a traveler imports Ebola into the United States. Parental presence at the bedside of a child with suspected or confirmed Ebola emerged as a challenging issue for pediatric health care providers and public health practitioners. At the heart of the issue was the balance of family-centered care and appropriate infection control, which are not easily aligned in the setting of Ebola. In the following dialogue, pediatricians, who participated in discussions about parental presence during the evaluation of pediatric persons under investigation, and a public health ethicist discuss the interplay between family-centered care and appropriate infection control. Reaching a balance between the 2 ideals is difficult and may require the facility and providers to engage in a deliberate conversation to determine how they will handle parental presence for such high-risk scenarios, including Ebola and other high-consequence pathogens, in their institution.

Purpose Specific deviations from United States Pharmacopeia standards were analyzed to investigate the factors allowing an outbreak of Serratia marcescens bloodstream infections in patients receiving compounded amino acid solutions. Methods Filter challenge experiments using the outbreak strain of S. marcescens were compared with those that used the filter challenge organism recommended by ASTM International ( Brevundimonas diminuta ATCC 19162) to determine the frequency and degree of organism breakthrough. Disk and capsule filters (0.22- and 0.2-μm nominal pore size, respectively) were challenged with either the outbreak strain of S. marcescens or B. diminuta ATCC 19162. The following variables were compared: culture conditions in which organisms were grown overnight or cultured in sterile water (starved), solution type (15% amino acid solution or sterile water), and filtration with or without a 0.5-μm prefilter. Results Small-scale, syringe-driven, disk-filtration experiments of starved bacterial cultures indicated that approximately 1 in every 1,000 starved S. marcescens cells (0.12%) was able to pass through a 0.22-μm nominal pore-size filter, and about 1 in every 1,000,000 cells was able to pass through a 0.1-μm nominal pore-size filter. No passage of the B. diminuta ATCC 19162 cells was observed with either filter. In full-scale experiments, breakthrough was observed only when 0.2-μm capsule filters were challenged with starved S. marcescens in 15% amino acid solution without a 0.5-μm prefiltration step. Conclusion Laboratory simulation testing revealed that under certain conditions, bacteria can pass through 0.22- and 0.2-μm filters intended for sterilization of an amino acid solution. Bacteria did not pass through 0.2-μm filters when a 0.5-μm prefilter was used.

Nucleic acid testing (NAT) for hepatitis C virus (HCV) is recommended for screening of organ donors, yet not all donor infections may be detected. We describe three US clusters of HCV transmission from donors at increased risk for HCV infection. Donor's and recipients' medical records were reviewed. Newly infected recipients were interviewed. Donor-derived HCV infection was considered when infection was newly detected after transplantation in recipients of organs from increased risk donors. Stored donor sera and tissue samples were tested for HCV RNA with high-sensitivity quantitative PCR. Posttransplant and pretransplant recipient sera were tested for HCV RNA. Quasispecies analysis of hypervariable region-1 was used to establish genetic relatedness of recipient HCV variants. Each donor had evidence of injection drug use preceding death. Of 12 recipients, 8 were HCV-infected-6 were newly diagnosed posttransplant. HCV RNA was retrospectively detected in stored samples from donor immunologic tissue collected at organ procurement. Phylogenetic analysis showed two clusters of closely related HCV variants from recipients. These investigations identified the first known HCV transmissions from increased risk organ donors with negative NAT screening, indicating very recent donor infection. Recipient informed consent and posttransplant screening for blood-borne pathogens are essential when considering increased risk donors.

Background.Patients in the neonatal intensive care unit (NICU) are at high risk for healthcare-associated infections. Variability in reported infection rates among NICUs exists, possibly related to differences in prevention strategies. A better understanding of current prevention practices may help identify prevention gaps and areas for further research.MethodsWe surveyed infection control staff in NICUs reporting to the National Healthcare Safety Network (NHSN) to assess strategies used to prevent methicillin-resistant Staphylococcus aureus (MRSA) transmission and central line–associated bloodstream infections in NICUs.ResultsStaff from 162 of 342 NICUs responded (response rate, 47.3%). Most (92.3%) NICUs use central line insertion and maintenance bundles, but maintenance practices varied, including agents used for antisepsis and frequency of dressing changes. Forty-two percent reported routine screening for MRSA colonization upon admission for all patients. Chlorhexidine gluconate (CHG) use for central line care for at least 1 indication (central line insertion, dressing changes, or port/cap antisepsis) was reported in 82 NICUs (51.3%). Among sixty-five NICUs responding to questions on CHG use restrictions, 46.2% reported no restrictions.ConclusionsOur survey illustrated heterogeneity of CLABSI and MRSA prevention practices and underscores the need for further research to define optimal strategies and evidence-based prevention recommendations for neonates.Infect Control Hosp Epidemiol 2014;35(9):1126-1132

A liver, heart, iliac vessel and two kidneys were recovered from a 39-year-old man who died of traumatic head injury and were transplanted into five recipients. The liver recipient 18 days posttransplantation presented with headache, ataxia and fever, followed by rapid neurologic decline and death. Diagnosis of granulomatous amebic encephalitis was made on autopsy. Balamuthia mandrillaris infection was confirmed with immunohistochemical and polymerase chain reaction (PCR) assays. Donor and recipients' sera were tested for B. mandrillaris antibodies. Donor brain was negative for Balamuthia by immunohistochemistry and PCR; donor serum Balamuthia antibody titer was positive (1:64). Antibody titers in all recipients were positive (range, 1:64-1:512). Recipients received a four- to five-drug combination of miltefosine or pentamidine, azithromycin, albendazole, sulfadiazine and fluconazole. Nausea, vomiting, elevated liver transaminases and renal insufficiency were common. All other recipients survived and have remained asymptomatic 24 months posttransplant. This is the third donor-derived Balamuthia infection cluster described in solid organ transplant recipients in the United States. As Balamuthia serologic testing is only available through a national reference laboratory, it is not feasible for donor screening, but may be useful to determine exposure status in recipients and to help guide chemotherapy.

We describe four solid-organ transplant recipients with donor-derived West Nile virus (WNV) infection (encephalitis 3, asymptomatic 1) from a common donor residing in a region of increased WNV activity. All four transplant recipients had molecular evidence of WNV infection in their serum and/or cerebrospinal fluid (CSF) by reverse transcription polymerase chain reaction (RT-PCR) testing. Serum from the organ donor was positive for WNV IgM but negative for WNV RNA, whereas his lymph node and spleen tissues tested positive for WNV by RT-PCR. Combination therapy included intravenous immunoglobulin (4 cases), interferon (3 cases), fresh frozen plasma with WNV IgG (2 cases), and ribavirin (1 case). Two of the four transplant recipients survived.Review of the 20 published cases of organ-derived WNV infection found that this infection is associated with a high incidence of neuroinvasive disease (70%) and severe morbidity and mortality (30%). Median time to onset of symptomatic WNV infection was 13 days after transplantation (range 5-37 days). Initial unexplained fever unresponsive to antibiotic therapy followed by rapid onset of neurologic deficits was the most common clinical presentation. Confirmation of infection was made by testing serum and CSF for both WNV RNA by RT-PCR and WNV IgM by serological assays. Treatment usually included supportive care, reduction of immunosuppression, and frequent intravenous immunoglobulin. The often negative results for WNV by current RT-PCR and serological assays and the absence of clinical signs of acute infection in donors contribute to the sporadic occurrence of donor-derived WNV infection. Potential organ donors should be assessed for unexplained fever and neurological symptoms, particularly if they reside in areas of increased WNV activity.

Microsporidia are spore-forming, obligately intracellular organisms related to fungi. Enterocytozoon bieneusi and 3 Encephalitozoon species (Encephalitozoon cuniculi, Encephalitozoon hellem, and Encephalitozoon intestinalis) are the most common microsporidia identified as pathogens of humans (1, 2). Studies indicate that asymptomatic microsporidial disease occurs in humans, and seroprevalence data suggest that humans may be frequently exposed to these organisms (3–5). Microsporidia cause a spectrum of disease, from self-limiting diarrhea to disseminated, life-threatening infections. Microsporidiosis is recognized predominantly among HIV-infected patients but has more recently been noted in non–HIV-infected individuals as an emerging pathogen (6, 7). Several reports describe microsporidial infections involving organ transplant recipients, but to our knowledge, these infections have not been proved to be transplant-transmitted (8–11). In February 2012, the Centers for Disease Control and Prevention (CDC) was notified of a cluster of 3 transplant recipients with febrile illness onset 7 to 10 weeks after receiving organs from a common donor. Initial evaluation included serologic, molecular, and culture-based assays against a broad range of bacterial, fungal, and viral pathogens. Concomitant illnesses, such as urinary tract infection and organ rejection, were appropriately treated, yet recipients remained ill. Subsequent diagnostic evaluation of recipients suggested infections with a Brucella species that were presumed to be donor-derived. However, despite directed therapy for brucellosis and continued empirical treatment for other infectious etiologies, the patients did not improve, and assistance was requested from public health authorities in determining a common cause for the illness cluster. Kidney biopsy samples sent to CDC from 1 recipient confirmed the diagnosis as microsporidiosis with Encephalitozoon cuniculi, and a public health investigation was initiated to confirm the diagnosis in the other recipients, assess donor and recipient risk factors, and provide therapy recommendations for ill recipients.

To identify a pediatric ventilator-associated condition definition for use in neonates and children by exploring whether potential ventilator-associated condition definitions identify patients with worse outcomes.Retrospective cohort study and a matched cohort analysis.Pediatric, cardiac, and neonatal ICUs in five U.S. hospitals.Children 18 years old or younger ventilated for at least 1 day.None.We evaluated the evidence of worsening oxygenation via a range of thresholds for increases in daily minimum fraction of inspired oxygen (by 0.20, 0.25, and 0.30) and daily minimum mean airway pressure (by 4, 5, 6, and 7 cm H2O). We required worsening oxygenation be sustained for at least 2 days after at least 2 days of stability. We matched patients with a ventilator-associated condition to those without and used Cox proportional hazard models with frailties to examine associations with hospital mortality, hospital and ICU length of stay, and duration of ventilation. The cohort included 8,862 children with 10,209 hospitalizations and 77,751 ventilator days. For the fraction of inspired oxygen 0.25/mean airway pressure 4 definition (i.e., increase in minimum daily fraction of inspired oxygen by 0.25 or mean airway pressure by 4), rates ranged from 2.9 to 3.2 per 1,000 ventilator days depending on ICU type; the fraction of inspired oxygen 0.30/mean airway pressure 7 definition yielded ventilator-associated condition rates of 1.1-1.3 per 1,000 ventilator days. All definitions were significantly associated with greater risk of hospital death, with hazard ratios ranging from 1.6 (95% CI, 0.7-3.4) to 6.8 (2.9-16.0), depending on thresholds and ICU type. Each definition was associated with prolonged hospitalization, time in ICU, and duration of ventilation, among survivors. The advisory board of the study proposed using the fraction of inspired oxygen 0.25/mean airway pressure 4 thresholds to identify pediatric ventilator-associated conditions in ICUs.Pediatric patients with ventilator-associated conditions are at substantially higher risk for mortality and morbidity across ICUs, regardless of thresholds used. Next steps include identification of risk factors, etiologies, and preventative measures for pediatric ventilator-associated conditions.

Ehrlichiosis is a tick-borne disease that ranges in severity from asymptomatic infection to fatal sepsis. Ehrlichiosis acquired from transfusion of blood products has not been documented in the literature to date. A case of Ehrlichia ewingii infection likely transmitted by transfusion of leukoreduced platelets is described, and public health implications are discussed.

Parenteral nutrition (PN) is widely used in healthcare settings to deliver critical nutrients to patients unable to tolerate enteral feeding. The intravenous formulation is intended to provide all daily nutritional requirements, such as electrolytes, amino acids, dextrose, and lipids, and is considered to be one of the most complex pharmaceuticals to prepare because of the need for careful titration and combination of multiple components [1, 2]. Preparation under rigorous sterile conditions is especially crucial as the nutrient-rich formulation can act as favorable growth media for microorganisms [3, 4] and because the process requires the multistep transfer of several ingredients into a single container, providing opportunities for microbial contamination during the compounding process [5]. In the United States, PN can be compounded in a healthcare facility, outsourced to a compounding pharmacy, or purchased as manufactured, premixed formulations [5]. Healthcare facilities that administer PN to patients often lack the time, expertise, and technology to produce these solutions in their own facilities. As a result, the preparation of PN is frequently outsourced to compounding pharmacies specializing in these practices. In 2011, approximately 43% of 556 US hospitals with >600 beds randomly surveyed reported outsourcing their nutrition support preparations [6]. Compounding pharmacies are expected to adhere to current standards for preparation and handling of compounded sterile preparations (CSPs). One such standard is the United States Pharmacopeia's (USP) General Chapter “Pharmaceutical Compounding—Sterile Preparations,” which details conditions and practices that minimize risks of contamination of CSPs, including PN [7]. Additional standards for compounding PN solutions also exist [8, 9]. The adoption of strict standards for sterile compounding have contributed to a decline in the burden of contaminated PN preparations, and US outbreaks related to mishandling of PN during compounding are rare [2]. However, compounding CSPs, especially using nonsterile active pharmaceutical ingredients (APIs), involves challenging and complex processes, and outbreaks associated with improperly compounded preparations are being increasingly reported [10–20]. In March 2011, the Centers for Disease Control and Prevention (CDC) was notified of 5 patients with Serratia marcescens bloodstream infection (BSI) in one hospital in Alabama. Receipt of PN from a single compounding pharmacy was identified as a potential common source. The pharmacy was an independent, state-licensed compounding pharmacy in Birmingham that was registered with the Alabama State Board of Pharmacy and subject to the state laws and regulations pertaining to the compounding of parenteral therapy [21]. During the outbreak period, the pharmacy supplied PN to 6 healthcare facilities (5 acute care hospitals and 1 long-term acute care hospital), all located within Alabama. Prescriptions for PN were received daily by the pharmacy, and compounded PN preparations were delivered to hospitals each night. On 15 March 2011, after being notified of these S. marcescens BSIs, the pharmacy voluntarily ceased all compounding activities and subsequently recalled all CSPs as a precautionary measure. An investigation was conducted by the Alabama Department of Public Health and CDC to determine the extent of the outbreak, identify risk factors for infection among PN recipients, and review PN compounding practices to identify potential sources of contamination.

Objective.To describe rates and pathogen distribution of device-associated infections (DAIs) in neonatal intensive care unit (NICU) patients and compare differences in infection rates by hospital type (children's vs general hospitals).Patients and Setting.Neonates in NICUs participating in the National Healthcare Safety Network from 2006 through 2008.Methods.We analyzed central line–associated bloodstream infections (CLABSIs), umbilical catheter–associated bloodstream infections (UCABs), and ventilator-associated pneumonia (VAP) among 304 NICUs. Differences in pooled mean incidence rates were examined using Poisson regression; nonparametric tests for comparing medians and rate distributions were used.Results.Pooled mean incidence rates by birth weight category (750 g or less, 751–1,000 g, 1,001–1,500 g, 1,501–2,500 g, and more than 2,500 g, respectively) were 3.94, 3.09, 2.25, 1.90, and 1.60 for CLABSI; 4.52, 2.77, 1.70, 0.91, and 0.92 for UCAB; and 2.36, 2.08, 1.28, 0.86, and 0.72 for VAP. When rates of infection between hospital types were compared, only pooled mean VAP rates were significantly lower in children's hospitals than in general hospitals among neonates weighing 1,000 g or less; no significant differences in medians or rate distributions were noted. Pathogen frequencies were coagulase-negative staphylococci (28%),Staphylococcus aureus(19%), andCandidaspecies (13%) for bloodstream infections andPseudomonasspecies (16%),S. aureus(15%), andKlebsiellaspecies (14%) for VAP. Of 673S. aureusisolates with susceptibility results, 33% were methicillin resistant.Conclusions.Neonates weighing 750 g or less had the highest DAI incidence. With the exception of VAP, pooled mean NICU incidence rates did not differ between children's and general hospitals. Pathogens associated with these infections can pose treatment challenges; continued efforts at prevention need to be applied to all NICU settings.

Obesity affects one third of children and adolescents, many of whom already have serious medical consequences. Therefore primary care providers must deliver clinical service that incorporates preventive practices, improves early diagnosis, and evaluates co-morbid conditions. In addition physicians must become more knowledgeable about changing practice in treating overweight and obese children.