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Predictions for ’09: What’S Old Is New Again

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Predictions for ’09: What’S Old Is New Again 10 INFECTIOUS DISEASES JANUARY 2009 • PEDIATRIC NEWS ID CONSULT Predictions for ’09: What’s Old Is New Again appy 2009! It’s time for the an- Klebsiella, Acinetobacter baumannii, a standing order to give vaccine to moth- rose again. There is concern that pro- nual look into the future of in- Pseudomonas aeruginosa, and Enterobacter ers before hospital discharge (if they have longed deferral of the Hib booster in the Hfectious diseases. species—which together are responsible not received a tetanus-containing vac- United States may produce similar re- Two common themes were evident for two-thirds of all health care–associat- cine in the past 2 years, or prior Tdap). sults, so be on the look out. last year: increasing antibiotic resistance, ed infections. While a few new drugs are Ǡ The new improved pneumococcal Ǡ Most physicians are still unaware of and changing epidemiology and vaccine- available or coming for MRSA, there are conjugate vaccine may be closer than the new guidelines for subacute bacteri- preventable infections. Last few that target gram-negative you think. The emergence of multidrug- al prophylaxis. In 2007, the American year’s predictions that were pathogens. For more informa- resistant serotype 19A disease has chal- Heart Association issued the first major on the mark included the rise tion, check out the article by lenged the management of pneumococ- revision of these guidelines and endorsed in pneumococcal serotype Dr. Helen Boucher of Tufts cal infection from acute suppurative antimicrobial prophylaxis for only five 19A, the drop in rotavirus cas- University (Clin. Infect. Dis. otitis media to more serious infections circumstances: prosthetic heart valves, es, the lack of a national so- 2009;48:1-12). like pneumonia and meningitis. Last prior infective endocarditis, cardiac trans- lution to vaccine reimburse- Ǡ Parental declinations of cer- May, the Food and Drug Administration plant with valvulopathy, unrepaired ment, the need for new tain vaccines will plateau. No granted fast-track designation for the cyanotic congenital heart disease, and re- strategies to raise vaccine cov- question that pediatricians are Wyeth 13-valent vaccine (which includes paired congenital heart disease with ei- erage rates, and the rise in spending an increasing 19A) to speed the process. ther prosthetic patch or other device in methicillin-resistant Staphylo- amount of time addressing Ǡ Cases of Clostridium difficile will in- the first 6 months after placement or be- coccus aureus (MRSA) infec- BY MARY ANNE parental concerns regarding crease. In 2005, the Centers for Disease yond that if there is a residual defect at tions. This year, some similar JACKSON, M.D. vaccines, but the majority of Control and Prevention alerted us to the the site of patch or device. Read more themes prevail and some parents still trust their pedia- reports of an increase in incidence and about it at: www.americanheart.org/ items may surprise you: trician to provide appropriate vaccine in- severity of C. difficile–associated disease presenter.jhtml?identifier=3047051. Ǡ MRSA will become a more prominent formation. The key, though, is making (CDAD), both community acquired and Ǡ A rise in tuberculosis cases will occur pathogen in your local neonatal intensive sure you appropriately address their con- health care–facility acquired or associat- in the United States. A recent study in care unit (NICU). Practicing pediatricians cerns and deliver a clear and positive ed. While most practitioners are aware Clinical Infectious Diseases showed a are well aware of the emergence of message with high-quality information. that the major driving force in CDAD is particular risk for undocumented immi- MRSA. As evidence, most have probably Check out Meg Fisher’s article in the antimicrobial use, this strain appears to grants with tuberculosis to be sicker drained more abscesses in the last year September 2008 Pediatric Infectious Dis- be causing infection in otherwise healthy longer than documented immigrants or than in their entire career to date. Spo- ease Journal for a great discussion of vac- persons who haven’t received antibiotics. U.S.-born patients. With this comes a po- radic phone calls have alerted us to cases cine safety (Pediatr. Infect. Dis J. 2008: One study confirmed that with respect to tential for increased risk for transmission. of MRSA infection in community hospi- 27:827-30). health care–associated CDAD, the avail- Ǡ Do you know about the CDC’s Web tal nurseries, and while we have not en- Ǡ Pertussis cases will hit an all time low ability of adequate infection control per- site for students who are planning to countered a NICU outbreak of MRSA in- overall but beware: Outbreaks will still oc- sonnel was associated with lower rates. Study Abroad (www.cdc.gov/Features/ fection, they are well reported and may be cur, particularly among older children. Ǡ You might see Haemophilus influenzae StudyAbroad)? It seems that interna- difficult to halt. Active NICU surveillance Implementation of the adolescent/adult type b (Hib) invasive infection in the tional travel is becoming a right of pas- (periodic nasal screening), screening of tetanus-diphtheria-reduced antigen acel- coming year. A Nov. 21 CDC report de- sage. This site provides information on new admissions hospitalized elsewhere, lular pertussis (Tdap) vaccine is ongoing, tailed information regarding the contin- a variety of infection- and non–infection- and utilization of contact precautions (un- but we still have a large susceptible pop- ued vaccine shortage (MMWR 2008; related topics, and connects you to oth- til results are available) may be necessary. ulation of children aged 8-12 years, as well 57:1252-5). (See Policy & Practice item, er key Web sites. Check it out, pass it on, Ǡ Multidrug-resistant gram-negative in- as adults. We recently cared for a 5-week- p. 23.) Vaccine supplies currently are in- and I wish you the best in 2009. ■ fections will emerge throughout pediatric old infant with whooping cough who re- sufficient to supply the booster dose, hospitals, and no new help is on the hori- quired ECMO (extracorporeal membrane and some studies suggest that this dose DR. JACKSON is chief of pediatric zon for these bad bugs, which have been oxygenation). I suspect we will continue is particularly important for protection infectious diseases at Children’s Mercy coined the ESKAPE bacteria. They in- to see such cases. and herd immunity. In the United King- Hospital, Kansas City, Mo., and professor clude two gram-positive bugs—Enterococ- The role of postpartum Tdap is im- dom, a booster dose was not initially rec- of pediatrics at the University of cus faecium, Staphylococcus aureus, and portant, and pediatricians should en- ommended; after an initial decrease in Missouri–Kansas City. Write to Dr. gram negatives including four species of courage their obstetrics colleagues to use disease, the rate of invasive infection Jackson at [email protected]. Varicella/speC Gene May Up Risk of Necrotizing Fasciitis BY KERRI WACHTER This observation was recently confirmed by the pub- not—56% and 14%, respectively. Toxic shock syndrome Senior Writer lic health department of Quebec. was also significantly more common among those who The researchers conducted a retrospective chart re- developed NF (33%) than in those who did not (4%). On WASHINGTON — Recent varicella infection and the view of all children (younger than 18 years) with doc- multivariate analysis, toxic shock syndrome was not presence of a specific virulence factor gene were strong- umented invasive group A streptococcal infections found to be a significant factor in the development of ly associated with the development of necrotizing from January 1999 to December 2007, in order to un- necrotizing fasciitis. This may be because of the low fasciitis among Quebecois children with invasive group derstand the risk factors for necrotizing fasciitis. Necro- number of cases (six in the NF group and two in the A streptococcal infections, according to a retrospective tizing fasciitis (NF) cases occurred only during the group without), Dr. Ovetchkine said in an interview. analysis involving 68 patients. years 2003-2005. Group A streptococcal isolates were evaluated for cell Children with varicella had a sixfold greater risk of Invasive group A streptococcal infection was defined surface M virulence protein gene (emm) typing and the necrotizing fasciitis (odds ratio 6.2) and those with the as the presence of a compatible clinical presentation and presence of several virulence factor genes (speA, speB, speC gene had a fourfold greater risk (odds ratio 4.0), the isolation of group A streptococcus from a normal- speC, ssa, smeZ, and sic). In terms of M protein genes, on the basis of a multivariate analysis, Dr. Philippe ly sterile body site; NF was defined as the presence of emm1 (30%) and emm12 (17%) were predominant. In Ovetchkine reported at the jointly held annual Inter- necrosis in the fascia and polymorphic infiltrate. A to- some patients without NF, the researchers did observe science Conference on Antimicrobial Agents and tal of 68 children with invasive group A streptococcal speC genes in the streptococcal strains. Chemotherapy and the annual meeting of the Infec- infections (44% girls, mean age 60 months) were iden- Dr. Ovetchkine hypothesizes that the presence of the tious Diseases Society of America. tified. Group A streptococcus was recovered from speC gene can lead to a specific phenotype of invasive “The story began a few years ago in Montreal, when blood culture in 38 of the children, cerebrospinal fluid group A streptococcal infections: necrotizing fasciitis. we observed a high number of children hospitalized for in 2, articular fluid in 4, pleural fluid in 7, and surgical “Moreover, speC could act as a superantigen and favors invasive group A streptococcal infections. In particular, intraoperative samples in 17. Eighteen children had NF, the occurrence of toxic shock syndrome in this con- we noticed concomitant necrotizing fasciitis,” said Dr.
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