prospective study to assess vancomycin serum concentrations in pediatric patients with current dosing guidelines

Concerns about increasing bacterial resistance to vancomycin, have caused the adult treatment guidelines to recommend higher trough concentrations based on the type and location of infectious disease. Although these recommendations are not specific to children, the values can be extrapolated. This prospective study was designed to evaluate efficacy of current vancomycin dosing recommendations to achieve therapeutic trough serum concentration in pediatric patients. Laboratory data, vancomycin dosing and subsequent serum concentrations of children in a community teaching pediatrics hospital were collected and analyzed. Trough serum levels were determined at steady state and compared with Infectious Disease Society of America [IDSA] 2011 guidelines for the treatment of Methicillin-Resistant Staphylococcus Aureus [MRSA] infections. In a prospective observational, cross-sectional study in a university medical center in Tehran, Iran, 50 patients, who received vancomycin for more than 4 doses, were recruited and their trough vancomycin level was determined. The mean age and creatinine clearance of patients were 5.47 +/- 4.24 and 87.5 +/- 31.25, respectively. Eleven [22%] patients received vancomycin at 40 mg/kg/day [low dose] and 39 [78%] at 60 mg/kg/day [high dose]. Considering trough goals of 10-14 and 15-20mg/L in low and high dose groups, serum levels in 91% [73% sub-therapeutics] and 85% [69% sub-therapeutics] of patients were not in recommended therapeutic range, respectively. This study has shown that current recommended vancomycin dosing regimens in pediatric patients [40-60 mg/kg/day], resulted in sub-therapeutic serum concentrations in our study population

Association of systemic Anaplastic large cell Lymphoma and active Toxoplasmosis in a child

Introduction: Anaplastic large cell lymphoma is a subset of non-Hodgkin lymphoma and an unusual disease in children

Case Presentation: Herein we have reported a 7- year- old girl with a large necrotic skin ulcer on the chest caused by systemic form of anaplastic large-cell lymphoma and simultaneous active toxoplasmosis diagnosed by PCR on lymph node specimen. There were few reports showing a role for toxoplasma infection to cause some malignancies such as lymphoma in adults

Conclusions: Based to our knowledge, this has been the first report of simultaneous systemic anaplastic large cell lymphoma and active toxoplasmosis, documented by positive PCR on tissue biopsy in a child. This case report has suggested more attention to the accompanying Toxoplasma gondii infection as a probable cause of some types of lymphomas

Antibiotic Susceptibility Evaluation of Group A Streptococcus Isolated from Children with Pharyngitis: A Study from Iran / 감염과화학요법

BACKGROUND: The aim of this study was to evaluate the antibiotic susceptibility of Group A streptococcus (GAS) to antibiotics usually used in Iran for treatment of GAS pharyngitis in children. MATERIALS AND METHODS: From 2011 to 2013, children 3-15 years of age with acute tonsillopharyngitis who attended Mofid Children's Hospital clinics and emergency ward and did not meet the exclusion criteria were enrolled in a prospective study in a sequential manner. The isolates strains from throat culture were identified as GAS by colony morphology, gram staining, beta hemolysis on blood agar, sensitivity to bacitracin, a positive pyrrolidonyl aminopeptidase (PYR) test result, and the presence of Lancefield A antigen determined by agglutination test. Antimicrobial susceptibility was identified by both disk diffusion and broth dilution methods. RESULTS: From 200 children enrolled in this study, 59 (30%) cases were culture positive for GAS. All isolates were sensitive to penicillin G. The prevalence of erythromycin, azithromycin, and clarithromycin resistance by broth dilution method was 33.9%, 57.6%, and 33.9%, respectively. Surprisingly, 8.4% of GAS strains were resistant to rifampin. In this study, 13.5% and 32.2% of the strains were resistant to clindamycin and ofloxacin, respectively. CONCLUSION: The high rate of resistance of GAS to some antibiotics in this study should warn physicians, especially in Iran, to use antibiotics restrictedly and logically to prevent the rising of resistance rates in future. It also seems that continuous local surveillance is necessary to achieve the best therapeutic option for GAS treatment.

Comparison of tuberculin skin test result and interferon gamma response to human PPD in BCG scar positive and negative children

The aim of this study is to compare Tuberculin Skin Test [TST] result and interferon gamma response to human PPD [purified protein derivative], in scar positive and scar negative BCG-vaccinated children. Between August 2007 and May 2008 a total of 236 children aged 1-168 months [mean 21 months] admitted to Mofid Children's Hospital, Tehran, Iran, were enrolled in a cross-sectional study. Each patient was examined for BCG vaccine scar and tested with TST and human PPD-based Interferon Gamma Release Assay [IGRA]. Two hundred and twenty one cases out of 236 [44% female, 1-168 months, mean age 21 months] were scar positive of whom 95% TST result was negative. Human PPD-based IGRA was positive in 110 [49.8%], negative in 85 [38.4%] and indeterminate in 26 [11.8%] of scar positive patients. Fifteen children [40% female, 1-156 months; mean age 42 months] were scar negative. All the scar negative cases were TST negative. Human PPD-based IGRA was positive in 10 [66.7%], negative in 4 [26.7%] and indeterminate in 1 [6.7%] of scar negative patients. Immune responsiveness to human PPD antigens in scar positive and negative children may not correspond with results of the Tuberculin Skin Test

Comparison of neutrophil apoptosis by the pseudomonas aeruginosa exotoxins between healthy individuals and term infants

Pseudomonas aeruginosa may be colonized in different human tissues and result in some infections potentially. Thus, considering that these bacteria are resistance to most of the current antibiotics, an examination on pathogenesis mechanisms of such bacteria can be effective in controlling the infections developed by it. In this project, among 40 blood samples [20 healthy persons, 20 infants], an amount of 5 ml [2 ml in the infants] heparinized blood was collected from each and then neutrophils were isolated by a standard method and were counted by neubauer lam. After culturing Pseudomonas bacteria in broth medium, some tubes with densities of 1, 2, 3 and 4 McFarland were prepared and the bacteria were isolated by centrifuge method with 3000rpm for 10 minutes and then its exotoxin were exposed to neutrophils of the groups under study. The effect of time and the bacteria count on the amount of the secreted toxin and in adjacency to neutrophils was measured. There were 11 men and 9 women in the health group and the infants group consisted of 12 boys and 8 girls. Death cell percentage of neutrophils was 100% in the health group and 8.90% in the infants group. Percentage of bacterial growth in the medium 1 and 2 McFarland was zero; in the medium 3 McFarland, it was 12.5% in the healthy group and 1% in the infants group [p<0.10]. The average rate of cell death in the minute 15th was different in two groups [68.5% in health group vs. 92.5% in the infants] [p<0.0005]. This study showed the effect of Pseudomonas bacteria on the development of early cell death in the infants very well. As it was shown, this effect is time-dependent and this cell death [apoptosis] is occurred in the infants earlier than health people

Association between serum levels of MASP-2 and neutropenic febrile attacks in children with leukemia

Infectious complications are a major etiology of morbidity and mortality in febrile neutropenic patients. Low serum man-nose-binding lectin [MBL]-associated serine protease-2 [MASP-2] concentration may represent a risk factor for infection in leukemia patients receiving chemotherapy. This study evaluates the relationship between serum levels of MASP-2 with neutropenic febrile attacks in children with leukemia. This prospective cohort study conducted between 2009-2010, we measured baseline serum MASP-2 levels by enzyme-linked immunosorbent assay [ELISA] prior to chemotherapy in leukemia patients less than 14 years of age. The relationship of febrile neutropenia [FN] episodes and duration of hospitalization with MASP-2 concentration was analyzed. We evaluated 75 children [38 girls [51%], 37 boys [49%]; mean age, 61.6 +/- 43.7 months]. There were 8 [10.7%] children with MASP-2 deficiency [< 200 ng/mL]. Mean MASP-2 was 673.2 +/- 288.7 ng/mL [range: 116-1112]. Eight patients had no FN episodes. Of the 129 FN episodes recorded, 19 [average 2.4 times] were from the MASP-2deficient group and 110 [average 1.6 times] were in the normal group. There was a significant difference between the mean MASP-2 concentration and FN episodes [P = 0.043]. There was an inverse relationship between FN episodes [r = -0.332, P = 0.004] and the duration of hospitalization [r = -0.334, P= 0.005] with MASP-2 concentration. MASP-2 deficient patients were hospitalized longer than the normal group, which was strongly significant [P < 0.001]. Our study confirmed the results of several previous studies. MASP-2 deficiency in leukemic children treated with chemotherapy was associated with an increased risk of FN episodes, prolonged cumulative duration of hospitalization, and intravenous antimicrobial therapy

relationship between osteogenesis imperfecta and spinal muscular atrophy

A 4-month-old female with osteogenesis imperfecta [OI] type II was admitted in PICU of our center due to severe respiratory distress and fever with a diagnosis of severe pneumonia, and mechanical ventilation was initiated. Due to severe hypotonia, NCV and EMG were performed, and spinal muscular atrophy [SMA] type I was diagnosed

Association of serum soluble triggering receptor expressed on myeloid cells levels in malignant febrile neutropenic patients with bacteremia and fungemia

Infections are the major cause of morbidity and mortality in febrile neutropenic patients with malignancy. Rapid diagnostic tests are needed for prompt diagnosis and early treatment which is crucial for optimal management. We assessed the utility of soluble triggering receptor expressed on myeloid cells [sTREM-1] in the diagnosis of bacteremia and fungemia in febrile neutropenic patients. Sixty-five febrile neutropenic children with malignancy hospitalized in Mofid Children's Hospital during a period of one year from January 2007 were recruited for this cross sectional study [mean age 66.2 +/- 37 months; 35 females and 30 males]. Thirty patients [46.2%] had acute lymphoblastic leukemia, 2 [3.1%] acute myeloid leukemia, one [1.5%] lymphoma and 32 [49.2%] were under treatment for solid tumors. Simultaneous blood samples were collected for measurement of serum sTREM-1 levels and for blood cultures which were grown in BACTEC media. Gold standard for the presence of infection was a positive BACTEC culture as a more sensitive method compared to current blood culture techniques. Blood cultures with BACTEC system were positive in 13[20%] patients [12 bacterial and one fungal culture]. The mean serum sTREM-1 level in BACTEC positive patients was 948.2 +/- 592.9 pg/ml but in BACTEC negative cases it was 76.3 +/- 118.8 pg/ml [P<0.001]. The optimal cut-off point of sTREM-1 for detecting patients with positive result of BACTEC was 525 pg/ml with sensitivity and specificity of 84.6% and 100%, respectively. Our study revealed a significant association between serum sTREM-1 level and bacteremia and fungemia in febrile neutropenic patients suffering malignancy with acceptable sensitivity and specificity

Approach of lymphadenopathy in children

Appropriate approach of the lymphadenopathy in children as a common finding is necessary .The proper time for following and checking up the palpable lymph node and its biopsy are significant considerations of approaching lymphadenopathy in children that are described in this review study. The lymphadenopathy could be properly studied using the correct patient history, physical examination and the characteristics of lymph nodes including: generalized or localized and associated signs and symptoms such as organomegaly, skin and mucosal lesions, fever, weight lose and sweating. The lymphadenopathy in children could be resulted from a common and insignificant finding following upper respiratory tract infections to a serious malignant etiology. The correct evaluation of unimportant and serious forms of lymphadenopathy can inhibits the wasting in money and refers on time

Diaper type as a risk factor in urinary tract infection of children

Urinary tract is one of the most common sources of infection in children under the age of two years. Many known and unknown risk factors predispose to this important disease in children. This study was conducted to determine whether using a specific type of diaper plays a role in urinary tract infection [UTI] in girls under the age of 2 years. This case control study was performed in hospitalized children; girls with their first urinary tract infection were selected as cases, and those admitted for other reasons comprised the control group. Two groups were matched for age [ +/- 1 month], and other known risk factors for UTI. Type of diapers [superabsorbent, standard disposable and washable cotton], used for these children during six months, from October 2007 to March 2008, were compared in both I groups. 59 matched pair infant girls less than 2 years were selected. It was revealed that in cases with UTI superabsorbent diapers were used more frequently than in controls [Odds ratio =3.29, P-value=0.005] There were no significant differences in other factors like number of diapers used per day, the time between defecation and diaper change, mothers' educational level, level of family income and mother's occupation. The use of superabsorbent diapers could be a risk factor for urinary tract infection in infant girls

Diagnostic potential of urinary tumor necrosis factor-alpha in children with acute pyelonephritis

Tumor necrosis factor-alpha [TNF-alpha] is an important mediator of the inflammatory response in serious bacterial infections. The aim of this study was to evaluate the potential of urinary TNF-alpha for diagnosis of acute pyelonephritis in children. This study was conducted from March 2006 to December 2007 on children with confirmed diagnosis of acute pyelonephritis. They all had positive renal scintigraphy scans for pyelonephritis and leukocyturia. The ratios of urinary TNF-alpha to urine creatinine level were determined and compared in patients before and after antibiotic therapy. Eighty-two children [13 boys and 69 girls] with acute pyelonephritis were evaluated. The mean pretreatment ratio of urinary TNF-alpha to urinary creatinine level was higher than that 3 days after starting on empirical treatment [P = .03]. The sensitivity of this parameter was 91% for diagnosis of acute pyelonephritis when compared with demercaptosuccinic acid renal scintigraphy as gold standard. Based on our findings in children, the level of urinary TNF-alpha-creatinine ratio is acute increased in pyelonephritis and it decreases after appropriate therapy with a high sensitivity for early diagnosis of the disease. Further research is warranted for shedding light on the potential diagnostic role of urinary TNF-alpha in pyelonephritis in children

Subcutaneous fat necrosis of the newborn complicated with hypercalcaemia

Subcutaneous fat necrosis of the newborn [SCFN] is an unusual disorder which occurs in term or post-term newborns due to perinatal stress. SCFN appears by firm nodules over the trunk, arm, buttock, thigh and cheeks in the first several weeks of life. Prevalence of SCFN is unknown. Race and sex do not play a role in this condition Hypocalcaemia and rarely hypercalcaemia are considered as major causes of morbidity and mortality in cases of SCFN. We report a case of SCFN in a two month male infant complicated with hypercalcemia and hyperuricemia

First report of Griscelli syndrome from Afghan population in Iran

A 4 month old Afghan male infant presented with partial albinism, hepatosplenomegaly and pancytopenia. Skin and hair shaft microscopic examination revealed large clumped melanosomes and Griscelli syndrome was diagnosed. Unless treated with bone marrow transplantation, it is a fatal disease in accelerated phase. Pediatricians should consider this syndrome in infants with abnormal light hair because early diagnosis could be life saving

[Antibiotic susceptibility patterns in H. influenzae type B isolated from healthy children oropharynx in day care centers of Tehran]

Haemophilus influenzae type b [Hib] is a most frequent cause of invasive diseases such as meningitis, septic arthritis and pneumonia in children under 5 years old. Asymptomatic oropharyngeal colonization is an origin of distribution of microorganism to others and probable bacteremia in the same child. The aim of this study was to determine antibiotic susceptibility of Hib in Tehran day care centers. Hib was isolated from oropharynx of 1000 children visiting 25 day care centers selected randomly in different parts of Tehran city during second half of year 2005. For antibiotic susceptibility determination we used disk diffusion test. Ampicillin resistance was 32.3% and Beta lactamase production was seen in 23.6%. Cephalosporins resistance except for cefixime was between 10% to 20% and in cefixime was 58.8%. Rifampin resistance was 17.6%. Resistance to studied macrolids including azythromycin and clarythromycin was 19.6% and 35.3%. On the base of high antibiotic resistance to Hib in our study and other similar studies in Iran, we recommend to use optimal effective and proper antibiotics to decrease the high rate of antibiotics resistance to Hib colonization and its invasive diseases

Staphylococcal nasal colonization in Mofid children hospital staff; carrier state and antibiotic susceptibility

Staphylococcus aureus [SA] is frequently found on normal human skin and mucous membranes. Methicilline resistance S. aureus [MRSA] strains have spread in many hospital isolates world wide since 1970s. Hospital personnel tend to have higher colonization rates than the general population. Colonized residents and personnel are sources for dissemination of organism. For this cross sectional study, Mofid children's hospital staff were evaluated for staphylococcal nasal colonization. Isolated staphylococci tested for methicilline sensitivity by MIC method and their antibiotic susceptibility was investigated for six antibiotics by Disk diffusion technique. Of 284 tested personnel, 56 [19.7%] revealed to have nasal colonization of whom 23 [8.1%] were methicilline resistant [MRSA]. Working in the office [p<0.003], age [p<0.008] and years of employment in hospital [p<0.039] were correlated with colonization with MRSA. Totally, 96% of carriers were persistent carrier. Logistic regression showed a significant association between the working place [health care] [p<0.049] and years of employment [p<0.07] with S. aureus nasal colonization rate. Hospitals should assess the advantages and disadvantages of routinely culturing personnel, however, in outbreak situation hospital personnel especially older persons may be sources of nosocomial infection

Interleukins 1 and 6 in children with acute pyelonephritis

Renal infection and scarring are the leading causes of end stage renal disease [ESRD] in some parts of the world [e.g. Iran]. Urinary interleukins [IL] 1 and 6 have been reported to be high in acute pyelonephritis in previous studies. This study was performed to determine the relation between IL 1 and 6 levels in the presence of acute pyelonephritis and the relation between the amount of these cytokines and the severity of pyelonephritis by dimercaptosuccinic acid [DMSA] scan. Children ages 1 month to 12 years who were admitted to the nephrology ward of Mofid Children's Hospital for pyelonephritis from January to July 2004 were enrolled in the study. Interleukins 1 and 6 and creatinine were measured in 80 random urine samples of 37 patients [81%female] with acute pyelonephritis and 43 healthy children [81% female]. Urinary cytokines were measured by Enzyme Linked Immunosorbent Assay [ELISA] and creatinine by spectrophotometry methods and recorded in microgram per mg of creatinine. Pyelonephritis was confirmed by positive urine culture and/or DMSA scan in all patients using SPECT apparatus. Data were analyzed by paired student t test and differences considered significant if p<0.05. Mean interleukin 1/creatinine [IL 1/Cr] ratio in patients with pyelonephritis was 0.70 +/- 0.96 [range 0.02-5.08] and in healthy children was 0.04 +/- 0.12 [range 0-0.51]. Mean interleukin 6/creatinine [IL 6/Cr] ratio in patients with pyelonephritis was 4.80 +/- 10.06 [range 0.01-44.74] and in healthy children was 0.15 +/- 0.37 [range 0-2.32]. There were significantly higher levels of urinary IL-1 and IL-6 in children with pyelonephritis than healthy children, but we didn't find any significant relationship between urinary interleukin levels and other parameters such as pyuria, ESR, CRP and different grades of renal involvement in DMSA scans