Retrospective identification of congenital cytomegalovirus infection using dried blood samples - missed opportunities and lessons.

BACKGROUND: Congenital cytomegalovirus (cCMV) is the most common congenital infection in children, with a potential to cause neurodevelopmental delay and sensorineural hearing loss. Not only are most infected newborns asymptomatic at birth, even those who are symptomatic are not always diagnosed in time. Newborn dried blood-spot (DBS) specimens collected routinely at birth, have been recently used for retrospective diagnosis of cCMV. Our objective was to assess the clinical characteristics of children retrospectively diagnosed with cCMV using DBS polymerase chain reaction (PCR) testing, and report whether an early diagnosis could have been achieved. METHODS: A retrospective data collection study comprising all infants followed at a dedicated cCMV clinic diagnosed between 2014 and 2019 by the DBS PCR test RESULTS: During the study period, 436 children were born with cCMV and 19 (4.4%) were diagnosed with cCMV by the DBS PCR test. 9/19 were diagnosed before the age of 3 months; 3 of them were diagnosed after the neonatal period, although significant findings suggestive of cCMV were present at birth. 10/19 were diagnosed between 3 and 36 months of age; 6 of these 10 exhibited findings suggestive of cCMV at birth . In total, 8/19 children suffered from long-term sequela, including severe hearing loss or profound developmental delay. CONCLUSIONS: We report the numerous missed opportunities for early diagnosis and treatment of children with cCMV. Universal newborn screening for cCMV may have prevented poor hearing and developmental outcomes in 8 of the 19 children described herein.

Children post liver transplantation hospitalized with fever are at a high risk for bacterial infections.

BACKGROUND: Although infections post liver transplantation are a main cause of morbidity and mortality, data are limited on transplanted children. The objective of this study was to investigate the incidence, etiology, and predictors of infection in pediatric liver transplant recipients (LTR) in the specific practical clinical setting of hospitalization for fever in order to elucidate the appropriate management of these patients. METHODS: Clinical and laboratory data were retrospectively collected for all febrile pediatric LTR hospitalized from 2004 to 2012. RESULTS: We analyzed 133 hospital admissions for fever among 44 pediatric LTR. Of these, 73 bacterial (54.8%) and 46 viral infections (34.5%) were diagnosed. No cases of protozoa or fungal infections were reported. Bacterial infections were most frequent during the first year post transplantation with ascending cholangitis being the most prevalent. Twenty-six (36%) bacterial infections were microbiologically documented and 47 (64%) were clinically documented. Of the microbiologically confirmed cases, gram-negative bacteria, namely Enterobacteriaceae, were most common (57.7%). Seven cases of bacteremia were observed including 1 case presenting with severe sepsis. Compared with the white blood cell count and absolute neutrophil count, C-reactive protein level was found to be a more sensitive biomarker for bacterial disease. Older age on admission was a significant risk factor for bacterial infection. CONCLUSION: Febrile hospitalized pediatric LTR are immunocompromised hosts at high risk for bacterial infections, and usually warrant prompt evaluation and empirical antibiotic treatment upon admission.

Hepatic involvement in congenital cytomegalovirus infection - infrequent yet significant.

Congenital cytomegalovirus (cCMV) infection can reside in many organ systems; however, the virus has a particular predilection towards inhabiting the reticuloendothelial system, especially the liver. Specific studies focusing only on hepatic involvement in infants with cCMV are lacking. We report our experience with a large cohort of infants treated in our hospital clinic due to cCMV and hepatic involvement. Hepatic involvement was defined either as hepatitis (elevated alanine transaminases (ALT) >80 units/L without cholestatic disease) or cholestatic disease (elevated ALT >80 units/L combined with direct bilirubin >2 mg/dL). During the study period, 198 infants were diagnosed with symptomatic cCMV in our clinic. Hepatic involvement was observed in 13 infants (6.6%); 7 (3.5%) with hepatitis and 6 (3%) with cholestatic disease. Maternal primary infection with cytomegalovirus during pregnancy was diagnosed in 7 (53.8%) of the 13 infants, nonprimary in 3 (23.1%) and unknown in 3 (23.1%). Among these 13 infants, central nervous system (CNS) involvement was observed in 11 (84.6%) and hearing impairment in 7 (53.8%). Treatment with an antiviral agent was initiated in all cases. Gradual improvement of hepatic enzymes and cholestasis was observed over a prolonged period. We found that the incidence of hepatic involvement in infants with cCMV is much less frequent than previously reported. The hepatic involvement in these infants may manifest in two different ways, and thus, a high index of suspicion and a stepwise approach will help in correctly diagnosing these infants. Antiviral treatment due to CNS involvement is warranted and prognosis is excellent.

Risk factors for colonization with extended-spectrum beta-lactamase-producing enterobacteriaceae on admission to rehabilitation centres.

Patients newly admitted to rehabilitation centres are at high risk of colonization with multidrug-resistant bacteria because many of them have experienced prolonged stays in other healthcare settings and have had high exposure to antibiotics. We conducted a prospective study to determine the prevalence of and risk factors for colonization with extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL-PE) in this population. Subjects were screened by rectal swab for ESBL-PE within 2 days of admission. Swabs were plated on chromagar ESBL plates and the presence of ESBL was verified by a central laboratory. A multilevel mixed effects model was used to identify risk factors for ESBL-PE colonization. Of 2873 patients screened, 748 (26.0%) were positive for ESBL-PE. The variables identified as independently associated with ESBL-PE colonization were: recent stay in an acute-care hospital for over 2 weeks (OR=1.34; 95% CI, 1.12, 1.6), history of colonization with ESBL-PE (OR=2.97; 95% CI, 1.99, 4.43), unconsciousness on admission (OR=2.59; 95% CI, 1.55, 4.34), surgery or invasive procedure in the past year (OR=1.49; 95% CI, 1.2, 1.86) and antibiotic treatment in the past month (OR=1.80; 95% CI, 1.45, 2.22). The predictive accuracy of the model was low (area under the ROC curve 0.656). These results indicate that ESBL-PE colonization is common upon admission to rehabilitation centres. Some risk factors for ESBL-PE colonization are similar to those described previously; however, newly identified factors may be specific to rehabilitation populations. The high prevalence and low ability to stratify by risk factors may guide infection control and empirical treatment strategies in rehabilitation settings.

Outbreak of multidrug-resistant Pseudomonas aeruginosa infection following urodynamic studies traced to contaminated transducer.

We report a nosocomial outbreak of urinary tract infection by extremely drug resistant Pseudomonas aeruginosa, susceptible only to colistin. Infection in three patients followed urodynamic studies. Two of the three patients were children, one of whom also developed urosepsis. The investigation led to detection of contaminated pressure transducers. Genotyping confirmed that patient and transducer isolates were identical. These transducers were not labelled as 'single use only' despite the possibility that contaminated urine may reflux and mix with the fluid in the device. The issue of re-usable versus single-use urodynamic devices is discussed.

Carriage of methicillin-resistant Staphylococcus aureus on admission to European rehabilitation centres--a prospective study.

This study aimed to determine the prevalence of and risk factors for methicillin-resistant Staphylococcus aureus (MRSA) carriage among patients newly admitted to rehabilitation centres. It is a prospective study examining MRSA carriage on admission to seven rehabilitation wards in four countries. Risk factors for MRSA carriage were analysed using univariate and multivariate analyses. A total of 1204 patients were studied. Among them, 105 (8.7%) had a positive admission MRSA screening result. The MRSA carriers were more likely to be male, to have had a recent stay in another long-term-care facility or >2 weeks acute-care hospital stay, history of colonization with MRSA, reduced level of consciousness, peripheral vascular disease and pressure sores. In multivariable logistic regression male gender (odds ratio (OR) 2.2, 95% confidence interval (CI) 1.4-3.6, p 0.001), history of MRSA positivity (OR 6.8, 95% CI 3.8-12.3, p <0.001), peripheral vascular disease (OR 2.5, 95% CI 1.2-5, p 0.013), recent stay in another long-term-care facility (OR 2.1, 95% CI 1.3-3.5, p 0.004), or long (>2 weeks) acute-care hospital stay (OR 1.9, 95% CI 1.2-3, p 0.004), remained significant risk factors for MRSA carriage. MRSA carriage is common on admission to rehabilitation centres but less so, than previously described in long-term-care facilities. Male gender, history of MRSA positivity, previous hospitalization and peripheral vascular disease may predict MRSA carriage, and may serve as indicators for using pre-emptive infection control measures.

Treatment of Achilles tendon calcinosis in juvenile dermatomyositis with external ilizarov fixator.

Calcinosis is a devastating complication of juvenile dermatomyositis and a challenging therapeutic problem. We report the use of an external Ilizarov fixator for the treatment of Achilles tendon calcinosis causing severe disability in a young girl with juvenile dermatomyositis.