When a Critically Ill Child is Oceans Away From a PICU: A Military Pediatric CCAT Mission.

A 4-year-old former 26-week premature male presented to the U.S. Naval Hospital Guam emergency department in respiratory failure secondary to human metapneumovirus requiring urgent intubation. His condition was complicated by a bradycardic arrest requiring 15 minutes of resuscitation before the return of circulation. He was admitted to the adult intensive care unit and was managed via pediatric telecritical care from San Diego. He developed acute respiratory distress syndrome, acute renal failure, hypotension requiring multiple pressors, and fluid overload necessitating bilateral chest tubes and two peritoneal drains. A pediatric critical care air transport team departed San Antonio within 36 hours of activation and transported the patient via C-17 to Hawaii, performing a tail swap to a KC-135. Before takeoff, mechanical delays caused prolonged ground time and lack of temperature control resulted in patient's hyperthermia to reach 104.2°F despite the ice packing. The ambient temperature caused equipment malfunction (suction, handheld blood analyzer, and ventilator), necessitating manual bagging. Despite initial temperature challenges, the team removed 700 mL of peritoneal fluid and substantially reduced the patient's ventilator settings. After 22 hours of care, the team arrived with the patient to a civilian pediatric intensive care unit in CA, USA. Over several weeks, the patient made a full recovery. This pediatric critical care air transport mission highlights the complications intrinsic to air transport. Missions of this severity and length benefit from utilization of pediatric specialists to minimize morbidity and mortality. Highlighting the challenges related to preparation, air frame, and equipment malfunction should help others prepare for future pediatric air transports.

Comparing outcomes among outpatients treated for pyelonephritis with oral cephalosporins versus first-line agents.

Fluoroquinolones and trimethoprim/sulfamethoxazole (TMP-SMX) are first-line agents for acute pyelonephritis. Oral ß-lactams are second-line agents owing to reported lower efficacy rates, primarily seen with aminopenicillins rather than cephalosporins. The increase in resistance rates and adverse effects associated with first-line agents provides justification to reconsider oral cephalosporins for pyelonephritis. Therefore, the objective of this study was to determine whether there is a difference in urinary tract infection (UTI) recurrence rates between oral cephalosporins and first-line agents in the treatment of acute pyelonephritis. This was a retrospective, single-centre, observational cohort study from 1 December 2018 to 31 May 2020. The study population was adult TRICARE beneficiaries with a diagnosis of acute pyelonephritis who were treated with oral antibiotics. The two cohorts compared were first-line antibiotics (ciprofloxacin, levofloxacin and TMP-SMX) and oral cephalosporins. The primary outcome was UTI recurrence rate at 30 days, which was defined as a repeat clinic visit, emergency department visit or hospital admission for a UTI (cystitis or pyelonephritis). The secondary outcome was to determine independent risk factors for UTI recurrence. A total of 268 cephalosporin and 211 first-line cases were included. The primary composite outcome of UTI recurrence within 30 days occurred in 44 (16%) cephalosporin and 36 (17%) first-line cases (P = 0.851). Independent risk factors for UTI recurrence were chronic kidney disease and Klebsiella spp. isolation. In conclusion, there was no significant difference in UTI recurrence rates between oral cephalosporins and first-line agents in the treatment of acute pyelonephritis in the outpatient setting.