Welcome to our educational modules for Pediatric Transplant Infectious Diseases, developed in collaboration with the Pediatric Infectious Diseases Society and the American Society for Transplantation. We recognized that this specialized area of pediatric ID care is a rapidly changing and growing practice area, with few resources to help us in management. The modules are intended to help pediatric ID fellows and faculty in their management of these patients.

Pediatric Transplant Infectious Diseases Educational Modules

The recent issue of JPIDS featured a notable study by Hysmith et al which makes us rethink our approach of differentiating between “harmless” pharyngeal carriage of group A streptococcus (GAS) versus actual infection. The study longitudinally assesses the human immune response to natural infection with GAS [1], and as Shulman et al point out in their accompanying editorial, the findings challenge our current understanding of pharyngeal colonization versus infection with GAS, and the immunologic responses associated with colonization versus infection [2].

Taking a subset of subjects from a larger study conducted at multiple U.S. academic centers, they looked at 41 children who experienced 51 new pharyngeal acquisitions of GAS during a two year study period [3, 4]. They defined a new acquisition as a throat culture that was positive for an emm type of GAS that had not been isolated previously, with a subsequent immune response to 1 or more of the antigens studied. The 31 GAS antigens studied included 18 M peptides and 13 other shared GAS antigens, chosen based on previous studies that indicated their immunogenicity and potential as vaccine candidates, and included streptolysin O (SLO) and deoxyribonuclease B (DNaseB). They evaluated serial throat cultures and 195 serum samples obtained on enrollment and at scheduled intervals throughout the study and when subjects had signs or symptoms of pharyngitis. Salient results included the following:

  • 32 (63%) of the 51 episodes produced an antibody response to the homologous M peptide (i.e. the M type of the strain cultured from the throat produced an antibody response to the same M type in the serum).
  • No subjects had a new acquisition of an M type against which they had preexisting antibodies to the homologous M type.
  • 65% of subjects with new acquisition of GAS were asymptomatic, but mounted immune responses to 1 or more (average 3.7) antigens.
  • 67% of new GAS acquisitions elicited an immune response to SLO and/or DNaseB.
  • 8 (20%) subjects had persistently positive throat culture results (>12 weeks) despite immune responses to homologous M peptides and/or shared antigens.
  • No shared antigen consistently evoked an immune response after a new GAS acquisition.

Given their observation that 65% of subjects had asymptomatic GAS acquisition, yet mounted an immune response to the acquisition, the majority of infections would not be detected based on symptoms alone, and therefore could cause missed opportunities for antimicrobial treatment and prevention of rheumatic fever and rheumatic heart disease. In addition, not all patients actually mount a response to SLO and/or DNaseB, the most commonly used commercially available GAS antibody tests used in the evaluation of patients with suspected acute rheumatic fever or post-streptococcal glomerulonephritis. This means that a negative ASO and/or DNaseB test does not necessarily prove a patient did not have a prior GAS infection and suggests a need to expand the panel of tests available for the clinical evaluation of patients for post-streptococcal nonsuppurative complications.

Shulman et al point out that the study gives us some answers, but also raises important questions that “challenge long standing dogma” for us in how to best prevent the sequelae of GAS [2]. They highlight the bottom line that “(1) anti-M protein protects against a new acquisition of GAS in a type-specific fashion; (2) our previous concepts about a significant GAS acquisition requiring demonstrable increases in antibodies to non-M protein antigens and/or to M protein antigens may not be true and (3) whether or not a new GAS acquisition is significant—risk for post-streptococcal sequelae, whether or not a new GAS acquisition is significant appears to be unrelated to symptomatic or symptomatic acquisition status, whether or not antibiotics were administered promptly, and whether there was or was not a clear immune response to classical streptococcal antigens.”

So perhaps to answer “Where do we go from here?” the first step is for clinicians to be aware of these important findings in their management of patients and assessment of post-streptococcal sequelae. It remains to be seen how these findings and the work that comes after will impact the availability of other GAS serologic tests, changes in GAS treatment guidelines, and the development of a GAS vaccine.

References:

  1. Hysmith ND, Kaplan E, Cleary PP, et al. Prospective Longitudinal Analysis of Immune Responses in Pediatric Subjects After Pharyngeal Acquisition of Group A Streptococci. Journal of the Pediatric Infectious Diseases Society 2017;6(2):187–96.
  2. Shulman ST, Tanz RR. Strep: Where Do We Go From Here? Journal of the Pediatric Infectious Diseases Society 2017;6 (2):197–8.
  3. Kurlan R, Johnson D, Kaplan EL. Streptococcal infection and exacerbations of childhood tics and obsessive-compulsive symptoms: a prospective blinded cohort study. Pediatrics 2008; 121:1188–97.
  4. Leckman JF, King RA, Gilbert DL, et al. Streptococcal upper respiratory tract infections and exacerbations of tic and obsessive-compulsive symptoms: a prospective longitudinal study. J Am Acad Child Adolesc Psychiatry 2011; 50:108–18 e3.

As you may know, San Diego has had a rise in Hepatitis A cases, primarily among its homeless population. We are confident that travel to San Diego is safe.

We do urge visitors to follow standard good hygiene, washing your hands before eating. Vaccines to prevent Hepatitis A are also available and non-health professionals should consult their doctor or other health professional.

After a brief warm welcome from our host Jason Newland, MD, from Washington University in St. Louis, the conference began with the much requested “ASP Basic Workshop”. Sarah Parker, MD, Children’s Hospital Colorado, explained how to use the antimicrobial stewardship “elevator speech” to develop a business plan and described successful strategies to pitch antimicrobial stewardship to the C-suite. Her pharmacy counterpart from Children’s Hospital Colorado, Amanda Hurst, PharmD, then outlined the ASP pharmacists’ role(s) as a jack of all trades, explained to new ASP pharmacists basic tools and understanding of what this role can accomplish, while illustrated to experienced ASP pharmacists concrete examples of the “handshake stewardship” model that has been so successful at her institution. Pranita Tamma, MD, from Johns Hopkins led a case-based discussion reviewing resistance mechanisms among gram negative bacteria and highlighted the latest literature supporting treatment options for patients with multidrug resistant gram negative infections including new antibiotics on the horizon such as plazomicin, fosfomycin, and aztretonam-avibactam. The addition of breakout sessions this year allowed an opportunity for physicians, pharmacists, and trainees to bring forth questions to their individual breakout groups for free discussion. These unstructured discussions facilitated the opportunity to informally benchmark and gauge how our peers approach common antimicrobial stewardship challenges and provided volumes of useful information.

In the afternoon, the “ASP Academic Conference” started off with duo David Hyun, MD, and Holly Maples, PharmD, returned for the popular annual “Literature Support for Antimicrobial Stewardship", and reviewed their selected “top ten” papers of the year relevant to pediatric antimicrobial stewardship. Dr. Hurst returned to the podium to discuss how to maximize pharmacokinetics and pharmacodynamics (including a compare/contrast of oral third generation cephalosporins) for the treatment of infections.

The PIDS Antimicrobial Stewardship Fellowship Award supports the development of future researchers in pediatric antimicrobial stewardship by providing mentorship to complete a scholarly research project during fellowship or residency. The project(s) awarded should be completed in one year, and the award provides travel funds to present their work at this annual conference.

The 2016 awardees delivered outstanding presentations of their work:

  • Kathleen Chiotos, MD, Children’s Hospital of Philadelphia “Empiric Antibiotic Use in Pediatrics: A Potential Opportunity for Antibiotic Stewardship”
  • Dustin Flannery, MD, Children’s Hospital of Philadelphia “Temporal Trends in Antibiotic Use for Risk of Early-Onset Sepsis Among Very Premature Infants Across the United States” and
  • Anna Sick-Samuels, MD, Johns Hopkins University “Characterizing Risk Factors for Multidrug-Resistant Gram-Negative Bloodstream Infections in Children”.

Concluding the first day of the conference, panel members Drs. Parker, Hurst, Tamma, and Maples answered live and tweeted questions addressing current issues in antimicrobial stewardship. Networking and fun continued through the evening as Washington University hosted a dinner at the Westin hotel (and several groups migrated thereafter to watch NBA finals and/or the Spelling Bee Championship.)

The second day of the conference focused on national efforts in antimicrobial stewardship. Barbara Warner, MD, Washington University/St. Louis Children’s Hospital, discussed the relationship between the neonatal microbiome and neonatal enterocolitis and the difficult balance between promoting “good” organisms while preventing “bad” organisms. Jeffrey Linder, MD, MPH, Northwestern, presented developments in outpatient antimicrobial prescribing and behavioral approaches, including a brief overview of the BEARI trial (“You are a top performer” vs. “You are not a top performer”). Katherine Fleming-Dutra, MD, returned with an update on the CDC’s continuing national antimicrobial stewardship efforts. She demonstrated the CDC’s interactive map of antimicrobial prescribing and the rate of acute care hospitals meeting the proposed core elements. She also informed the audience that “Get Smart about Antibiotics Weeks” is going to undergo some rebranding (to “Antibiotic Awareness Week”) and asked us to join in on the efforts November 13-19. David Hyun, MD, in a return performance,  presented on the changing legislative and policy landscape affecting antimicrobial stewardship, highlighting potential effects of altering the Affordable Healthcare Act as well as Centers for Medicaid and Medicare Services proposed hospital requirements for antimicrobial stewardship that appear to be on hold.

Several abstracts are submitted for poster presentation and a few are selected for oral presentation in the afternoon. This year, abstracts were presented by:

  • Heidi Andersen, MD, MS, Cincinnati Children’s Hospital Medical Center “Precision metagenomics detects colonization, invasion and transmission of multidrug-resistant bacteria”
  • Kevin Messacar, MD, Children’s Hospital Colorado “Development of an integrated diagnostic and antimicrobial stewardship approach to rapid diagnostic testing in children with suspected central nervous system infections”
  • Katherine Cook, PharmD, Monroe Carell Jr. Children’s Hospital at Vanderbilt, “Incidence of Nephrotoxicity among pediatric patients receiving vancomycin with either piperacillin/tazobactam or cefepime”
  • Jason Child, PharmD, Children’s Hospital Colorado, “Pharmacokinetic and pharmacodynamics properties of metronidazole in pediatric patients with acute appendicitis”
  • Kathryn Timberlake, PharmD,The Hospital for Sick Children, “Reducing vancomycin in the neonatal intensive care unit” 

Jason Newland, MD, MEd rounded out the meeting with an update of the Sharing Antimicrobial Reports for Pediatric Stewardship (SHARPS) collaborative. The collaborative initially started with handful of children’s hospitals throughout the US and now has grown to include 45 pediatric institutions! Participants in the SHARPS collaborative attend a monthly webinar presented by other members of the group and meet annually prior to the pediatric antimicrobial stewardship meeting.

After eight years and a change in location (bye, Kansas City – hello, St. Louis!), the International Pediatric Antimicrobial Stewardship Conference continues to grow and expand. Additionally, with an increasing legislative and regulatory support for antimicrobial stewardship, it continues to be a wonderful resource for both new and experienced practitioners.

Written By: 

Rana Hamdy, MD, MPH, Children's National Health System
Diana Yu, PharmD, Doernbecher Children's Hospital

In the recent issue of the Journal of the Pediatric Infectious Diseases Society, Paydar-Darian et al examine the role of lumbar puncture (LP) on management of children with facial palsy in a Lyme endemic area (1). The authors performed a retrospective cross sectional study of 620 children with peripheral facial palsy who presented to a single emergency department in a Lyme disease endemic area. Case of Lyme associated facial palsy was defined as the presence of clinically diagnosed erythema migrans or positive 2 tier serology test. The primary outcome was whether an LP was performed. Of 620 unique patients, 211 had facial palsy due to Lyme disease. Other causes of facial palsy included mastoiditis, otitis media, trauma and presumptive herpes simplex infection. Clinicians were more likely to perform LP on patients presenting with headache, meningitis and during summer months. The median cerebrospinal fluid (CSF) count was higher among patients with Lyme disease compared to other patients, 61 cells/mm3 (IQR 18-155) vs 2 cells/mm3 (IQR 1-3 cells/mm3). Majority, 70 (86%) of patients with Lyme disease had CSF pleocytosis. Children who underwent LP were more likely to have received parenteral antibiotics 71/149 (63%) LP performed vs 6/80 (2%) no LP performed and were more likely to be hospitalized 87/140 ( 62%) LP performed vs 29/480 (6%) LP not performed. The authors conclude that LP maybe useful in patients with unknown cause of meningitis but question its utility for patients with confirmed Lyme infection (1).

This study addresses an important clinical dilemma regarding a need for LP in patients with facial palsy due to suspected Lyme disease. LP is recommended for patients with facial palsy and symptoms consistent meningitis. For patients with CSF pleocytosis, the AAP Committee on Infectious Diseases Red Book committee recommends ceftriaxone or cefotaxime. Oral doxycycline is recommended for patients with severe allergy to cephalosporins as an alternative to cephalosporin desensitization (2). Multiple European studies showed that oral doxycyline is an acceptable alternative to parenteral antibiotics for treatment of neuroboreliosis. Oral doxycycline is inexpensive, rapidly absorbed and its bioavailability (when taken on empty stomach) is excellent (>90%), (3). CNS penetration exceeds the estimated MIC for B burgdorferi (4). Given the morbidity associated with the use of peripherally inserted central catheters (5) and unclear benefit of parenteral antibiotics over oral doxycycline, their use is increasingly questioned (1, 6). Oral doxycycline has been shown to be effective in treating facial palsy and meningitis due to Lyme disease in European pediatric and adult populations but data from the US are lacking. Lyme neuroboreliosis in Europe is primarily caused by B garinii and or B afzelii. It is not clear whether this experience can be extrapolated to the US population where neuroboreliosis is caused by B burgdorferii sensu stricto. The clinical efficacy of oral doxycycline in US Lyme neuroborreliosis should be further examined.

So which patients need LP?  Patients who present with meningitis and facial palsy due to unknown cause or who are ill appearing should undergo a diagnostic LP in order to determine etiology and best treatment. Advent of CSF multiplex PCR panels aid in rapid diagnosis of common causes of meningitis and further increase the utility of LP. Patients with facial palsy without meningitis can be safely treated with oral antibiotics. Because patients with Lyme facial palsy often have CSF pleocytosis even in the absence of symptoms of meningitis, and can be safely treated with oral doxycycline, it is unclear what if any benefit LP adds to management of patients with known Lyme neuroborreliosis. Prospective comparative studies conducted in the US focusing on neuroborreliosis in older pediatric patients with CSF pleocytosis would assist clinicians in evidence based decisions regarding the safety and efficacy of oral doxycycline and the need for LP.

Written by: Jana Shaw, MD, MPH, SUNY Upstate Medical University

References

  1. Paydar-Darian N, Kimia AA, Lantos PM et al. Diagnostic Lumbar Puncture Among Children With Facial Palsy in a Lyme Disease Endemic Area. J Pediatric Infect Dis Soc. 2017; 6: 205-208.
  2. Lyme disease. In: Kimberlin DW, Jackson MA, Long SS, ed. Red Book: 2015 Report of the Committee on Infectious Diseases. 30 ed. Elk Grove Village, IL. American Academy of Pediatrics 2015:516-523.
  3. Saivin SHouin G. Clinical pharmacokinetics of doxycycline and minocycline. Clin Pharmacokinet. 1988 Dec;15(6):355-66.
  4. Dotevall L, Hagberg L. Successful oral doxycycline treatment of Lyme disease-associated facial palsy and meningitis. Clin Infect Dis 1999; 28: 569–74.
  5. Thompson ADCohn KAShah SS et al. Treatment complications in children with Lyme meningitis. Pediatr Infect Dis J. 2012; 31:1032-5.
  6. Wormser GP, Dattwyler RJ, Shapiro ED, et al. The clinical assessment, treatment, and prevention of Lyme disease, human granulocytic anaplasmosis, and babesiosis: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2006; 43:1089–134.
  7. Dotevall L, Hargberg L. Penetration of Doxycycline into Cerebrospinal Fluid in Patients Treated for Suspected Lyme Neuroborreliosis . Antimicrob Agents Chemoth.1989; 33: 1078-1080

Following the introduction of routine childhood vaccination against rotavirus, a common cause of diarrheal illness, more than 380,000 children avoided hospitalization for diarrhea from 2008 to 2013 in the U.S., thus saving an estimated $1.2 billion in direct medical costs. The estimates, from a new study published in the Journal of the Pediatric Infectious Diseases Society, provide additional evidence for the substantial impact of routine rotavirus vaccination. They also suggest even greater benefits from immunization if other avoided costs were to be considered.

For the study, researchers analyzed data from community and academic hospitals in 26 states, focusing on hospitalizations for acute gastroenteritis among children under 5 years old, to estimate the impact of rotavirus vaccination nationwide. They compared periods before and after vaccination licensure in 2006, excluding the first year during which vaccine coverage rates were low and uneven. Following the start of routine rotavirus vaccination in 2006, diarrhea hospitalizations decreased by between 31 percent to 55 percent from 2008 to 2013, with greater reductions in the later years. The researchers estimated that more than 380,000 hospitalizations for severe diarrhea in children younger than 5 were avoided across the U.S. during this six-year period.

“Our findings confirm the sustained impact and effectiveness of the rotavirus vaccine program,” said author Eyal Leshem, MD, formerly of the Centers for Disease Control and Prevention (CDC) at the time of the study and who is currently affiliated with the Sackler Faculty of Medicine at Tel-Aviv University in Israel. “Increasing vaccine coverage likely resulted in the larger declines of rotavirus hospitalizations observed in the later years studied.”

The researchers estimated that the direct medical cost savings from avoided hospitalizations for diarrhea in infants and young children were $1.2 billion nationwide during the 2008-2013 period. This amount likely underestimates the overall economic impact, the study authors noted, because other costs, such as those associated with averted doctor’s office or emergency room visits for rotavirus disease, were not included in their analysis.

In 2015, an estimated 73 percent of U.S. children 19-35 months old received rotavirus vaccines, lower than rates for other routine childhood vaccines, including the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine, which 95 percent of the children in this same age group received, according to CDC. Future research should explore the reasons behind the lower than optimal rotavirus immunization rates and interventions to improve them, Dr. Leshem said. “Efforts to further increase rotavirus vaccine coverage rates to better protect all children in the U.S. against rotavirus disease should continue.”

Fast Facts

  • Rotavirus is a common cause of diarrheal illness in infants and young children in the United States.
  • Diarrhea hospitalizations in U.S. children under 5 decreased by between 31 percent and 55 percent from 2008 to 2013, following the start of routine rotavirus vaccination in 2006.
  • Researchers estimated that more than 380,000 diarrhea hospitalizations were averted nationwide during this six-year period, saving an estimated $1.2 billion in direct medical costs.

Click here to read the study published in the Journal of the Pediatric Infectious Diseases Society. 

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Published quarterly, the Journal of the Pediatric Infectious Diseases Society represents the spectrum of peer-reviewed, scientific and clinical information on perinatal, childhood, and adolescent infectious diseases. The journal is a publication of the Pediatric Infectious Diseases Society (PIDS), the world's largest professional organization of experts in the care and prevention of infectious diseases in children.

PIDS membership encompasses leaders across the global scientific and public health spectrum, including clinical care, advocacy, academics, government, and the pharmaceutical industry. From fellowship training to continuing medical education, research, regulatory issues and guideline development, PIDS members are the core professionals advocating for the improved health of children with infectious diseases both nationally and around the world, participating in critical public health and medical professional advisory committees that determine the treatment and prevention of infectious diseases, immunization practices in children, and the education of pediatricians. For more information, visit http://www.pids.org.

Remarks of HIVMA Board Chair Wendy Armstrong, MD, FIDSA:

As the U.S. Senate considers action on the “Better Care Reconciliation Act of 2017,” the HIV Medicine Association, Infectious Diseases Society of America and the Pediatric Infectious Diseases Society are releasing a position paper on the Medicaid Program and the pivotal role the program plays in public health and providing access to necessary services and treatment for people living with HIV. The Policy Statement on the Medicaid Program, Public Health and Access to HIV Care is here.

The policy positions articulated in the paper reflect the individual and public health imperatives of uninterrupted access to medical services and to antiretroviral treatment for people living with HIV, and the benefits that have been realized since the Medicaid expansion under the Affordable Care Act.

The Medicaid program and more recently the Medicaid expansion have been pivotal to progress against the HIV epidemic in the U.S. because consistent access to care and treatment for people with HIV allows them to stay healthy, have a near normal life expectancies and prevents transmission of the virus. The program is important to preventing the transmission of HIV by pregnant women to their babies by providing access to care and treatment for low-income mothers and their newborns. Covering more than 40 percent of patients with HIV, the Medicaid program plays an essential role in improving the lives of people with HIV and in preventing new HIV infections.

At a time when the U.S. House of Representatives has approved deep cuts to Medicaid spending through a per person cap on federal funding and an end to the Medicaid expansion, when the Senate is close to taking similar actions without stakeholder input, the program’s importance to people with HIV, and to control the epidemic must be weighed. HIVMA, IDSA and PIDS recommend policies that:

  • Maintain the Medicaid Program as a program supported by an open-ended federal/state matching formula giving states flexibility to respond to disease outbreaks, increases in healthcare costs and to medical advances, including those seen in recent years in treatments for HIV, cancer, and hepatitis C;
  • Continue the Medicaid expansion with federal financing that will remain fixed at 90 percent of costs in 2020;
  • Ensure that Medicaid beneficiaries have access to the range of services they need to stay healthy by maintaining the current minimum benefits and coverage requirements and by expanding requirements to ensure all Medicaid beneficiaries have access to critical services, including preventive screenings, prescription drugs, mental health and substance use treatment;
  • Maintain protections that limit premiums and cost sharing based on income and continue to bar denial of medical care for failure to pay cost sharing for those enrollees with incomes under 100% of the federal poverty level;
  • Ensure access to adequate services so Medicaid beneficiaries can stay healthy and able to work, care for their families, and/or pursue educational and training opportunities without linking Medicaid eligibility to work requirements;
  • Continue support for waivers that allow states to evaluate innovative delivery systems as well as benefit and payment models that promote high quality, comprehensive, cost effective care;
  • And evaluate models for improving Medicaid provider payment equity.

About HIVMA

HIVMA is an organization of nearly 5,000 clinicians and researchers whose professional focus is HIV medicine. HIVMA’s mission is to promote quality in HIV care by advocating policies and supporting programs that ensure a comprehensive and humane response to the AIDS pandemic informed by science and social justice. Nested within the Infectious Diseases Society of America, HIVMA's work includes creating clinical and educational tools and resources; supporting clinical training and research opportunities to build HIV workforce capacity; and promoting policies and programs to improve access to HIV prevention and care.

About IDSA

The Infectious Diseases Society of America (IDSA) represents physicians, scientists and other health care professionals who specialize in infectious diseases. IDSA’s purpose is to improve the health of individuals, communities, and society by promoting excellence in patient care, education, research, public health, and prevention relating to infectious diseases.

About PIDS

PIDS is the world's largest organization of professionals dedicated to the treatment, control and eradication of infectious diseases affecting children. Membership is comprised of physicians, doctoral- level scientists and others who have trained or are in training in infectious diseases or its related disciplines, and who are identified with the discipline of pediatric infectious diseases or related disciplines through clinical practice, research, teaching and/or administration activities.

Pillars - PIDSThe PIDS 2017 Spring Business Meeting was held on Monday, May 8, in conjunction with the PAS Meeting, in San Francisco, California.  Dr. Janet Gilsdorf, PIDS President, gave her farewell report on the state of the Society.  She reminded members of PIDS’ vision and mission statements along with the 2015-2017 strategic pillars that derived from the 2015 strategic planning meeting.

Dr. Gilsdorf then provided a brief summary of activities for a few of the pillars.  She also thanked the PIDS Board of Directors, committee chairs, and liaisons for working so diligently to accomplish the Society’s mission. 

Next, Dr. Gilsdorf provided membership statistics for the last seven years noting the increase in the number of resident and medical student memberships in 2016-2017.  She then reminded members to pay their 2017 member dues if they had not already done so and introduced Dr. Charles Woods, Secretary-Treasurer, to update members on the financial status of PIDS.

PIDS End of Year Net Worth chartDr. Woods provided a list of all sources of revenue and the major expenses of the Society.  He then provided a comprehensive report of the operational and foundation accounts, concluding that PIDS’ 2016 “End of the Year Net Worth” is $2,934,927.

Dr. Gilsdorf then announced the 5th year anniversary of the Journal of the Pediatric Infectious Diseases Society (JPIDS), provided a brief snapshot of the journal’s accomplishments over the last 5 years, and thanked Dr. Theo Zaoutis, JPIDS Editor-in-Chief, for his leadership and the associate editors for their diligence in making the journal successful.

JPIDS Celebrates 5 yearsDr. Zaoutis expressed sincere gratitude to the Society for allowing him to serve as editor and noted that continued success relies heavily on manuscript submissions from PIDS members.  He then encouraged members to submit their original science to JPIDS.

Dr. Gilsdorf then announced the 2017 PIDS election results. 

  • Officers:  Dr. Kris Bryant, President-Elect and Dr. Buddy Creech, Secretary-Treasurer
  • Board of Directors Members-at-Large:  Dr. Jason Newland and Dr. Debra Palazzi
  • Nominations and Awards Committee:  Dr. Angela Campbell, Dr. Lara Danziger-Isakov, and Dr. John Williams

Congratulations to all!

2017-2019 AimsDr. Gilsdorf also thanked Drs. David Kimberlin and Buddy Creech for their service on the PIDS Board and thanked the Society for allowing her to serve as President for the past two years.  With that said, she announced Dr. Paul Spearman as the incoming PIDS President.  Dr. Spearman provided the PIDS Aims discussed at this year’s strategic planning meeting.  These Aims will govern the Society’s activities for the next two years.

A summary of the strategic planning meeting will be provided in the June issue of PIDSNews.  The business meeting concluded at 5:50 pm PDT. Click here to view the full business meeting slide presentation.

Vision Statement: Freedom from infections for all children through excellent clinical care, research, education and advocacy.

Mission Statement: To enhance the health of infants, children, and adolescents by promoting excellence in diagnosis, management and prevention of infectious diseases through clinical care, education, research and advocacy.

It has been my great honor to serve as PIDS President for the past two years and have been amazed at the generosity of our members in giving their time and expertise to PIDS’ many activities.

PIDS’ SEVEN FOCUS AREAS, OR PILLARS, BASED ON THE SPRING 2015 STRATEGIC PLANNING SESSION

PIDS leadership and staff have made great strides in developing and implementing projects directed at the seven focus areas that came out of the 2015 PIDS strategic planning session.  While some projects are still ongoing, PIDS has accomplished the following:

Pillar 1: Value of PID to the Healthcare System

  • Established Value of Pediatric Infectious Diseases Workgroup
    • The workgroup drafted a manuscript based on the results of the Value qualitative study.  The manuscript is currently under review.
    • The quantitative study to evaluate the impact of PID consultation on patient outcomes is currently in the data analysis phase.
    • The committee plans to author a white paper, based on these study results, to emphasize the value of PID.
    • The Value workgroup is also working to develop deliverables for disseminating to PIDS members.
  • Developed an opinion piece on what’s next for AS in pediatrics as well as a toolkit for small pediatric and community hospitals through input from the Pediatric Committee on Antibiotic Stewardship (PCAS).  Both projects are expected to be completed by the end of the year.
  • Established collaborative initiatives with AAP, IDSA, SHEA, and other organizations on AR and ASP.  Some initiatives include:
    • Developed  a white paper on ID Physician Leadership on ASP (in progress)
    • Collaborated with IDSA’s Multistakeholder Measure Development Workgroup to establish stewardship measures to report to CMS
    • Collaborated with Stakeholder Forum on Antimicrobial Resistance (S-FAR) Group (ongoing)
    • Established the AAP/PIDS Antimicrobial Resistance and Stewardship Workgroup to assess current practices that impact antimicrobial stewardship within pediatrics and develop educational programming for NCE (in progress)
    • Established the IDSA/SHEA/PIDS Stewardship Leadership Group to identify new collaborative initiatives as well as minimize overlap in activities with some of the same external organizations on various issues/at different times (ongoing)

Pillar 2: Recruitment of Future ID Pediatricians

  • Developed recruitment tools for utilization by pediatric infectious disease programs.  Efforts include:
    • Fellow Video Contest on “A Day in the Life of an ID Fellow”
    • Several videos of PIDS members telling their stories
      • What is a “Day in the Life of a Peds ID Doc?
      • How did you decide on this career path?
      • What parts of your career give you the great satisfaction?
      • How do you balance your professional and personal life?
      • How did Peds ID assist in advancing you to your current position?
      • What would you say to someone to encourage them to become a Pediatric ID specialist?
    • Message from the President – Membership Video
    • Updated career brochure
  • Worked with IDSA to enhance interest in ID as a specialty
  • Submitted NIH R13 Conference Grant for residents & students to attend St. Jude/PIDS conferences (funded) 

Pillar 3: Training & Guidance for PID Fellows

  • Developed Fellows’ Survival Guide, with templates for inquiring about job opportunities
  • Improved Fellows’ Day at IDWeek
  • Established very popular Fellows Networking Happy Hour at IDWeek 
  • Appointed fellows to committees/assigned projects
  • Developed  online educational modules (in progress)
  • Established Career Development sessions at St. Jude/PIDS conferences
  • ASP Basics Workshop at the ASP Conference

Pillar 4: Research activities related to PID

  • Increased fellowship/research award opportunities
  • Developed research opportunities for PIDS Transplant Network (in progress)
  • Implemented a clinical observership exchange program with ANZPID

Pillar 5: Engagement of new and established PIDS members

  • Increased visibility at meetings
  • Identified new member prospects (ongoing)
  • Created a digital archive and release it via Twitter, Facebook and the PIDS website 
  • Increased member involvement in committee activities
  • Increased international members

Pillar 6: Growth of the Pediatric Infectious Diseases Society Education and Research Foundation

  • Established the Resource Development Committee to assist staff in identifying potential funding opportunities (ongoing)
  • Expanded opportunities for philanthropic giving to the Foundation
  • Created the foundation website 
    • Who we are? 
    • Fellowship Infographics report to summarize the successful outcome of the Fellowship Awards Program and past fellowship award recipients 
    • Education and Research Programs
    • How to contribute with donation link

Pillar 7: Success of the Journal of Pediatric Infectious Diseases Society

  • Celebrated JPIDS’ fifth birthday 
  • Increased revenue
  • Increased visibility at meetings
  • Maintained manuscript submissions
  • Identified potential collaborations with international societies (ongoing)
  • Enhanced options for on-line only publication

It’s been a very productive two years.  We all look forward to the extremely capable leadership of our next President, Dr. Paul Spearman, in moving our Society into an even brighter tomorrow.

 

Attending conferences and symposia as pediatric infectious diseases fellows is usually an exciting and intellectually stimulating experience. Seeing advances in research presented, learning about varying topics from around the world, and meeting leaders in the field make any large gathering of infectious diseases physicians a great learning opportunity.

As a 3rd year fellow, after having the privilege of attending more than 10 conferences as a trainee at this point, I looked forward to the PIDS Transplant Symposium and Research Conference this year just a little more than all of the others. It has the added benefit above all others I’ve attended of being smaller, more manageable in size and schedule, and being specifically focused on the needs of fellows and early career infectious diseases physicians.

After learning from the presenters at the conference, I was then able to come back and share with my section at Tulane in New Orleans the numerous topics I had learned in my time in Memphis. I was able to discuss with them Dr. Ann Leen’s research on infusions of activated T-cells for preventing transplant-associated viral infections, present Dr. David O’Connor’s findings on Zika virus infection in a Rhesus Macaque model, and review Dr. Miriam Laufer’s research on malaria. Over the course of 1 of hour-long weekly section conferences, we also briefly discussed neonatal tolerance in solid organ transplantation, how the microbiome can affect bone marrow transplant patients, and the lack of effect of treatment of schistosomiasis in pregnant women.

The PIDS Transplant Symposium and Research Conference in Memphis has been a wonderful learning opportunity for me as a trainee, and my entire section has been very interested in learning from the topics presented each year, even if they are not in attendance. This wonderful learning opportunity from PIDS and St. Jude has benefited our entire group of Pediatric Infectious Diseases specialists at Tulane in New Orleans, and I know I will continue to look forward to attending and learning in the future!

Dr. Paul Spearman, President-elect of PIDS, gave a presentation to the Presidential Advisory Council on Combating Antibiotic-Resistant Bacteria (PACCARB) at HHS headquarters in Washington DC on January 25th. PACCARB is advisory to the administration, and is charged with gathering input and providing policy recommendations to fight antimicrobial resistance, and is chaired by Dr. Martin Blaser of NYU. Other organizations presenting in this public session included SHEA, APIC, IDSA, and ACGME. The focus of the session PIDS was asked to participate in was on workforce and education issues in Infection Prevention. As suggested by several of our PIDS leaders who work in this area, Dr. Spearman provided a pediatric-focused viewpoint of the unique aspects of infection prevention in the pediatric hospital and the pediatric ambulatory setting. He emphasized the need for infection prevention research that includes infants and children, and urged greater participation of pediatric ID specialists in formulating guidelines in this area. The need to maintain a strong pipeline of pediatric ID specialists who are trained in infection prevention and are poised to become leaders both locally and nationally was also emphasized. Council members were very engaged in this discussion, and are likely to include these pediatric ID-specific topics in their report to the President.

To view an archived webcast and minutes from the PACCARB meeting, please visit https://www.hhs.gov/ash/advisory-committees/paccarb/meetings/upcoming-meetings/january-25-2017-public-meeting/index.html

Infections caused by a type of bacteria resistant to multiple antibiotics are occurring more frequently in U.S. children and are associated with longer hospital stays and a trend towards greater risk of death, according to a new study published in the Journal of the Pediatric Infectious Diseases Society. Previously acquired mostly while children were already in the hospital, the new findings also suggest the infections--caused by bacteria from the Enterobacteriaceae family that are resistant to multiple drugs--may be spreading more often in the community.

"Antibiotic resistance increasingly threatens our ability to treat our children's infections," said study author Sharon B. Meropol, MD, PhD, of University Hospitals Rainbow Babies and Children's Hospital in Cleveland and Case Western Reserve University School of Medicine. "Efforts to control this trend are urgently needed from all of us, such as using antibiotics only when necessary, and eliminating agricultural use of antibiotics in healthy animals."

In the retrospective study, researchers analyzed data from 48 children's hospitals throughout the U.S., focusing on approximately 94,000 patients under the age of 18 who were diagnosed with Enterobacteriaceae-associated infections between 2007 and 2015. The proportion of these infections caused by bacteria that were resistant to multiple antibiotics increased from 0.2 percent in 2007 to 1.5 percent in 2015, a more than 700 percent increase in prevalence over the eight-year period.

Bacterial infections resistant to multiple drugs are especially concerning in children, for whom there are a limited number of stronger antibiotics currently approved for use compared to adults, putting kids at higher risk for worse outcomes. In the study, children with Enterobacteriaceae infections resistant to multiple antibiotics had hospitals stays that were 20 percent longer than patients with infections that were susceptible to antibiotics, the researchers found. The results also suggest a greater mortality risk among pediatric patients infected with the resistant strains, although the increased odds for death were not statistically significant.

Most of the resistant infections were present when the children were admitted to the hospital, suggesting the bacteria may be increasingly spreading in the community. Older kids, children with other health conditions, and those living in the Western U.S. were more likely to have the infections, the study found. The results build on previous research reporting rising rates of these infections in adults and outbreaks in hospitalized children, especially in less-developed countries in Latin America and Asia, where antibiotics are available over the counter.

Future research should focus on better ways to limit the transmission of resistant Enterobacteriaceae bacteria, including between hospitals and long-term care facilities and their communities, in addition to the development of new antibiotics that are safe and effective to use in children, Dr. Meropol said. "While the march of antibiotic resistance seems inexorable, informed and rigorous efforts to reverse this trend have been successful for other types of organisms, and are urgently needed within this context."

Fast Facts

  • Infections caused by a type of bacteria resistant to multiple antibiotics are increasing in U.S. children and are associated with longer hospital stays and a trend towards greater risk of death.
  • Caused by members of the Enterobacteriaceae family of bacteria that are resistant to multiple antibiotics, these infections may be increasingly spreading in the community, not just in hospitals.
  • Efforts to control rising antibiotic resistance, including the appropriate use of antibiotics in humans and animals, and the development of new antibiotics, are urgently needed.

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Editor's Note: The study was funded by the National Institute of Allergy and Infectious Diseases at the National Institutes of Health. 

In August, 2008, UpToDate®, in conjunction with Texas Children’s Hospital, established a series of pediatric subscription awards in honor of Dr Ralph David Feigin, who had been Editor-In-Chief of the Pediatrics Section of UpToDate since its inception in 1999.  The award program grants up to six, three-year subscriptions to UpToDate®  to physicians, other health care providers, or health care facilities that provide care to underserved or low-income children and who could not otherwise afford the subscription.  The deadline for applications is May 30; awardees will be announced in June; and the subscriptions will start in July, 2017. 

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Applicants must meet all four (A, B, C, and D) of the following qualifications.

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    3. a community or area designated by a governmental agency or governmental representative as medically underserved or qualifies as a health professional shortage area
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  • Deliver health care to children or health education to children and their families
  • Do not currently have access to UpToDate® and are unable to afford the initial one-year subscription of approximately $500 and the approximately $400 yearly renewal fee.
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Application Process

Applicants should complete the application below electronically.  Cells may be expanded as needed. 

Completed applications (as a word document) should be returned to Martin I Lorin, MD (This email address is being protected from spambots. You need JavaScript enabled to view it.) by May 30, 2017. Click here to download an application.

 

The first Antimicrobial Stewardship Research Workshop (ASRW) was held November 29-30, 2016, and was co-organized by Society of Healthcare Epidemiology of America, Infectious Diseases Society of America, Society of Infectious Diseases Pharmacists, Pediatric Infectious Diseases Society, and Centers for Diseases Control and Prevention and was supported by a grant from Merck. The audience was multidisciplinary with multiple backgrounds: teaching hospital, community, adult, pediatric, and industry. Additionally, the workshop had live following on Twitter, with the hashtag, #ASRW16.

The two-day workshop was filled with several topics, but gave a broad overview of the need for and challenges of studying antimicrobial stewardship. For the first half of the day, speakers set the stage of the antimicrobial stewardship research agenda: Drs. Lauri Hicks and Preeti Malani presented outpatient and inpatient stewardship research, respectively. For review of basic concepts of research, Dr. Ebbing Lautenbach provided an epidemiology toolbox presentation. Defining the right kind of question for research can be difficult and Dr. Vanessa Stevens walked the audience through various examples of good and bad research questions and the following presentation on the various areas of research in antimicrobial stewardship by Dr. Rebekah Moehring complemented it well. After this introductory morning, groups were encouraged to breakout and discuss different approached to a research question and included various themes, such as hospital vs. outpatient and internal vs. external funding of research.

For the second half of the day, the discussion focused further into the different aspects of research: Drs. Pranita Tamma and Jeffrey Linder presented on defining exposures, outcomes, and confounders of interest based on inpatient and outpatient settings, respectively. Dr. Marc Scheetz explained the nuances between research for generalized knowledge vs. quality improvement and assurances projects. The audience was introduced to how social sciences can be involved in antimicrobial stewardship, with Dr. Heather Reisinger giving an overview of implementation science and how the models may be able to be used in stewardship research. Dr. Stevens returned to discuss the pros and cons of health economics to evaluate stewardship programs and Dr. Julia Szymczak ended the evening with a vigorous reminder that there are many behavioral factors associated with antimicrobial prescribing and identification of these factors may help with implementation of stewardship interventions.

After a heavy first day, everyone returned bright-eyed for the second day, which was more concentrated on various strategies for evaluating antimicrobials stewardship interventions. Dr. Jessina McGregor explained the ins-and-outs of interrupted time series analysis and how they can be very helpful in evaluating programs; following that, Dr. Theoklis Zaoutis educated the audience of how the cohort design can be used for studying the impact of an intervention. Other assessment strategies were reviewed: Dr. Jonathon Edwards explained how the National Healthcare Safety Network (NSHN) will use the Antimicrobial Use and Resistance (AUR) report to benchmark antimicrobial usage through the standard antimicrobial administration ratio (SAAR), which was followed by Dr. Scott Fridkin’s presentation on what kind of metrics and comparisons should be used and how to include variation into assessment of programs.  Dr. Deverick Anderson highlighted the pitfalls of just relying on antimicrobial consumption as a metric and discussed how desirability of outcome ranking (DOOR) and response adjusted for duration of antibiotic risk (RADAR) may be able to shine more light on specific outcomes of interest.

After lunch, the final topic was to put all the different concepts together for a successful research program. Dr. Anderson returned to the stage to discuss the details needed for data management and common issues that arise when developing the components. Dr. Elizabeth Dodds-Ashley, Jeffrey Gerber, and Fridkin led an open discussion of different funding mechanisms for research in antimicrobial stewardship (NIH, AHRQ, professional societies, foundations, industry, etc.). Lastly, Dr. Malani wrapped up the workshop with a presentation on the importance of disseminating research and various mechanisms to maximize the audience reach.

Overall, the workshop seemed highly successful; the topics were broad which provided a great base for new researchers and reinforced concepts for more advanced researchers. Additionally, it provided concrete examples of multiple concepts that are used in antimicrobial stewardship research, as well as pitfalls in the current mechanisms of evaluation (e.g. duration of therapy) and areas in need of further development. The ASRW will continue to build, with projected meetings for 2017 (in Chicago) and 2018 (in Baltimore).

The Pediatric Infectious Diseases Society (PIDS) supports universal vaccination of children according to evidence-based policies as outlined by leading public health agencies and professional societies, including the Centers for Disease Control and Prevention (CDC), the Advisory Committee on Immunization Practices (ACIP), the American Academy of Pediatrics (AAP), the Infectious Diseases Society of America (IDSA), and many other reputable organizations.

PIDS stands behind the overwhelming scientific evidence showing that vaccines do not cause autism. It is dangerous to perpetuate this myth and doing so is likely to result in harm to our children from vaccine-preventable diseases. Statements by those claiming a connection between vaccines and autism with no scientific basis should be recognized as fraudulent and misleading. The false link between autism and vaccines was first popularized by Dr. Andrew Wakefield, a British physician who falsified data and later profited from his false theory. Dr. Wakefield’s work was proven to be fraudulent, his medical license was revoked, and he has been discredited by leading medical societies and medical journals.

Vaccines provide tremendous health benefits to individuals and to society. PIDS calls on our government leaders to recognize the overwhelming evidence showing the outstanding safety of childhood vaccines and to avoid the temptation to equate anecdotes with scientific evidence. We further call on our government leaders to avoid providing a hint of legitimacy to myths such as this one for which there is no scientific evidence. To do so will unnecessarily endanger the lives of American children.

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The Pediatric Infectious Diseases Society (PIDS) is the world’s largest professional organization of experts in the care and prevention of infectious diseases in children. PIDS membership includes leaders in clinical care, public health, academia, government, and industry who advocate for the improved health of children nationally and globally. The Society fulfills its mission through research, advocacy, guideline development, fellowship training, continuing medical education, its support of immunization practices in children, and The Journal of the Pediatric Infectious Diseases Society, its quarterly peer-reviewed publication. To learn more about PIDS, visit www.pids.org and follow PIDS on Facebook and Twitter.

 

If it has seemed like you’ve been seeing more cases of antibiotic-resistant Pseudomonas aeruginosa over the past few years, the study by Logan and colleagues suggests you may be right.  This retrospective study used data from the Surveillance Network Database to describe the epidemiology of Pseudomonas aeruginosa isolates from children and trends in antibiotic resistance from 1999-2012. This national network of clinical microbiology laboratories included data from 300 US hospitals diverse in location, size, and patient population. The analysis included isolates from children 1-17 years of age without a known diagnosis of cystic fibrosis. Per the definition by the Centers for Disease Control and Prevention, multidrug-resistance (MDR) was defined as nonsusceptibility to agents in 3 of the following 5 antimicrobial classes: cephalosporins, β-lactam/β-lactamase-inhibitor combination, carbapenems, fluoroquinolones, and aminoglycosides. Carbapenem-resistance (CR) was nonsusceptibility to at least 1 of the 3 agents in the cabapenem class (imipenem, meropenem, or doripenem).

The authors report a number of interesting findings. First, among 77,349 P. aeruginosa isolates included in the analysis approximately 20% were MDR, 11% were CR, and 8.4% were both MDR and CR. The highest proportions of MDR and CR P. aeruginosa isolates were from inpatient settings (especially those in an ICU), respiratory sources, and children 13-17 years old. Second, the overall trends indicate significant increases in both MDR and CR among P. aeruginosa isolates in the US. During the 13.5 year study period, the proportion of MDR isolates increased from 15.4% to 26% and the proportion of CR isolates more than doubled from 9.4% to 20%. This trend was observed in nearly all age categories and patient locations, the only exception being children 13-17 years old in an inpatient setting. As shown in figure 1, there were steady increases seen from 2010-2012 in both MDR and CR isolates. 

Finally, when examining resistance to individual antibiotics, rather than classes of antibiotics, some location-specific differences were seen. In the inpatient setting during the latter years of the study (2008-2012) the highest rates of resistance were seen to doripenem (27.6%), gentamicin (26.1%), cefepime (19.7%), ceftazidime (18.0%), and levofloxacin (16.9%). However, during the same time period in the outpatient setting the highest resistance rates were seen to gentamicin (28.4%), amikacin (21.8%), tobramycin (17.3%), ciprofloxacin (13.6%), and levofloxacin (13.1%). Additionally, significantly increasing resistance during the entire study period was seen to gentamicin and piperacillin-tazobactam in both inpatient and outpatient settings.

As noted in the manuscript, the reason for increasing rates of antibiotic resistance among P. aeruginosa isolates is likely multifactorial, with antibiotic usage, device usage, and increasing numbers of medically complex children all potentially playing a role. Given the limitations of the database, the authors were unable to differentiate colonization from infection and with respiratory isolates being the most common, some of these may represent colonization in patients with tracheostomy and/or ventilator dependence. Unfortunately, the Surveillance Network disbanded after 2012 so this study does not include data beyond 2012, which may be helpful in determining the impact of more widespread pediatric antimicrobial stewardship efforts. Despite the limitations, these findings highlight the importance of continued efforts in antimicrobial stewardship, as well as vigilance in infection prevention and control efforts to hopefully slow the spread of drug-resistant organisms.

Logan LK, Gandra S, Mandal S, Klein EY, Levinson J, Weinstein RA, Laxminarayan R. Multidrug-and Carbapenem-Resistant Pseudomonas aeruginosa in Children, United States, 1999–2012. Journal of the Pediatric Infectious Diseases Society. 2016 Nov 16