By: Rebecca Wallihan, MD

Between abundant vaccine myths and increasingly vocal anti-vaccine celebrities, it seems like an uphill battle each year to increase rates of influenza vaccination. This year we are faced with an additional challenge.

Written by Chris Nyquist, MD, MSPH

What is the value of Pediatric Infectious Disease fellowship training? Is the equation "Value equals Quality divided by Cost" valid? Is the Pediatrics journal article, "Does Fellowship Pay?" (Pediatrics 2011;127:254) describing a negative financial impact of over $800,000 associated with pursuing a career in Pediatric Infectious Diseases compared to a career in general pediatrics accurate?

As we look to creating our future and understanding where it may be progress, PIDS is sponsoring a qualitative research study to explore the value of Pediatric Infectious Disease Specialists. This important global look at perception of value, work force, and our role in healthcare of children will provide us with actionable measures but will also raise more questions for the future. Before the study is complete we must start the journey and individually recognize our own value as a Pediatric Infectious Disease Specialist. This is the first step to more effectively recruit and retain the best pediatricians to an infectious diseases fellowship and to assert the overall value of Pediatric Infectious Diseases.

Recruitment and Retention:

  • Relationships Matter. This year fellowship opportunities exceed the number of applicants for the positions. Think back to how you decided to pursue a career in Peds ID. Was it a passion for the topic? Was it the Peds ID Attending who you sought to emulate? My path was set when during my first rotation on the Pediatric Communicable Diseases ward as a third year medical student. I was involved in the care of an incredibly interesting patient who developed cutaneous coccidiomycosis in the arm after a glass cut at a cock fight in Texas. (PIDJ 1986;5:485-486. Read the article to find out the fascinating details). My attending, Dr. Janet Gilsdorf, taught me, inspired me, and became a lifetime mentor. This experience helped to cement my desire to become a pediatrician specializing in infectious diseases. The relationship I developed interviewing the patient and the family in addition to the research I did to better understand the etiology of the illness was the first bright spark of my interest in Pediatric Infectious Diseases. Relationships with patients and families and mentors can encourage us and drive us toward a career in Peds ID.
  • Mentorship is Important but Sponsorship is Critical. Mentors will help to guide you in your career but sponsors will give you opportunities that push you forward. In short, mentors advise; sponsors act. Hewlett states that, "Mentors act as a sounding board or a shoulder to cry on, offering advice as needed and support and guidance as requested; they expect very little in return. Sponsors, in contrast, are much more vested in their protégés, offering guidance and critical feedback because they believe in them." We need to continue to play both roles.
  • Jobs and Opportunities Abound. Basic research, clinical and translational research, patient care, hospital epidemiology, antimicrobial stewardship, public health and industry are all potential paths for a successful career in Pediatric Infectious Diseases. We need to continue to improve the diversity of our academy and encourage residents and fellows to pursue a fellowship in infectious disease.

The Value Equation:

  • Change is Constant. The health care system is continuing to change and the academy of Peds ID physicians must continue to adjust to meet these demands. The highest compliment is that you are often asked for a consult because your colleagues know that you will complete a comprehensive history, you will fully examine the patient and review the old records and lab results. The patient will thank you and the overall care will improve. We are a critical cog in the fulfillment of the IHI Triple Aim: improve the patient experience of care (including quality and satisfaction); improve the health of populations; and reduce the per capita cost of health care. We need to measure our outcomes and share this information with stakeholders.
  • Being Invisible is Not an Option. The hospital infrastructure is clearly supported by the work of Pediatric Infectious Diseases which ranges from antimicrobial stewardship, outpatient antimicrobial treatment, transplant and immunocompromised programs, the microbiology laboratory, infection prevention, vaccination programs to ultimately inpatient and outpatient care. Our scope is broad and the goal is to move from invisibility to clearly identifying and stating what we do to support the hospital infrastructure and academic enterprise.

Written by: Buddy Creech, MD, MPH

On my shelf are two staphylococcal books from the 1960s - Proceedings from Staphylococcal Symposia held at the the NY Academy of Sciences and in Warsaw, Poland.

ARLINGTON, Va. (October 31) – The Society for Healthcare Epidemiology of America (SHEA), the Infectious Disease Society of America (IDSA), the Association for Professionals in Infection Control and Epidemiology (APIC), the Pediatric Infectious Disease Society (PIDS), the HIV Medicine Association (HIVMA) and the Center for Global Health Policy remain opposed to mandatory quarantines being imposed on asymptomatic healthcare workers returning from Ebola-stricken countries in West Africa.

Written by: David Kimberlin, MD

At the PIDS Business Meeting held on October 10 at the 2014 IDWeek meeting, I shared good news about the state of the society and its numerous activities. Let me start by prefacing that PIDS continues to be financially stable. Our investment accounts are weaker than last year, but investments are not tapped for operating expenses and therefore are not impacting our current budget. PIDS leaders continue to press forward using the roadmap from the 2013 strategic planning session. The roadmap consists of four focus areas: 1) the value of pediatric infectious diseases as a subspecialty; 2) education and training for pediatric infectious specialists the future job markets; 3) communication to members and among members; and 4) the visibility of PIDS in the crowded marketplace of expertise that exists in this decade. Below is a list of activities that PIDS currently is doing or will soon undertake in the coming months as we focus on each of these areas.

Value of Pediatric ID as a Subspecialty

  • We have undertaken three separate studies to define the value of what we do in terms that department chairs, hospital administrators, and others will appreciate. To coordinate this effort, we created a Work Group to develop, implement, and analyze the studies.
  • At the outset, two focus group sessions at the 2013 IDWeek meeting to solicit additional input.
  • The three studies are summarized as follows:
    • The first is a qualitative study that will identify how clinical stakeholders at different types of hospitals define the value of pediatric ID. To date, interviews have been conducted at The Children's Hospital of Philadelphia, Kaiser in Oakland and Sacramento, California, Hasbro Children's Hospital in Providence, Rhode Island, and Arkansas Children's Hospital in Little Rock, Arkansas. The final interview will take place at Beaumont Children's Hospital in Royal Oak, Michigan. Preliminary findings were presented at the October 9, 2014, PIDS Board of Directors meeting. Final results will follow the final interview at Beaumont Children's Hospital later this year.
    • The second study is a systematic review of pediatric antimicrobial stewardship programs (ASPs). A manuscript and accompanying editorial were submitted for publication in JPIDS in August.
    • The third study is a quantitative study addressing the impact of ID consultation on several common pediatric infectious diseases, collecting data of osteomyelitis and complicated pneumonia patients ~3,000 charts per disease from the PHIS database. These efforts will harmonize with those undertaken independent of this mechanism by Janet Gilsdorf at her home institution.

Education and Training for the PID Job Market of the 21st Century

  • The Research Affairs Committee and Pediatric Transplant ID working group consisting of Jan Englund, Betsy Herold, Elaine Tuomanen, Lara Danziger-Isakov, Michael Green, Bill Steinbach, Marian Michaels, Monica Ardura, and Tanvi Sharma continue to develop great programming for the annual St. Jude/PIDS Pediatric Infectious Diseases Research Conference and Pediatric Transplant ID Symposium. In addition, a survey to seek interest in participating in a formal Pediatric Transplant ID Working Group for the broader PIDS membership was sent this past spring. The Working Group met for the first time at the 2014 IDWeek meeting, with 50 participants present in person or via teleconference. The WG now will proceed toward the goal of establishing a more formal network to facilitate research initiatives in this developing field.
  • The Pediatric Transplant ID Curricula was published in the Journal of the Pediatric Infectious Diseases Society (JPIDS) online in Advance Access on December 6, 2013.
  • The 5th annual Pediatric Antimicrobial Stewardship Conference (co-sponsored with Children's Mercy Hospital) was successful with record attendance (n=100). The total number of attendees over all five renditions of the conference is 300. Plans for 2015 are underway.
  • The first inaugural Antimicrobial Stewardship Research Mentoring Award was announced at the PIDS Business Meeting during 2014 IDWeek meeting. This year's winners were Beatriz Larru, The Children's Hospital of Philadelphia, and Joseph B. Cantey, University of Texas Southwestern Medical Center. 
  • The 2015 recipient of the Journal of the Pediatric Infectious Diseases Society Ralph D. Feigin Apprenticeship Award is Pui-Ying Iroh Tam, University of Minnesota.
  • The PIDS Poster Presentation Program, immediately following the Business Meeting, recognized five top ranked abstracts presented by PIDS fellows for outstanding research. This year's awardees were Kalpana Manthiram, Vanderbilt University Medical Center; Liset Olarte, Baylor College of Medicine; Sabine Schyner, Boston Medical Center; Ilan Youngster, Boston Children's Hospital; and Karl Yu, University of Chicago.
  • The Education Committee continues to meet regularly to discuss additional initiatives.


  • The Communications Committee developed a communication plan that focuses on web updates and social media.
  • The committee already has revamped PIDSNews (monthly newsletter). A reader survey was included in the September issue. Click here to provide your feedback.
  • They also have initiated outreach efforts to increase awareness of the Society and JPIDS. Activities include:
    • Two press releases for JPIDS articles since October 2013
    • The Infectious Diseases in Children print and online publications develop news stories from JPIDS articles
    • Several posts on the PIDS Twitter and Facebook pages

Visibility of PIDS

  • To begin this important process, we changed the PIDS Council to the PIDS Board of Directors. This aligns us more directly with other professional societies.
    • The PIDS Bylaws were changed to include member descriptions and establishment of the Fellow of the Pediatric Infectious Diseases Society ("FPIDS") designation. The advancement to Fellow of Pediatric Infectious Diseases Society 2014 launch was successful. Eighty-seven PIDS members advanced to FPIDS. The next cycle for nomination of new FPIDS member will begin in January 2015.
  • The PIDS Executive Committee also approved the development of a Media/Rapid Communications List (starting with members of the Board and the Communications Committee. The first media training session was held during IDWeek 2013. Plans to hold media training utilizing webinar capabilities are underway.

A critical aspect of increasing PIDS' visibility is the continued enhancement of the visibility of the society's journal, the Journal of the Pediatric Infectious Diseases Society (JPIDS). I strongly encourage you, the esteemed experts in our field, to submit your research to our journal via I also ask that you encourage your colleagues to do the same. I promise that you will find the peer review and online publication of manuscripts to be very rapid, the feedback from reviewers to be thoughtful, and the editorial staff of the journal to be extremely responsive. In addition, the Society will feature key articles to our membership via the enhanced Communications efforts detailed above.

Other Society activities include outreach efforts to international sister societies, including SLIPE, ESPID, Australian/New Zealand Pediatric Infectious Diseases Society (ANZPID), and the India Academy of Pediatrics. This is an ongoing initiative being housed under the International Affairs Committee. The discussions with SLIPE have resulted in updates from Latin America as a regular featured article in JPIDS that began in the June 2014 issue (Volume 3 Number 2). If you have international colleagues interested in collaborative initiatives with PIDS, please contact me via email (This email address is being protected from spambots. You need JavaScript enabled to view it.) as I am happy to discuss additional ways to advance our international efforts.

In addition to the International Affairs Committee, PIDS has 12 other committees that are actively working toward advancing the Society's goals and bringing value to its members. This year, 61% of members offering to serve on committees were assigned to their 1st or 2nd committee preferences. There is still much to do, so please contact me if you are passionate about a particular issue that you think PIDS can help with (or that it can help with PIDS).

I encourage you to read this entire issue of PIDSNews. Meeting information such as the Call for Cases for the St. Jude/PIDS Transplant ID Symposium, Call for Abstracts for the St. Jude/PIDS Pediatric Infectious Diseases Research Conference, and other important information are provided. In addition, the Antibacterial Resistance (AR) Leadership Group is seeking pediatric proposals in their efforts to reduce the public health threat of AR. Please follow the link provided in this newsletter to learn more.

Finally, I want to update you on Ebola and PIDS' response to the recent Centers for Disease Control and Prevention (CDC) guidance and the implications for pediatricians. On October 28, PIDS publicly joined with IDSA to implore our political leaders to follow the science in the development of public policy relating to this unfolding human catastrophe. We must think strategically when faced with challenges of this magnitude, and PIDS members are uniquely suited to address those areas that affect children's health. To be certain, this is a dynamic and fluid situation. Our approach to it, therefore, must be flexible as well. We believe that by joining our voices with those of the CDC, American Academy of Pediatrics (AAP), and others, we can most favorably impact the care provided to children with documented or suspected Ebola virus infection. Many of these efforts will be behind the scenes – we all have seen the detrimental effects of too many voices adding to the confusion perceived by the public. But rest assured that we are doing the work, both as individuals and as a group. We – the Pediatric Infectious Diseases community – are making a difference.

In the coming months and years, I am excited about our Society's continuing growth as an organization, maintaining a focus on important issues related to pediatric infectious diseases and providing value to our members. On behalf of the PIDS leaders, thank you for all of your support, hard work, and commitment to the Society!

Written by: David K. Hong, MD

The continuing Ebola crisis in West Africa has been unprecedented. As of October 22, 2014, there have been 9936 confirmed cases of Ebola, many more cases than any previous Ebola outbreak (1).

The Pediatric Infectious Diseases Society (PIDS) endorses Statement from the Infectious Diseases Society of America (IDSA) regarding involuntary quarantine of healthcare workers returning from Ebola-affected countries. PIDS is the world's largest organization of professionals dedicated to the treatment, control and eradication of infectious diseases affecting children. PIDS agrees that strategies to limit Ebola Virus disease transmission should be based on the best available medical, scientific, and epidemiological evidence, as stated by IDSA. Furthermore, PIDS supports the policies promoted by the Centers for Disease Control and Prevention and the National Institutes of Health to end the Ebola outbreak without further losses.

Drs. Georgina Peacock, Timothy Uyeki and Sonja Rasmussen published "Ebola Virus Disease and Children: What Pediatric Health Care Professionals Need to Know" in JAMA Pediatrics.

In AAP News, Dr. Carrie Byington authored the article, " Ebola and Children: Identifying and Meeting Their Needs."

The United States has been experiencing a nationwide outbreak of enterovirus D68 (EV-D68) associated with severe respiratory illness. The most recent version of key points on EV-D68 is now available.

On October 14, 2014 the Centers for Disease Control and Prevention (CDC) issued a press release sharing news about a new lab test developed by CDC for EV-D68 which will allow more rapid testing of specimens. Because of this new test, confirmed cases of EV-D68 will appear to rise rapidly over the next 7-10 days as specimen testing accelerates, however, changes in case counts won't represent a real-time influx of new cases.

Almost all of the CDC-confirmed cases this year of EV-D68 infection have been among children. Many of the children had asthma or a history of wheezing. Many parents continue to be worried about the outbreak and want information about what they can do to prevent illness and protect themselves and their families. CDC has developed information and resources for parents about EV-D68. Please help us to address parents' questions and concerns and make them aware that these resources are available.

Below are CDC resources about EV-D68 developed for parents:

A Prospective, International Cohort Study of Invasive Mold Infections in Children
Written by: Pia S. Pannaraj, MD, MPH

Invasive mold infections (IMI) are life-threatening infections in immunocompromised children. Most of our current knowledge of the epidemiology, diagnosis, treatment, and outcomes of pediatric mold infections is extrapolated from studies in adults. Whereas amphotericin B formulations (polyenes) were once the mainstay of therapy of IMIs, new generation azoles and novel echinocandins have expanded the arsenal of antifungal agents and are being used in children despite limited pediatric pharmacokinetic and efficacy data. In addition, treatment with a combination of different classes of antifungal agents appears attractive despite a paucity of studies. In the Journal of the Pediatric Infectious Diseases Society Advance Access online on July 19, 2014, Wattier et al. and the International Pediatric Fungal Network (PFN) addressed these issues by characterizing the current epidemiology of IMIs in children with varied underlying conditions, describing the patterns of antifungal therapy, and reporting contemporary outcomes from their large, international, multicenter network.

Between 2007 and 2011, PFN enrolled 131 children diagnosed with proven or probable IMIs from 22 study sites (12 US, 10 international) of 42 sites in the network. Most children (75%) had invasive Aspergillosis (IA); 25% had other mold infections. Malignancy and hematopoietic stem cell transplantation were the most common underlying conditions, but the study also characterized IMIs in children with inherited immunodeficiencies, autoimmune diseases, and non-malignant hematologic conditions.

Three main points are emphasized from this study of IMI in children:

  1. Case-fatality rates (CFR) in children who develop IMI remain high at 30%. Active fungal disease was present at the time of death in 85% of children. Fortunately, we have seen a decrease from CFRs as high as 42-85% reported for IA in the early 2000s. One reason for this may be earlier diagnosis allowing for more timely treatment. Traditionally, IMI diagnosis relied on clinical signs, radiographic evidence and attempts to isolate the pathogen. These methods were nonspecific, lacked sensitivity or were invasive. Galactomannan enzyme immunoassay, licensed by the FDA in 2003, offers an adjunctive, non-invasive diagnostic test for guiding initiation of anti-Aspergillus therapy. Of 64 patients with probable invasive Aspergillus (IA) in this study, the diagnosis was established by a positive galactomannan assay in 66%. A second reason for improved outcomes may be the availability of more antifungal treatment options. Voriconazole was used in 82% of patients with IA and has replaced polyenes as the most frequently used agent to treat IA, likely based on evidence primarily in adults showing superiority of voriconazole to amphotericin B deoxycholate in outcome and tolerability. Polyenes were most commonly used for mucormycosis, and voriconazole and polyenes were used in equal frequency to treat other IMIs. Improved therapies in combination with good prospective treatment studies in children are necessary to decrease the CFR even further.
  2. The study describes but does not answer the question of which is better: monotherapy or combination antifungal therapy in the treatment of IMI. Given the high CFRs associated with IMI, using combination antifungal therapy is appealing to achieve potential synergistic effects by acting on different targets, inhibiting different steps in the same pathway, or possibly reducing acquired drug resistance. However, experimental animal studies, clinical series, and randomized trials have been performed with varying and sometimes contradicting results. In this PFN study, 53% of patients received combination therapy with 2 or more concurrent agents sometime within the 12 weeks after diagnosis. Median time to start combination therapy was 5 days. Importantly, combination therapy was significantly associated with almost 2 times increased risk of adverse events but did not change treatment outcome. The variation in combination regimens, timing, and duration of therapy, however, make it difficult to analyze this outcome. Well-designed randomized controlled trials are still necessary to adequately address whether combination antifungal therapy provides any additional benefit over monotherapy.
  3. Exposure to mold active antifungals was associated with higher risk for mucormycosis and other non-Aspergillus IMIs compared to IA. Children with mucormycosis and other non-Aspergillus IMIs did not have more severe underlying conditions or immunologic risk factors compared with those with IA. They differed only in exposure to voriconazole, posaconazole, or an echinocandin for at least 3 days during the 30-days preceding the IMI diagnosis. Unfortunately, the study sites were not required to report the doses, duration, or indication for use (i.e., prophylaxis vs. empiric therapy). Other studies have shown similar breakthrough IMI in patients receiving voriconazole, posaconazole, and caspofungin. The 12-week treatment success of IA, mucormycosis, and other IMIs was similar in this study.

This large study of IMI in children had some limitations. The majority of patients were enrolled from 6 sites, with 25% of the patients from one site alone. Twenty PHN sites did not enroll any patients. The study did not document if this was due to lack of cases or lack of time/resources for the investigators to enroll patients. The study did attempt to control for potential confounding by adjusting for clustering by site in the outcomes analysis. Study sites also may differ in their interpretation of underlying risk factors, approach to diagnostic evaluation, and reporting of adverse events. Furthermore, they may differ in aggressive treatment with surgical excision of localized infection known to improve outcome; this study did not collect data on surgical interventions. Despite these limitations, PHN's study provides us with additional understanding of the epidemiology, contemporary treatment, and outcomes of IMIs in children. More pediatric studies are needed.

Written by: Sunil K. Sood, MD

Enteroviruses (EV) circulate year-round, but illnesses caused by these viruses peak in the summer and autumn months in the U.S. Common clinical manifestations include mild gastroenteritis, meningitis, non-specific illness with or without rash, and hand-foot-mouth disease. Common reasons for pediatric admissions are fever in an infant, and meningitis. EV-D68, however, manifests primarily as a respiratory illness. In late August of this year, there was an unusual spike in Emergency Department visits for severe respiratory illness, which correlated with increased detection of rhinovirus/enterovirus, at the Children's Mercy Hospital in Kansas City, Missouri. Over a 3- 4 week period, there were 475 admissions including about a 100 to their PICU and an excess of 100 emergency room or urgent care visits per day. (Mary Anne Jackson, MD personal communication to Lorry Rubin, MD; and Angela Myers, MD personal communication. Shortly thereafter, a similar cluster was observed at the University of Chicago Comer Children's Hospital. An investigation by the CDC revealed that 80-95% of nasopharyngeal swab specimens tested yielded EV-D68 RNA. The age range was 6 weeks to 16 years. As of September 30, 2014, 43 states have reported EV-D68 related illnesses. The last known clusters of EV-D68 associated with respiratory illness in the United States during were reported during 2009 and 2010. (CDC. Clusters of acute respiratory illness associated with human enterovirus 68—Asia, Europe, and United States, 2008–2010. MMWR 2011;60:1301–4.)

EV, encompassing Polioviruses, Coxsackie A and B, Echo and other (numbered) viruses, belong to the Picornavirus Family, which include rhinoviruses. Rhinoviruses are among the most common pathogens of humans, and are a well known cause of upper and lower respiratory tract infection. Most currently used respiratory viral assay panels detect RNA that is generic for EV and rhinoviruses, and are reported as "rhinovirus/enterovirus." Because "rhinovirus/enterovirus" is reported year round, and most such children do not have severe illness, the current outbreak represents an emerging infection, and warrants further study of its epidemiology. At the time of this writing, the time course and extent of the outbreak cannot be predicted.

Current guidance from the CDC is to "consider EV-D68 as a possible cause of acute, unexplained severe respiratory illness, even if the patient does not have fever." It is important to recognize the following unusual clinical characteristics among the children studied thus far:

  • The majority have presented without fever
  • Wheezing is prominent and hypoxemia is common
  • The presentation is more severe in children with known reactive airways disease
  • ICU admit rate is high; some have required mechanical ventilation or ECMO

A new dimension to this outbreak is the re-emergence of acute neurologic illness with focal limb weakness, first observed in California last year. Nine cases were identified during August 9–September 17, 2014 in Colorado.This neurologic illness appears to follow the respiratory illness by about 2 weeks. MRI findings can include a spinal cord lesion largely restricted to gray matter. Acute onset of focal limb weakness in a child occurring on or after August 1, 2014, should be reported immediately to local health departments.

Treatment is supportive, and until there is future understanding of the epidemiology, it is prudent to maintain suspected inpatients on contact and droplet precautions for the duration of illness.


Severe Respiratory Illness Associated with Enterovirus D68 — Missouri and Illinois, 2014Weekly September 12, 2014 / 63(36);798-799 

CDC. Clusters of acute respiratory illness associated with human enterovirus 68—Asia, Europe, and United States, 2008–2010. MMWR 2011;60:1301–4.CDC. Clusters of acute respiratory illness associated with human enterovirus 68—Asia, Europe, and United States, 2008–2010. MMWR 2011;60:1301–4. 

Organizations and agencies involved in fighting the continuing West Africa Ebola crisis are calling for medical personnel, supplies and training to address the outbreak and its impact on health systems in one of the poorest areas in the world. The links below give information on opportunities to volunteer, donate, and learn more about the outbreak and needs:

Médecins Sans Frontières (Doctors Without Borders) is seeking physicians and nurses with experience in highly contagious wards and personal protective equipment, who are familiar with infection control and safety practices inside isolation areas, and are available for 6-8 weeks for a field assignment in West Africa. Information on MSF's work in West Africa is here.

The United States Agency for International has created a registry for experienced health sector workers interested in volunteering to help those affected by the outbreak. The agency may share information submitted with nongovernmental organizations working in West Africa or with the Centers for Disease Control and Prevention.

The Centers for Disease Control and Prevention has developed a safety training course for healthcare workers who plan to go to West Africa to treat patients in Ebola units. The three-day courses will be taught by CDC staff epidemiologists, infection preventionists, MSF staff members and other professionals. Ten course sessions are scheduled from Oct. 6 to January 4, 2015. Detailed information is available here.

The CDC Foundation is helping staff deployed by the Centers for Disease Control and Prevention meet needs that currently include laptop computers for communication and disease tracking, personal protective equipment, thermal scanners, infection control training, as well as isolation beds through its Global Disaster Response Fund.

The Global Giving Ebola Epidemic Relief Fund has established a fund to provide aid organizations on the ground in West Africa with resources that include medical supplies, protective equipment and educational campaigns.

Partners in Health is seeking donations to support its work with local organizations in Sierra Leone and Liberia to set up Ebola treatment units in rural locations, train health care workers to identify and treat patients and strengthen primary health care.

Learn more:
IDSA News: The September edition provides a compilation of informational links, including to the IDSA Ebola Guidance for ID Clinicians, CDC Ebola evaluation guidelines, resources, and information for volunteers, SHEA Ebola resources, and journal articles on Ebola.

Measles, mumps, whooping cough. Diseases that were largely eradicated a generation ago in the United States are returning. Why?

Written by: Pia S. Pannaraj, MD, MPH

The technical advancement in microbial genomics is revolutionizing the field of infectious diseases.  The first complete genome sequence of a free-living organism, Haemophilus influenzae, was completed in 1995.  Since then, over 23,000 bacteria, 600 fungi and 4000 viruses have been sequenced. Most were completed in the last year and many more are in progress thanks to new high-throughput DNA sequencing technologies, a.k.a. Next Generation Sequencing (NGS).

Why is this exciting for pediatric infectious disease specialists?

NGS allows us to look at the complete DNA fingerprint of microbes with increasing speed and decreasing cost. We have deepened our ability to investigate outbreaks, detect antibiotic resistance genes, characterize difficult-to-culture organisms, and monitor host-microbe interactions at an unprecedented level of detail.

For example, the Centers for Disease Control and Prevention (CDC)'s PulseNet uses NGS to quickly detect multi-state foodborne outbreaks caused by Listeria, Escherichia coli, Salmonella and other dangerous bacteria. Bacterial cultures may take up to 3 days to grow in a laboratory while the foodborne pathogen continues to spread. NGS can determine information about the species, serovar, and subtype of bacteria within hours. This technology was used to determine the origin of a recent multi-state outbreak of Listeria in Hispanic-style cheese products. In March 2014, the Food and Drug Administration (FDA) suspended food production by Roos Food, Inc. after their cheese tested positive for a strain of Listeria indistinguishable from the outbreak strain. A 2011 multi-country outbreak of Shiga toxin-producing E. coli O104:H4 affected 4075 people, including 908 cases of hemolytic-uremic syndrome and 50 deaths. Researchers analyzed and published the complete genome mapping of the outbreak strain within 3 months of the outbreak's inception. A horizontal genetic transfer of a Shiga-toxin-encoding phage from an enterohemorrhagic E. coli onto an enteroaggregative E. coli strain resulted in an accumulation of synergistic virulence factors. Data sharing and open collaboration allowed researchers across the globe to analyze the outbreak strain with extraordinary speed.

Virulent pathogens – new and old – and increasingly multidrug resistant pathogens are becoming greater infection control challenges. In 2011, an outbreak of carbapenem-resistant Klebsiella pneumoniae affected 18 patients at the U.S. National Institutes of Health Clinical Center, 11 of whom died, despite early implementation of infection control procedures. Whole genome sequencing performed on patient and environmental isolates lead to the discovery that the index patient had left the hospital 3 weeks before the strain was isolated from another patient indicating that K. pneumoniae could silently colonize patients. Thus, effective surveillance protocols before isolation of multi-drug resistant strains were as important as infection control strategies after isolation.

The aggressive and highly lethal Ebola virus is an example of a pathogen that has been hard to study due difficulties in obtaining samples from remote areas where the outbreaks have occurred. Researchers are rapidly studying the current outbreak strain of the Ebola virus sequence to obtain insights on its origin, understand the virus' mutation over time, learn about the mechanisms underlying its pathogenicity, and determine how to design more sensitive and accurate diagnostic tests in the field. The current outbreak so far has caused 2,127 cases of disease and 1,145 deaths in Guinea, Liberia, Nigeria, and Sierra Leone.

Finally, sequencing technology has transformed our thinking about microbes on and in the human body. The human body contains over 100 trillion bacteria cells. We have just recently come to appreciate how these symbiotic microbes benefit us by breaking down our food, suppressing pathogenic bacteria, and nurturing our immune system. Multiple studies have revealed an intriguing association between the types and diversity of microbes in a child's gut and risk of asthma, diabetes, obesity, response to vaccines, and even behavior. Prospective studies in germ-free mice support these findings. What is important for pediatricians to know is that early exposures determine an infant's microbial composition as an infant. Mode of delivery, gestational age, breastfeeding vs. formula feeding, administration of antibiotics and the local environment all play a role in obtaining the "right" microbes. How do we know which are the "right" microbes? There is much more to discover, and NGS technology has opened the door to explore this question and many more.

An Attendee's Perspective (and why all of you should go)
Written by: Saul Hymes, MD

Every year so many large conferences, courses, and annual meetings vie for our attention and our dollars.