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. http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html. 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." http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html 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.

References:

Severe Respiratory Illness Associated with Enterovirus D68 — Missouri and Illinois, 2014Weekly September 12, 2014 / 63(36);798-799 http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6336a4.htm?s_cid=mm6336a4_w 

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. 

http://www.cdc.gov/non-polio-enterovirus/about/EV-D68.html 

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:

Volunteer:
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.

Donate:
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.

Written by: Pui-Ying Iroh Tam, MD

Health outcomes for Americans have improved substantially over the last generation due to a number of factors including improved sanitation, vaccinations, increased education, and better health care.

Written by: Christina Gagliardo, MD

As pediatric infectious disease physicians, there are several key questions we all ask in order to obtain a thorough exposure history, including: "Do you have pets or animal exposures? Are your vaccines up to date? Have you ever travelled outside the country?" This last question has become increasingly important for several reasons which include ascertaining risk for tropical infections such as tuberculosis, malaria, typhoid, or dengue, vaccine-preventable illnesses such as polio and measles, but also to assess risk for colonization with multidrug resistant bacteria. A growing number of studies demonstrate acquisition of multidrug resistant bacteria during travel abroad. Likely every pediatric infectious disease physician has encountered an otherwise healthy child who is either colonized with, or has an infection from an extended spectrum beta-lactamase (ESBL) producing or other multidrug resistant organism (MDRO) with no discernible classic risk factors such as prior hospitalization, prior antibiotic use, or other medical problems. An underappreciated and likely relevant part of the history for MDRO colonization is international travel.

Travel to Southeast Asia appears to be an emerging risk factor for acquisition of ESBL-producing Enterobacteriaceae with several prospective cohort studies identifying international travel as a risk factor for colonization and travel to India or the Indian subcontinent as the highest risk factor (1-5).
A prospective study of 100 Swedish adults travelling outside Northern Europe demonstrated 24 individuals with negative pre-travel stool samples were colonized with ESBL-producing Escherichia coli after return home. They found a statistically significant higher risk of acquisition of ESBL-producing Escherichia coli with travel to India and an association with gastroenteritis related to travel, which could be a surrogate parameter for exposure to fecally contaminated food or water (2).

Van der Bij provides a comprehensive list of studies which demonstrate the role international travelers play in the global spread of MDROs, some of whom did report contact with healthcare systems abroad (6). Several large clinical trials are currently looking at the acquisition of MDR Enterobacteriaceae including COMBAT: Carriage of Multidrug Resistant Bacteria After Travel (ClinicalTrials.gov Identifier: NCT01676974) and the VOYAG-R Study: Acquisition of Multidrug-resistant Bacteria After Travel in the Tropics: Prevalence, Determinants and Length of Carriage (ClinicalTrials.gov Identifier: NCT01526187). These studies are also evaluating duration of colonization and rate of secondary transmission within households. VOYAG-R reported on three healthy French travelers returning from India who reported no contact with any healthcare center while abroad who acquired carbapenemase-producing Enterobacteriaceae (CPE) (7).

A recent study utilized a metagenomic approach and investigated resistance genes in the human gut microbiota after international travel. They reported high rates of acquisition of the ESBL- encoding gene blaCTX-M and quinolone resistance encoding genes qnrB and qnrS related to international travel. The prevalence of the resistance genes increased from 9.0%, 6.6%, and 8.2% before travel to 33.6%, 36.9%, and 55.7% after travel, respectively (5).

These findings raise several questions and have implications for policies regarding infection control measures. Should we counsel patients about these risks during pre-travel consultation when there is no specific intervention or recommendation to be made? Should we screen and isolate patients after travel abroad if they are hospitalized? In France the Healthcare Safety Advisory Committee made national recommendations to screen and place any individual transferred from or hospitalized outside France on contact isolation (6). While at this time there is certainly not enough evidence to support screening and isolating every person who has recently travelled, the impact of international travel on the spread of MDROs is crucial to understand on the patient and public health level to determine optimal interventions and policies.

References:

  1. Kennedy K, Collignon P. Colonisation with Escherichia coli resistant to "critically important" antibiotics: a high risk for international travelers. Eur J Clin Microbiol Infect Dis. 2010;29:1501–6
     
  2. Tängdén T, Cars O, Melhus A, Lowdin E. Foreign travel is a major risk factor for colonization with Escherichia coli producing CTX-M–type extended-spectrum beta-lactamases: a prospective study with Swedish volunteers. Antimicrob Agents Chemother. 2010;54:3564–8
     
  3. Ostholm-Balkhed A, Tarnberg M, Nilsson M, Nilsson LE, Hanberger H, Hallgren A, et al. Travel-associated faecal colonization with ESBL-producing enterobacteriaceae: Incidence and risk factors. J Antimicrob Chemother. 2013;68:2144–53
     
  4. Paltansing S, Vlot JA, Kraakman MEM, Mesman R, Bruijning ML, Bernards AT, et al.Extended-spectrum β-lactamase–producing enterobacteriaceae among travelers from the Netherlands. Emerg Infect Dis. 2013;19:1206–13
     
  5. von Wintersdorff CJH, Penders J, Stobberingh EE, Oude Lashof AML, Hoebe CJPA, Savelkoul PHM et al. High acquisition rates of antimicrobial drug resistance genes after international travel, the Netherlands. Emerg Infect Dis. 2014
     
  6. van der Bij, AK, Pitout JDD. The role of international travel in the worldwide spread of multiresistant Enterobacteriaceae. J. Antimicrob. Chemother. (2012)67 (9): 2090-2100
     
  7. Ruppé E, Armand-Lefèvre L, Estellat C, El-Mniai A, Boussadia Y, Consigny PH, Girard PM, Vittecoq D, Bouchaud O, Pialoux G, Esposito-Farèse M, Coignard B, Lucet JC, Andremont A, Matheron S. Acquisition of carbapenemase-producing Enterobacteriaceae by healthy travellers to India, France, February 2012 to March 2013 . Euro Surveill. 2014;19 (14)

Written by: Matthew Kronman, MD, MSCE

In the last cycle of the match for fellowship positions in Pediatric Infectious Diseases, there were approximately 80% as many applicants (55 total) as there were available fellowship positions [1].

CDC has provided updated key points regarding the Middle East Respiratory Syndrome Coronavirus (MERS-CoV), dated 5/12/2014. Updates include information about the second imported case of MERS in the United States.

CDC and Florida Department of Health officials are investigating the second case of MERS-CoV infection in the United States. MERS-CoV, a virus relatively new to humans, was first reported in Saudi Arabia in 2012.  On May 2, 2014 CDC reported the first case of MERS in the United States.

WHO:

  • Tom Frieden, M.D., M.P.H., Director, U.S. Centers for Disease Control and Prevention
     
  • Anne Schuchat, M.D. (RADM, USPHS) Assistant Surgeon General, United States Public Health Service; Director, National Center for Immunization and Respiratory Diseases
     
  • John H. Armstrong, MD, FACS, FCCP Florida's State Surgeon General and Secretary of Health

WHEN: Monday, May 12, 2014 at 2:00 p.m. ET

DIAL-IN:
Listen-only: 877-546-1574
Passcode: CDC MEDIA

Transcript:
A transcript of this media availability will be available following the briefing at the CDC web site at www.cdc.gov/media.

U.S. Department of Health and Human Services
CDC works 24/7 saving lives, protecting people from health threats, and saving money through prevention. Whether these threats are global or domestic, chronic or acute, curable or preventable, natural disaster or deliberate attack, CDC is the nation's health protection agency.

Written by: Christina Gagliardo, MD

Sammons JS, Gerber JS, Tamma PD, Sandora PD, Sandora TJ, Beekmann SE, Polgreen PM, Hersh AL. Diagnosis and Management of Clostridium difficile Infection by Pediatric Infectious Disease Physicians. J Pediatric Infect Dis Soc 2014 Mar; 3(1):43-48.

Summary:

In the March 2014 issue of the Journal of the Pediatric Infectious Disease Society, Sammons and colleagues report on practices for the diagnosis and management of mild, severe, and recurrent Clostridium difficile infection (CDI) by pediatric infectious disease (ID) physicians. They performed a web-based survey via the Emerging Infections Network (EIN) whose membership includes nearly one-quarter of all pediatric ID physicians who received board-certification since 1994. The survey was adapted and modified from an EIN survey of adult physicians on treatment of CDI and use of fecal microbiota transplantation. The survey included questions regarding diagnostic techniques and treatment strategies employed for CDI in children with clinical vignettes aimed to determine how treatment would differ based on clinical presentation (recurrent, severe, etc.), underlying chronic conditions, and patient age. They defined severe CDI as presence of WBC count >15,000 cells/µL, serum creatinine ≥ 1.5 times patient’s baseline, hypotension or shock, ileus, perforation, or megacolon. Recurrent CDI was defined as an episode occurring 8 weeks or less after the onset of a previous episode, provided symptoms had resolved from the previous episode.

Of 285 physicians surveyed, 145 (51%) responded and were included for analysis (twenty-two other respondents were excluded because they reported they had not managed patients with CDI in the past year). To diagnose CDI, 97 (67%) respondents used nucleic acid amplification assays alone or in combination with other laboratory methods, while 32 (22%) respondents used toxin enzyme immunoassay (EIA), and of these, over one-third used EIA alone. Forty respondents reported infant testing was restricted or required approval, with the majority reporting restrictions for below 12 months of age. Mild CDI in an immunocompetent host was managed with oral metronidazole in 100% of respondents, however oral metronidazole use varied and was less frequently preferred for patients with underlying comorbidities such as Crohn’s disease, renal transplant, and neutropenic AML patients. Oral vancomycin alone or in combination with at least one other agent was the preferred treatment for severe CDI by 65% of respondents. Oral vancomycin alone or in combination with another agent was used for treatment of a second recurrence by 131 (92%) respondents, with 16 of these respondents indicating they would initiate a vancomycin taper. For a third CDI recurrence and beyond, management varied greatly and included use of combination therapy or single agents including metronidazole, vancomycin, nitazoxanide, rifaximin, fidaxomicin, intravenous immunoglobulin, and fecal microbiota transplantation. Fecal microbiota transplantation was recommended most commonly for treatment of a third or later recurrence.

Commentary:

This study highlights the variability in practice among pediatric ID physicians in the diagnosis and management of recurrent and severe CDI. With regards to diagnosis, nearly 10% of respondents rely on toxin EIA only which has been shown to have poor sensitivity. Testing of infants < 12 months of age was not restricted at most institutions and some physicians felt CDI was a viable diagnosis in certain infants. The AAP 2013 Policy Statement [1] recommends that testing in infants < 12 months of age be limited to those with gastrointestinal motility disorders and outbreaks, and alternative diagnoses to be sought even in the event of a positive C. difficile test due to the high rate of colonization in infants [1]. The AAP also acknowledges the difficulty in test interpretation in the two and three year old age group. Wendt and colleagues recently reported results from a large community based epidemiologic surveillance study that young children from 1 to 3 years of age actually represent the highest CDI infection incidence and felt this young age group reflected true disease and not colonization [2]. This emphasizes the need for further study of CDI in this younger age group.

For treatment of mild CDI in immunocompetent children, oral metronidazole was unanimously the treatment of choice. For mild CDI in children with underlying chronic conditions, for severe CDI, and for recurrent CDI, treatment varied significantly. Although the AAP recommends oral vancomycin for severe CDI [1], this was not uniformly used by the respondents for severe disease. One recent study  identified predictors of vancomycin use for CDI in children and identified significantly more vancomycin use in patients who were older, white, had private insurance, who had testing within 48 hours of admission, who were on antibiotic at the time of testing, or who had a gastrointestinal comorbidity [3]. Many respondents reported use of alternative agents such as fidaxomicin, which is not FDA approved in children, and use of fecal microbiota transplantation which demonstrated efficacy in a randomized controlled trial of adults [4]; pediatric data for both treatments are lacking.

Limitations of the study included use of EIN membership, which may not be generalizable to all pediatric ID physicians, clinical vignettes which may not reflect actual practice, and recall bias. The study highlights the important issue of variability in approach to management of severe and recurrent CDI, CDI in certain subpopulations of children, and the lack of comparative effectiveness studies for the optimal treatment of CDI in children. Finally, antibiotic overuse plays an important role in CDI and emphasizes the role for antimicrobial stewardship in the outpatient and inpatient settings. In short, less antibiotic use and more studies are needed for CDI in children.

References:

  1. Schutze GE, Willoughby RE; Committee on Infectious Disease; American Academy of Pediatrics. Clostridium difficile infection in infants and children. Pediatrics 2013; 131(1):196-200.
     
  2. Wendt JM, Cohen KA, Mu Y, et al. Clostridium difficile Infection Among Children Across Diverse US Geographic Locations. Pediatrics 2014; 133(4):651-8.
     
  3. Schwenk HT, Graham DA, Sharma TS, et al. Vancomycin Use for Pediatric Clostridium difficile infection Is increasing and Associated with Specific Patient Characteristics. AAC 2013, 57(9):4307-13
  4. van Nood E, Vrieze A, Nieuwdorp M, et al. Duodenal Infusion of Donor Feces for Recurrent Clostridium difficile. NEJM 2013; 386(5): 407-15

Written by: Pui-Ying Iroh Tam, MD

 Previous PIDS newsletters have included worthy and weighty communications on issues of profound importance, from vaccinations to antimicrobial stewardship. Certainly, part of the mission of PIDS is to 'care for children worldwide, through clinical care, education, research and advocacy,' and those are compelling problems that we hope to address and overcome in this generation. However, what has occupied my thoughts more recently have been more banal thoughts of billing codes.

Now, to be clear, I have never before had any interest in billing. I never received any orientation nor training on this as a medical student, resident, or fellow. To me this was the antithesis of why I went into medicine, something I regarded as another bureaucratic hurdle in order to complete my documentation.

However, I have developed a keen interest in the International Classification of Diseases, 10th Edition (ICD-10), which was scheduled to go into effect on 1st October, 2014, but has now been pushed back to 2015. With these codes, which include codes for new procedures and diagnoses that improve the information available for payment purposes, the healthcare delivery system will be transformed. As the secretary of the Department of Health and Human Services, Kathleen Sebelius, wrote, "ICD-10 is foundational for building a modernized health care system that will facilitate broader access to high quality care."

What has fascinated me most has been the new, expanded medical billing codes designed to provide greater detail in describing illnesses, injuries, and treatments. The 10th Edition was evaluated by a technical advisory panel in consultation with physician groups and clinical coders, and overseen by the World Health Organization. The main intent behind ICD-10 is to serve as a tool in classifying morbidity data for medical care review, indexing health records, and for basic health statistics; however, in the United States the codes are also used for billing purposes.

The uniqueness of some of the billing codes has captivated me. I have been enthralled by how one could have envisioned a use for a medical billing code for burn due to water skis on fire (V91.07XD) to being bitten by an Orca whale (W56.21XS – being struck by an Orca whale is a different code W56.22XS). What about a code for problems in relationship with spouse or partner (Z63.0)? Can I use it to bill myself when I've had a fight? It seems it would be difficult to outdo one of the earlier ICD classifications of 'visitation from God' as a cause for death; however, the ICD-10 code of 'asphyxiation as a result of encasement in a discarded refrigerator' (T71.231D) may have done just that.

Humor aside, these billing codes lead me to reflect on how the field of pediatric infectious diseases is recognized and remunerated. With the newest edition, 18,000 ICD codes have now expanded to around 140,000 codes, and one gets a sense from perusing this how much more weight is placed on surgical services. For balloon accidents and spacecraft injuries, there are 14 results each. There are 27 ICD-10 codes for various injuries to the nose, from abrasion to blister to contusion to puncture wound to laceration to nonvenomous insect bite. Conversely, when I typed in 'infection,' there were only 103 results. And not anything as exciting as involving chicken coops (Y92.72) or opera houses (Y92.253) or bunjee jumping (Y93.34). About half were infection billing codes associated with orthopedic procedures.

Therein lies the limitation of billing codes and the problematic orientation of insurance companies to our specialty as a whole. Why is there no billing code for severe infection caused by an esoteric organism that was identified by an astute physician? What about a billing code for quality of life improved and illness prevented due to immunization? Instead, we have a code for infection following immunization (T88.0XXS).

Given our specialty's relative adeptness at extracting details in the history, perhaps the ICD-10 codes are beckoning us to coding greatness. Whom else would be better able to identify whether an event occurred on the interstate highway (Y92.411), parkway (Y92.412), state road (Y92.413), sidewalk (Y92.480), parking lot (Y92.481), bike path (Y92.482) railroad track (Y92.85) or exit ramp (Y92.415)? Curiously, ICD-10 has 13 codes for immunization that were not administered because of various reasons, including due to patient refusal (Z28.21) and caregiver refusal (Z28.82). Billing for something that was not done? Perhaps that is progress.

References

Anna Wilde Mathews, Wall Street Journal, "Walked Into a Lamppost? Hurt While Crocheting? Help Is on the Way." 13th September, 2011.

US Department of Health and Human Services, News release. 24th August, 2012.

Erin McCann, Health IT news, "8 zaniest ICD-10 codes." 25th July, 2013.

Andrew Pollack, New York Times, "Roughed Up by an Orca? There's a Code for That." 29th December, 2013.

ICD-10 codes, http://www.cdc.gov/nchs/data/icd/Detailed%20List%20of%20Codes%20Exempt%20from%20POA.pdf accessed 4th February, 2014

Chris Dimick, Journal of AHIMA, "Senate passes ICD-10 delay bill." 31st March, 2014.

 

 

 

Written by: Matthew Kronman, MD, MSCE 

Simon TD, Mayer-Hamblett N, Whitlock KB, Langley M, Kestle JRW, Riva-Cambrin J, Rosenfeld M, Thorell EA. Few Patient, Treatment, and Diagnostic or Microbiological Factors, Except Complications and Intermittent Negative Cerebrospinal Fluid (CSF) Cultures During First CSF Shunt Infection, Are Associated with Reinfection. J Pediatric Infect Dis Soc. 2014 Mar;3(1):15-22.

Summary

In the March 2014 issue of the Journal of the Pediatric Infectious Diseases Society, Simon and colleagues report the findings of their retrospective cohort study of children at Primary Children’s Medical Center with first ventricular shunt infection. The authors compiled an extensive dataset through meticulous chart review, gathering records on 118 children who had a first shunt placed between January 1, 1997 and October 12, 2006, and who developed a first shunt infection prior to December 31, 2006. The authors then collected patient, treatment, and surgical factors to evaluate which factors were associated with developing a second shunt infection prior to June 28, 2010. The overall median follow-up time was 5.7 years, and 31 (26%) subjects developed a shunt re-infection.

The authors evaluated numerous factors, but found only three factors associated with risk of re-infection in their adjusted multivariate model: use of ventriculoatrial shunts (adjusted hazard ratio [aHR] 4.0, 95% confidence interval [CI] 1.3-10.0) or complicated shunts, defined as shunts involving multiple reservoirs or connections (aHR 7.7, 95% CI 1.2-28.1); complications – including shunt malfunction, hemorrhage, and abdominal abscess – after first infection (aHR 3.1, 95% CI 1.2-7.0); and what the authors termed "intermittently negative CSF cultures" – i.e., having positive CSF cultures, followed by negative cultures, and then having further subsequent positive cultures (aHR 3.2, 95% CI 1.3-7.0). In a sensitivity analysis, higher white blood cell count in the CSF at first infection was also associated with re-infection. None of the many other variables that were evaluated - including pathogen isolated at first infection, duration of first infection treatment, concordance of antibiotics with pathogen identified, use of intrathecal antibiotics, or surgical approach - were associated with the risk of developing re-infection.

Commentary

Ventricular shunt infections are a common reason for inpatient Infectious Disease consultation. It can be difficult to know how intensively to evaluate for a shunt infection in patients with ventricular shunts who have only non-specific symptoms such as fever. Once identified, ventricular shunt infections often lead to substantial morbidity, including invasive surgery and prolonged hospitalization. While the 2004 IDSA meningitis guidelines mention ventricular shunt infections, there is little current guidance for Infectious Disease physicians to assist in treating these infections in children and preventing recurrences [Tice et al.].

This study builds upon our existing knowledge of factors associated with re-infection after a first ventricular shunt infection. Prior pediatric multicenter work has demonstrated a similar 26% rate of re-infection, and suggested that duration of antibiotic treatment is not associated with risk of ventricular shunt infections recurrence [Kestle et al.]. The rate of infection relapse or re-infection in children appears to be higher than that in adults [Conen et al.]. Retrospective studies to determine whether use of antibiotic-impregnated catheters can reduce the risk of subsequent shunt infection have had mixed results, with some studies demonstrating no benefit [Kan et al.], and others demonstrating a reduction in shunt infections [Parker et al.].

In the Simon et al. study, duration of antimicrobial therapy was not associated with re-infection risk, and the median duration was nearly identical between the groups that did (15 days) or did not (13 days) develop re-infection. Likewise, rates of intrathecal antibiotic and rifampin use were similar between the two groups but very low in both groups, limiting the ability to evaluate the impact of these factors. Future studies may elucidate whether there are patients who could safely receive a shorter duration of antibiotics without increasing the risk of re-infection, and whether intrathecal antibiotics or adjuvant rifampin decrease the risk of re-infection.

Notably, none of the factors associated with re-infection in this study were ones that Infectious Disease physicians might typically influence. The association of complex and ventriculoatrial shunts with re-infection seems logical, given the difficulty and likely increased operative time for these procedures; Infectious Disease physicians may be able to discuss these data with their neurosurgeon colleagues to help them determine what replacement shunt position is best after a first infection. It is not clear, however, why intermittent negative CSF cultures predict shunt re-infection. These intermittent negative cultures may simply suggest factors associated with a more difficult infection to clear, such as a larger burden of organism, more loculated and therefore intermittently draining collections, subtherapeutic antibiotic penetration and levels, or organisms that produce biofilms.

While more work needs to be done to illuminate the optimal treatment of ventricular shunt infections in children, a history of uncommon shunt types and prior complications or intermittently negative cultures with a prior infection should all increase the suspicion for shunt re-infection. After an infection of a ventriculoatrial shunt, it may also be worth placing the new shunt in a non-atrial position, if feasible.

References:

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  2. Tice AD, Rehm SJ, Dalovisio JR, et al. Practice guidelines for outpatient parenteral antimicrobial therapy. IDSA guidelines. Clin Infect Dis 2004 Jun 15;38(12):1651-72.
  3. Kestle JR, Garton HJ, Whitehead WE, et al. Management of shunt infections: a multicenter pilot study. J Neurosurg 2006 Sep;105(3 Suppl):177-81.
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