Pediatric Infectious Disease Newsletter
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June 2009  

Rotavirus 2009
This year, rotavirus arrived during the usual season, peaking in activity by February with 21 cases that month. The total numbers still remain significantly below what we used to see just 2 years ago, when our peak month would have 90-150 cases. From December 2008 through May 21, 2009, we have had 55 positive test results for rotavirus among inpatients and outpatients at ACH. Of those, 6 (11%) were under 6 months of age and, therefore, too young to have been fully immunized unless they received the newer 2-dose rotavirus vaccine. Another 38 (69%) were 23 months or older, making it unlikely that they had received the original 3-dose rotavirus vaccine. That leaves about 20% between 6 and 22 months of age who may have been old enough to receive rotavirus vaccine; we do not have immunization records for this group. 
Decline in Cases of Hepatitis A and B in the United States
The May issue of the Morbidity Mortality Weekly Report reported a 92% decline in acute cases of hepatitis A. There was an incidence of 12 cases per 100,000 in 1995 and 1 case per 100,000 in 2007.  The greatest decline in disease occurred in the pediatric population in states where vaccination became routine in 1999.  Cases of hepatitis B are on the decline as well with an 82% decrease from 1995 with 8.5 cases per 100,000 to 2007 with 1.5 cases per 100,000. Hepatitis B infection dropped in all age groups but was the lowest in children younger than 15 years of age. This decline for both hepatitis A and B is the steepest ever recorded.

MMWR (CDC)
May 2009
Staphylococcus aureus (SA) Community-Acquired Pneumonia and the Use of Antiviral Agents for Influenza
A recent CDC (Centers for Disease Control and Prevention) survey (survey prior to novel H1N1) was sent to members of the Emerging Infections Network. Of those that responded to the survey, 58% had been involved in the care of patients with SA pneumonia this past influenza season compared to 53% last season and 30% in 2006-2007. Reports of methicillin-resistant SA remained unchanged or slightly decreased compared to the two prior seasons. There was a decrease in the use of antivirals for the 2008-2009 season compared to 2007-2008 season as well as a drop in the use of prophylaxis this season.  Zanamavir treatment increased with a decrease in oseltamavir for 2008-2009 compared to 2007-2008.

EIN Report: Influenza 2009
Centers for Disease Control and Prevention Query
Unilateral Eye Swelling... Is it Really an Infection?
We were recently presented with a challenging case of a school age child with chronic unilateral periorbital eye swelling. Prior to our consultation, he was treated with almost 2 months of antimicrobial therapy for periorbital cellulitis. He was minimally responsive to antibiotics over this period of time. His other symptoms included abdominal pain (attributed to C. difficile infection) and complaints of knee pain.  After failing an alternative antimicrobial treatment, we suspected possible extraintestinal manifestations of inflammatory bowel disease. The patient had presence of autoantibody suggestive of Crohn's disease and is undergoing further evaluation. With our ophthalmology colleagues we have been treating the patient for a condition called orbital inflammatory pseudotumor.  The patient age range is 4 to 80 years old. It most commonly presents with unilateral orbital pain with swelling and proptosis. The condition may be bilateral in children and may be recurrent. Compressive effects to orbital structures may occur.  It has been divided into several different types, including vasculitic, granulomatous, sclerosing and eosinophilic based on pathology.  The cause is not well defined but may be related to autoimmunity, poor wound healing or infection resulting in an inflammatory infiltrative process.  Diagnosis is made on clinical grounds and the differential includes sarcoidosis, orbital cellulitis, tumors and metastatic cancer.  Patients are extremely responsive to oral steroids with tapering.

Mumps in Japan with a High Incidence of Hearing Loss
A prospective outpatient-based study was carried out to determine the incidence of hearing loss in Japanese children with mumps. There were 40 practices in the study and all children in the study were <=20 years old.  Parents were instructed to conduct a hearing test by rubbing fingers near the child's ears twice a day for 2 weeks. Patients suspected of having hearing loss had further testing by an otolaryngologist.  There were 7400 children that had hearing assessment after mumps infections.  Seven patients had confirmed hearing loss. None of these patients were vaccinated.  All of the children had unilateral hearing loss that did not improve over time. The incidence of hearing loss in children secondary to mumps was approximately 1/1000.  This is greater than the previously reported incidence of 0.5-5/100,000 cases of mumps from older studies.  The mumps vaccine is not regularly used in Japan. Vaccine coverage rates of all the patients in this study were as follows:  8% received one dose of vaccine, 92% without a history of vaccination and the status was unknown in 5 patients.  Other complications of mumps infection include aseptic meningitis (incidence 0.5-15%). This was not assessed in this study.  This paper illustrates two very important points: mumps infection can have serious individual consequences that are more common than previously described and that the absence of universal vaccination results in devastating costs to the pediatric population.

An Office-Based Prospective Study of Deafness in Mumps
Commentary: Is Japan Deaf to Mumps Vaccination?
PIDJ 2009;28 (3)
Update from Pediatric Academic Society (PAS) Meeting May 2009
 
Osteoarticular Infections: New Insights-Management of community-associated methicillin resistant Staphylococcus aureus (CA-MRSA) osteomyelitis

Most participants agreed that the initial management of CA-MRSA osteomyelitis is with vancomycin IV.  With increasing MICs in some hospitals to CA-MRSA, some institutions have aimed for higher vancomycin trough levels of 15-20 mcg/ml.  There was some discussion regarding whether combination therapy should be used empirically. Various combinations were mentioned including vancomycin/rifampin, vancomycin/gentamicin/rifampin, and vancomycin/nafcillin (nafcillin until you know whether or not the pathogen is MRSA) to no combination therapy.  In regard to changing to oral therapy, most agreed -- when a patient is responding clinically, afebrile, and has decreasing inflammatory markers (CRP 2-3 mg/dl) to change to oral therapy. At San Diego Children's Hospital, they will transition to clindamycin as their oral drug of choice.  However, it was not mentioned whether or not they have a high rate of inducible clindamycin resistance.  (Here at All Children's Hospital, 22% of our MRSA isolates exhibit either constitutive or inducible resistance to clindamycin.) They have also found that some of the CA-MRSA osteomyelitis patients need longer treatment (6-10 weeks).

New Tools for the Diagnosis of Infectious Diseases-Viral PCR

This session focused on the use of Polymerase Chain Reaction (PCR) to detect a variety of organisms.  The general recommendation for obtaining a respiratory specimens by PCR was a nasopharyngeal (NP) wash. Throat swabs are not sensitive for viral PCR.  Experts also favor NP wash over the NP swab for RSV detection.  PCR also has greater sensitivity to detect viruses over direct fluorescent antibody.  Viral PCR has also been useful in the research setting detecting new viruses or reemerging viruses: novel coronaviruses and adenovirus 14.  It is has been a useful tool for screening for CMV infection.  Early detection of viremia allows for early anti-viral intervention in blood and marrow transplant patients.  There have also been studies using PCR in determining viral shedding in young children.  Viral shedding from greatest to least:  rhinovirus > adenovirus > coronavirus > parainfluenza > RSV > influenza. Even though RSV is not the most shed virus, it still remains one of the most significant in pediatrics as far as healthcare utilization.

Vaccine Advocacy in an Era of Controversy and Concern: From Science to Practice to Policy

We need to be advocates for children! We need to continue to educate our patients and families regarding the importance and safety of vaccinations.  Use anecdotes, not data, of what the vaccine-preventable diseases can do to children. Families need to understand that vaccinations are to protect the individual as well as the community. We have seen over this past 1-2 years examples of what can happen when vaccination rates drop. These include recent outbreaks of measles in US cities of San Diego and Pittsburgh.  These cases were traced back to waiting rooms in healthcare facilities. Additionally, recent outbreaks of invasive Haemophilus influenzae type B have been reported in Minnesota and Pennsylvania.  We need to direct our patients to the appropriate websites. Websites that provide reliable vaccine information for parents are listed below.

False-Positive Hepatitis B Surface Antigen Test in a Recently Vaccinated Infant
Recently, we encountered a false-positive hepatitis B surface antigen (HBsAg) in a hospitalized infant.  Elevated liver function enzymes prompted the neonatology team to obtain the test. However, the patient had been vaccinated with Energix B within 48 hours of testing.  Repeat HBsAg the following week was negative. 

The two available vaccines, Recombivax HB and Energix B, both contain the Hepatitis B surface antigen; however, only Energix B has been associated with this antigenemia.  There is no established length of time in which the antigenemia should resolve, though most studies show resolution within 1 week.  The American Red Cross "defers donors for 7 days after the hepatitis B vaccine." One case report uncovered a patient with positive HBsAg eighteen days after immunization; conversion to seronegative with a positive surface antibody was seen by 48 days.  Pediatricians should be aware that the Hepatitis B vaccine might result in a false-positive antigenemia persisting up to three weeks after vaccination. 

Lunn E, et al. Pediatrics. "Prolonged Hepatitis B Surface Antigenemia After Vaccination".  2000; 105(6).e81.

Summary by Julia Franks, M.D. (PGY-1 Pediatric resident)
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In This Issue
Rotavirus 2009
Decline in Cases of Hepatitis A and B in the United States
Staphylococcus aureus (SA) Community-Acquired Pneumonia and the Use of Antiviral Agents for Influenza
Unilateral Eye Swelling... Is it Really an Infection?
Mumps in Japan with a High Incidence of Hearing Loss
Update from Pediatric Academic Society (PAS) Meeting May 2009
False-Positive Hepatitis B Surface Antigen Test in a Recently Vaccinated Infant
Our New and Improved Infectious Disease Newsletter
Tune in to upcoming Grand Rounds ID topics
Pediatric Infectious Disease Telephone Consult Experience
David M. Berman, D.O.
Juan Dumois III, M.D.
Shirley Jankelevich, M.D.
Allison Messina, M.D.
Dale Bergamo, M.D.
Patricia Emmanuel, M.D.
Jorge Lujan-Zilbermann, M.D.
Carina A. Rodriguez, M.D.
Katie Namtu, Pharm.D.

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Our New and Improved Infectious Disease Newsletter
Please email your comments and suggestions so we may continue to improve our newsletter! 
Tune in to upcoming Grand Rounds ID topics 
You can log in to the www.allkids.org website with a broadband internet connection to view live presentations of the weekly Pediatric Grand Rounds lectures at All Children's Hospital. If you miss one, you may view the archived webcasts and receive CME credit. Upcoming ID topics include:
 
July 17
Vaccine-Preventable Infections
Dr. Allison Messina 
 
August 21
Influenza Update
Dr. Juan Dumois
  

August 28
Cat Scratch Disease Update
Dr. David Berman
  

September 11
Infections in Cancer Patients
Dr. John Greene
Pediatric Infectious Disease Telephone Consult Experience
A recent survey by the AAP Section of Infectious Disease (SOID) was done regarding telephone conversations between infectious disease consultants (ID) and non-infectious disease physicians. The results were interesting. Overall, 221 members of SOID responded to the survey. 179 members reported having phone consultations with non-infectious disease physicians. 58% of ID physicians had between 10-150 calls per month with 53% spending >= 6 hours on the telephone.  The most common reason for phone calls from non-ID physicians was for management decisions for a proven/suspected infection (just over half of the respondents answered this question). More than half of these calls did not result in a "formal consult."  Many ID groups do not have policies in place to address the informal phone consultation and almost do not track these phone calls.
 
Letter to Members of the AAP Section of Infectious Disease May 2009