Pediatric Infectious Disease Newsletter
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August 2009  

Novel H1N1 (Swine) Flu Update
  1. Worldwide, the majority of all influenza A at this this time is the novel H1N1 (Swine) Flu.
  2. CDC recommends that people with influenza-like illness remain at home until at least 24 hours after they are free of fever (100 F [37.8C]), or signs of a fever without the use of fever-reducing medications.
  3. More information: Home Care Guidance: Physician Directions to Patient/Parent
Reinstatement of H. influenzae type B (Hib) Booster Dose
The Advisory Committee on Immunization Practices (ACIP) has recommended reinstatement of the fourth dose of Hib vaccine for children 12-15 months who have completed the primary three dose series. At this time, there is a sufficient supply to administer all four doses. The 12-15 month dose should be given on time. Children that initially had the dose deferred should be immunized at their next medical visit.
 
Updates (2009) to the 2003 Recommendations from the AAP Regarding the Use of Palivizumab for RSV
  1. Recommendations for initiation and termination of prophylaxis are modified to reflect current CDC descriptions of RSV seasonality in different geographic locations within the United States.
  2. The recommendations remain unchanged for infants with congenital heart disease, chronic lung disease of prematurity and birth before 32 weeks' gestation.
  3. Regardless of the month when the first dose is administered, the recommendation for a maximum number of 5 doses for all geographic areas is emphasized for infants with hemodynamically significant congenital heart disease, chronic lung disease of prematurity or birth before 32 weeks' gestation and for a maximum number of 3 doses for infants with a gestational age of 32 to 35 weeks without hemodynamically significant congenital heart disease or chronic lung disease.
  4. Risk factors for severe RSV lower respiratory tract disease among infants born between 32 to 35 weeks' gestation have been modified to include only:
    1. Infant attending child care
    2. Siblings living in the household are less than 5 years of age
  5. Infants 32 to 35 weeks' gestation age who are born within the 3 months before the onset of RSV season and throughout the RSV season will qualify for prophylaxis if they have at least one risk factor. Earlier recommendations required 2 of 5 risk factors.
  6. Infants who qualify for prophylaxis in the 32 to 35 weeks' gestation age group should receive prophylaxis only until they reach 90 days of age or a maximum of 3 doses (whichever comes first). This is a change from the previous recommendation for 5 months of prophylaxis.
  7. The AAP's definition of gestational age is used throughout this document. For example, 32 to 35 weeks' gestation is defined as 32 weeks, 0 days through 34 weeks, 6 days.

AAP 2009

Bitten By A Bat? Have We Got Good News For You!
The Advisory Committee on Immunization Practices (ACIP) will now recommend reducing the rabies post exposure prophylaxis (PEP) schedule from 5 doses of active vaccine to 4. This is based upon collected data from 1980 through the present in which no cases of rabies were seen in people lacking the 5th dose of vaccine. This recommendation comes altogether too late for Ozzy Osbourne, however, who in January of 1982 did indeed receive the standard 5 doses of vaccine after an on-stage altercation with a bat in Des Moines, Iowa.

The current rabies PEP for persons not previously vaccinated against rabies is:

Day 0 - Rabies Immune Globulin (RIG) 20 IU/kg (infiltrate as much as possible into wound, and deliver the rest IM) PLUS 1 ml IM of Human diploid cell vaccine (HDCV) or Purified chicken embryo vaccine (PCEC). The RIG and the active vaccine should be delivered at separate sites.

Day 3, 7 and 14- 1 ml IM of Human diploid cell vaccine (HDCV) or Purified chicken embryo vaccine (PCEC).

For people who are immunocompromised, the recommendations are still to give RIG, plus 5 doses of active vaccine on days 0, 3, 7, 14 and 28. Titers should also be done in immunocompromised people 1-2 weeks after the vaccines are given.

For people previously immunized with rabies vaccine, the PEP has not changed, and consists of: two doses of active vaccine on day 0 and 3. No RIG is recommended for patients who have previously been vaccinated with rabies vaccine.

Reducing Complication Rates Associated with Pediatric Outpatient IV Antimicrobial Therapy (OPAT)
Articles and abstracts in the literature show a high rate of complications with OPAT in pediatrics ranging from line infections to adverse drug reactions (drug-induced hepatitis, renal insufficiency and neutropenia).  These complications result in unnecessary emergency center visits and hospitalizations.

When ready for hospital discharge, our infectious disease practice makes every effort to transition pediatric patients to oral antibiotics when feasible. However, there are situations when IV antibiotics are still required. 

The hospital is taking steps to reduce these complications. A pilot program is being initiated at All Children's Hospital to help streamline the care to reduce complications associated with OPAT. The program will include: an infectious disease consultation; case manager that will help arrange the discharge and continue to follow the patient after discharge by phone; appointments arranged with infectious disease and the primary prescriber prior to hospital discharge; follow-up phone calls to the family (including the 1st 24 hours); and follow-up calls to the home health care company. A standard questionnaire will be used for the phone calls and a log will be kept.

Division of Pediatric Infectious Disease (All Children's Hospital)
Adverse Drug Events (ADE) in Children Receiving Outpatient Parenteral Antibiotics (OPAT) for Osteomyelitis
To investigate ADE in children receiving OPAT, data was collected retrospectively from patient records (1986-2005). Children were included if they received at least one or more weeks of IV antibiotics, received weekly labs, and were followed by an infectious disease specialist. Forty-five children met inclusion criteria.  They were treated with 82 courses of antimicrobial therapy with 14 different antibiotics. Age range 5 months to 20 years with a median 9.3 years. Over 50% of patients experienced an ADE. These events included leukopenia (40.9%), hepatitis (20.5%), non-urticarial rash (18.2%), and urticaria (9%). The drug with the highest ADE was vancomycin followed by oxacillin and ceftriaxone. The only antibiotic without ADE was cefazolin. Thirty-two percent of courses of antibiotics had to be discontinued secondary to ADE.

This study is an important reminder to closely monitor children receiving OPAT to monitor for ADE!  This includes weekly laboratories to monitor for signs of hematologic, renal, and hepatic toxicity.

Pediatric Infectious Disease Journal 2009;28 (6):539
Perinatal Hepatitis B Virus Vaccine-Why It Is STILL a Good Idea
If an infant is infected with HBV at birth, that child stands a 90% chance of becoming chronically infected. Among those with chronic HBV infection, 1 in 4 will die a premature death, in most cases related to cirrhosis or hepatocellular carcinoma. Since guidelines for administration of HBV vaccination at birth were set in place, an estimated 6800 cases of perinatal HBV infections have been prevented.

A July 2009 CDC study looked at one particular county in Arkansas with a large Marshallese population. HBV is endemic in the Marshall Islands, with about 10% of the population being seropositive. Indeed, their study found that of those Marshallese mothers tested, about 10% were HbsAg positive (in comparison, the rate was 0.1% for non-Marshallese mothers). Unfortunately, despite their increased risk of HBV positivity, Marshallese women were far less likely than non-Marshallese mothers to have had prenatal screening for HbsAg prior to admission to the hospital (57% vs 91%). However, because of careful attention by the birth hospitals in regard to rapid HbsAg testing on admission and standing orders for HBV vaccine for all infants and HBIG administration (to mothers known to be positive for HbsAg and those with unknown HBSag status), the rate of actual infection with HBV was similar among Marshallese and non-Marshallese women, despite their added high risk. This study highlights the point that the delivery hospital can serve as an effective "safety net" in the prevention of vertically transmitted HBV disease--a concept that should not be dismissed even as our national rates of HBV decline.

Fischer, G. et al. Pediatric Infectious Disease Journal. 28 (7) 2009
Hepatitis E Infection in the United States
We often think about hepatitis viruses A, B, C, and D when a patient presents with viral hepatitis, however, we usually do not evaluate them for hepatitis E. Investigators tested 18,695 serum samples by EIA to measure for hepatitis E antibody in US non-institutionalized individuals. The samples were collected from 1988-1994 and divided into 8 age categories.

21% of the serum samples had hepatitis E antibody detected.  In US born pediatric patients, the seropositivity was less than 10% in the 6-11 year-old group; however, if born in Mexico, the seropositivity was 10-15%.  Increased seroprevalence occurred among individuals born in Mexico between age groups of 12-19 years and 20-29 years. Among all individuals born in the US, the presence of antibody increased with age and was most marked between age groups 20-29 and 30-39 years.  Having a pet at home and consumption of liver (or other organ meat) greater than once per month was significantly associated with seropositivity.  US-born non-hispanic white males living in the Midwest had the highest seroprevalence.

Our clinical impression of this article is that hepatitis E should be included in your differential diagnosis in patients suspected of having viral hepatitis when no other etiology is identified, especially in older children with identified risk factors.

Journal of Infectious Diseases 2009;200:48-56 
Clinical Pearls: Do not Forget Neonatal Herpes Simplex Virus (HSV) Infection Presenting as Pneumonia
As most pediatricians are aware, neonatal HSV may present in three forms: SEM, CNS, and disseminated disease.  The disseminated form may include hepatitis, pneumonia, and  +/- CNS disease.  We have been involved in the care of two patients over the past year that had pneumonia as their clinical presentation of HSV infection.  Pneumonia is frequently overlooked as a viral etiology, particularly in an infant.  Both of these infants presented with respiratory symptoms in the first 1-2 weeks of life. One infant had fulminant hepatic failure but the other infant had very minimal signs of viral hepatitis.

Besides bacterial causes of pneumonia, HSV needs to be on the top of the differential diagnosis in any infant with suspected viral pneumonia presenting in the first 3 weeks of life. Infants should be started on acyclovir pending the evaluation. The evaluation should include viral cultures from all mucosal surfaces (this includes conjunctiva, oropharyngeal, nasopharyngeal and other respiratory specimens, urine and rectal specimens and skin lesions), HSV DNA PCR from the spinal fluid with cytology/chemistry and consideration of HSV DNA PCR from the blood.  HSV infection has devastating consequences if it is not recognized, including fulminant hepatic failure, respiratory failure, and seizures with permanent neurologic sequelae. The next neonate you manage with pneumonia, keep HSV high on the differential diagnosis.

Division of Pediatric Infectious Disease (All Children's Hospital)
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In This Issue
Novel H1N1 (Swine) Flu Update
Reinstatement of H. influenzae type B (Hib) Booster Dose
Updates (2009) to the 2003 Recommendations from the AAP Regarding the Use of Palivizumab for RSV
Bitten By A Bat? Have We Got Good News For You!
Reducing Complication Rates Associated with Pediatric Outpatient IV Antimicrobial Therapy (OPAT)
Adverse Drug Events (ADE) in Children Receiving Outpatient Parenteral Antibiotics (OPAT) for Osteomyelitis
Perinatal Hepatitis B Virus Vaccine-Why It Is STILL a Good Idea
Hepatitis E Infection in the United States
Clinical Pearls: Do not Forget Neonatal Herpes Simplex Virus (HSV) Infection Presenting as Pneumonia
Our New and Improved Infectious Disease Newsletter
Tune in to upcoming Grand Rounds ID topics
Infectious Disease Recommendations for International Travel
Genetic Predisposition to Infectious Disease Based on Blood Group
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.

Inpatient Consultation:
All Children's Hospital
Tampa General Hospital
Bayfront Medical Center Nursery

Outpatient Clinics:
Infectious Disease
International Adoption

Phone: 727-767-4160
Fax: 727-767-8270
Email: pidhl@allkids.org
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:
 
August 21
A Century of Influenza
Dr. Juan Dumois
  

August 28
Cat Scratch Disease Update
Dr. David Berman
  

September 11
Infections in Cancer Patients
Dr. John Greene
Infectious Disease Recommendations for International Travel
The new Centers for Disease Control and Prevention (CDC) Yellow book has been published for 2010. This document contains updated information for individuals traveling outside the US.  The book is broken down into 9 chapters covering various travel topics including: required vaccinations by country, discussion of vaccine preventable diseases, advice for prevention of vector borne illness, and management of the returning traveler with illness.  The book can be purchased in hard copy or viewed from the CDC website free of charge.

Genetic Predisposition to Infectious Disease Based on Blood Group
A group of investigators from India studied blood group susceptibility to Chikungunya fever to determine whether a particular blood group would make an individual susceptible or resistant to clinical disease.  Chikungunya virus is transmitted by the Aedes mosquitoes.  The symptoms include chills, headache, fever, and severe arthralgias. There have been outbreaks in India, other areas of SE Asia, and Italy.  During an outbreak from July-October 2006, investigators identified 100 affected families with a total of 468 members. Blood groups were identified from the 468 individuals. Patients were assessed for disease symptoms. Of the 468 subjects, the most susceptible subjects appeared to be blood group O+ 227/235 (96%). A+ 85/106 (80%), B+ 56/94 (60%), and AB+ 5/20 (25%). There were 12 subjects that were Rh- among A, B, and O blood groups (none in AB). None of the 12 patients had disease symptoms. 

This study highlights the importance of genetic susceptibility to infectious diseases.

Virology Journal 2009; 6 (77)