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Tag: urinary tract infection

Published on Leave a comment on “The horror! The horror!”*

Well, not really horror stories, but it was a slow week for epidemics that allowed me to finish two somewhat disturbing pieces of literature. First, the news.

I'm pleased to report nothing particularly new on the measles front, so I won't bother with the recitation of statistics and graphs. Based on the measles incubation period, it appears we are out of the woods from the Chicago clusters thanks to excellent public health interventions. The Florida school issue hasn't surfaced again though we are still lacking accurate descriptions of how it was managed - did un-immunized children isolate at home, were catch-up immunizations administered?

A Few Covid Updates

This past week the World Health Organization Technical Advisory Group on COVID-19 Vaccine Composition (TAG-CO-VAC if you're attracted to cumbersome acronyms) advised use of a monovalent JN.1 variant vaccine for the next iteration. Although the WHO TAG-CO-VAC doesn't make official recommendations for the US, none of these discussions occur in a vacuum and I expect the FDA VRBPAC to come to the same conclusion when they meet on the subject on May 16. The CDC/ACIP likely will rule on this in late June, in time for potential fall booster recommendations.

The most recent variant tracking in the US largely shows JN.1 and its offspring as predominant.

Here's the latest family tree in the US showing the.relationships of the currently circulating variants.

Also noteworthy is a change in hospital covid reporting. As of May 1, hospitals no longer are required to report covid hospitalizations. Although efforts are underway to go back to mandatory reporting, for now all hospital reporting is voluntary which will likely mean no reporting for many institutions. So, don't try to compare future covid hospitalization rates to prior data. It would be another apples and oranges comparison.

Lessons From Quality Improvement

This month's issue of Pediatrics contained some QI articles. They are worthwhile reading for the QI aspects, but I think many front-line pediatric healthcare providers might want to compare their own practices to the standards used in two of the studies concerning infectious diseases.

The first of the studies involved standards for management of well-appearing febrile infants ages 8 to 60 days in emergency departments. Parenthetically, I'm in awe of the authors for pulling off a multi-institutional research study in the midst of the pandemic. I barely had time to breath during some of those months.

The authors looked at multiple outcomes, and I won't go into the actual QI processes themselves. Here are the primary measures they sought to improve (remember these are all well-appearing infants):

  • 90% of infants 29–60 d with normal inflammatory markers (and either a negative UA or a positive UA) DO NOT have CSF obtained 
  • 90% of infants 29–60 d with normal inflammatory markers and negative UA discharged from the ED 
  • 90% of infants 29–60 d with normal inflammatory markers and negative UA DO NOT receive antibiotics 
  • 90% of infants 8–60 d with negative cultures have appropriate discharge from the hospital within 36 h from the time blood cultures were received by the laboratory 

How does your local ED or practice compare?

The second article also was hospital-focused and carried out during pandemic peaks. It dealt with minimizing unnecessary antibiotic use in common pediatric infections for children above 60 days of age. Again, many outcomes were examined, but think about these in your own practice:

  • Antibiotic duration for community-acquired pneumonia < 10 days
  • Antibiotic duration for UTI < 10 days
  • Antibiotic duration for skin and soft tissue infections < 5 days

The above durations for CAP and UTI probably are too long. It would be difficult to justify therapy beyond 7 days for these entities assuming good clinical response, and courses as short as 5 days have been suggested.

There's a lot more to these studies that I haven't mentioned. Please look at them if you manage these types of patients in your practice.

Of Cows and Cats

Bird flu, primarily influenza A H5N1, continues to surprise us. Let me state up front, however, there is no reason to be overly concerned about consumption of pasteurized dairy products or getting rid of your pet cat. People who ingest unpasteurized dairy or have close contact with cows or chickens (including those backyard coops) need to be cautious.

The count of bird flu in wild mammals continues to expand:

Genetic testing of dairy cow milk samples and of 2 cats who died at the dairy farm strongly suggests transmission of influenza A H5N1 from cows to cats. The cats had ingested unpasteurized milk at the farm. The cows were only mildly ill, but the cats had severe neurologic symptoms due to the virus. This report concerns only a few animals but at the least suggests that humans could be at risk for infection from unpasteurized dairy products.

We still have only one known human infection related to dairy cows in the US, but now we have more details about that case. As reported earlier, this dairy farm worker had mild symptoms consisting of pain and redness of the right eye. Especially given the perhaps mild and atypical presentation of influenza in this instance, more testing of asymptomatic dairy workers and other high risk individuals is needed.

I had mentioned in previous posts I'm trying to monitor USDA updates on this situation, but so far most have just clogged my inbox with irrelevant notices. I did receive one relevant alert that at least told me someone is watching out for us. Due to concerns about bird flu in the Chiba prefecture in Japan, imports of live birds as well as bird products and byproducts are prohibited. In case you are thinking about bringing back some bird souvenirs from Chiba, please be aware:

"Processed avian products and byproducts, including eggs and egg products, for personal use originating from or transiting a restricted prefecture and entering in passenger baggage must:  

  • have a thoroughly cooked appearance; or 
  • be shelf-stable as a result of APHIS-approved packaging and cooking (i.e., packaged in a hermetically sealed container and cooked by a commercial method after such packing to produce an article that is shelf stable without refrigeration); or  
  • be accompanied by an APHIS import permit and/or government certification confirming that the products or byproducts were treated in accordance with APHIS requirements. 

Unprocessed avian products and byproducts for personal use or in passenger baggage originating from or transiting a restricted prefecture will not be permitted to enter the United States. This includes hunter harvested, non-fully finished avian trophies and meat."

Reliable information on bird flu is increasing. It seems very likely that pasteurization effectively inactivates live H5N1 from dairy products and that these influenza strains remain susceptible to commonly available antiviral agents used for influenza. But, I still have questions:

  • What is the range of symptoms of avian flu infection in a wide range of animals, including humans?
  • How common is asymptomatic infection in various species?
  • What is the specificity and sensitivity of commonly-used influenza detection methods for influenza A H5N1?

For now, even though we are beyond our winter flu season, anyone with flu-like illness should be tested for influenza and also asked about exposure risks involving domestic or wild animals or ingestion of unpasteurized dairy products. Look to the CDC website for guidance.

My Disturbing Week

My wife abandoned reading Ian McEwan's latest novel, Lessons, due to its unsettling content in its early pages. Nonetheless, I decided to slog through this nearly 500-page tome and found I couldn't put it down. It was truly disturbing, including depictions of abuse of the young male protagonist that were hard to read. Ultimately, though, I found the novel very thought-provoking in spite of the fact that the protagonist wasn't very likable and seemed to respond passively to much of his life events. These events were shaped by a series of historical occurrences that also were meaningful to me: World War II (before my time, but still significant) the Cuban missile crisis in the 1960s, the fall of the Berlin wall, the September 11 attack, and more recently the January 6 attack, among others.

About a week ago I happened to watch Apocalypse Now Redux, the longer version of the 1979 movie about the Vietnam War which itself was a take on Joseph Conrad's Heart of Darkness. The longer movie version added more uncomfortable scenes to the already unsettling original. As a boy I had read at least 3 of Conrad's novels plus maybe a few short stories, but never Heart of Darkness. It's really a novella, just under 150 pages, and I felt compelled to read it this week. I loved it, as I do most of Contrad's works. More than that, I was astounded at how deftly the novella was transplanted from the late 19th century into late 1960s Vietnam. How did it not win the academy award for best adapted screenplay? (That was Kramer vs. Kramer.) I found myself waiting to see if the 19th century Kurtz would have the same *final utterance as in the movie version. You'll need to read the book to find out!

My Respite Week

Given the slow times in infectious diseases (now I've jinxed myself) and a busy week of other activities in front of me, I'm planning to skip a Sunday post for Mother's Day. Barring any major events, I'll see you next on May 19.

Published on Leave a comment on Are You an Owl or a Lark?

Another round of Daylight Saving Time. I came across a new article suggesting that potential harms of DST depend on your individual chronotype, or, more simply, whether you are an owl or a lark. I definitely fall into the lark category. More on this later, but let's dive into what's been happening in pediatric infectious diseases the past week.

New IDSA Laboratory Test Guidelines

Just out is an updated guideline from the Infectious Diseases Society of America. It might be my favorite guideline of all time, but at 244 pages I recognize it's not for everyone. Let me mention a couple items that I notice some frontline healthcare providers may not know about but are important to avoid misleading test results (a garbage-in-garbage-out scenario).

First concerns the use of swabs, starting on page 8 of the pdf guideline document. Always use a swab for sampling throats, conjunctiva, superficial wounds (aerobic culture only), some nose, nasopharynx, and vaginal testing, and sometimes in special circumstances related to institutional- or manufacturer-related instructions for the product. Never use a swab for surgical tissue - submit the tissue itself making sure it doesn't dry out before processing. The same applies for "respiratory fluids and secretions, endophthalmitis and keratitis, nasal sinus, otitis media, biopsy, abscess fluid, fungal and acid-fast bacilli specimens, formed stool, epiglottitis, diarrheal illness, and when anaerobes are suspected opt for tissue or fluid in anaerobic transport... Never submit a swab for analysis that has been dipped into a fluid or exudate. Send an adequate volume of the fluid or exudate instead." There's also an in-between situation where larger volume sampling isn't feasible, such as with an open wound (at least obtain a needle aspirate of leading edge).

The second pertains to urine specimens, the bane of my existence when consulting on possible UTI based on specimens that have sat around for considerable time before processing, such as placed in a lab collection box in an outpatient setting. Some key points, starting on page 119: "Urine collected for culture should not be kept at room temperature for more than 30 minutes. Hold at refrigerator temperatures or utilize a preservative tube if not processed by the laboratory within 30 minutes." The authors also mention the perils of relying on urinalysis because techniques have not been standardized and often require subjective interpretation. Especially if you are dealing with a child with possible UTI, obtain a good mid-stream voided or catheterized urine specimen and, again, don't let it sit at room temperature too long before analysis.

Different considerations arise when sampling urine for sexually transmitted infection - here, the first portion of urine voided is best for detecting pathogens by nucleic antigen amplification testing.

Speaking of Throat Swabs

The biggest problem in diagnosis of streptococcal pharyngitis is performing throat testing in children highly unlikely to have streptococcal pharyngitis. In this setting, a positive result is much more likely to represent a clinically-irrelevant carrier state and result in unnecessary antibiotic exposure for the child. Some heavy hitters in the group A streptococcal world published a review on this recently, but unfortunately it is not available without subscription to the journal. The authors describe differences in GAS testing between the US and Europe, compare and contrast rapid antigen detection and NAAT testing, and again mention situations where testing should not be performed: children less than 3 years of age unless known exposure, children with signs of viral infection including cough, runny nose, or hoarseness, and absence of "bona fide" clinical suspicion for strep throat if you use a clinical scoring system such as Centor or McIsaac.

Nirsevimab Worked Liked We Hoped

Nirsevimab effectiveness was 90% in preventing hospitalization for RSV infection in infants during their first RSV season, according to CDC data on 699 hospitalized infants. This is actually at the upper end of the confidence interval from prior clinical trials.

AI for Otitis Media

I seem to be on a track of personal banes of my existence as a consultant; misdiagnosis of acute OM is near the top. Although I don't see any of us being replaced by artificial intelligence anytime soon, a new report has some glimmer of hope that it might help us with AOM. It uses a not-yet-available iPhone app with an otoscope; you can use voice to control when to take a photo. Watch the video (at the link to the article, not in the screenshot below) to get an idea of what's involved. It's not nearly ready for prime time, but stay tuned.

Is Covid a Risk for Development of Autoimmune Rheumatologic Inflammatory Disorders?

This study of millions of adult patients from Korea and Japan utilizing a claims database would suggest that it is, with adjusted hazard ratios around 1.25 - 1.3. So far this is just an association and does not determine causality. Also, genetic risks for autoimmune disorders differ in Asian versus US populations (think Kawasaki Disease), so the results may not be broadly applicable.

Influenza is Still With Us

I've officially retired my WRIS (Winter Respiratory Infection Season) section. Really we're only waiting for flu to wind down, though we still have too many covid hospitalizations and deaths. Here's the most recent Fluview map, looking a little more encouraging:

In the meantime, the FDA VRBPAC met on March 5 to officially recommend trivalent vaccines for next fall. The disappearance of the B/Yamagata lineage means we won't need a quadrivalent vaccine as in past years. Next up is CDC/ACIP recommendation in June.

Medical Injustices in the Past

It was painful for me to read, but I highly recommend the NEJM series highlighting medical injustices and biases perpetuated in its publications. The current article is about eugenics. Apparently there were a few voices trying to speak up against these practices in the early part of the 20th century, but they were drowned out by the majority, many of them physicians. You don't need a subscription to the journal for this series.

My Inner Lark

On a lighter note, I was delighted to learn that I might not be at such high risk for adverse events of Daylight Saving Time. A recent study looked at the effects of the DST change on sleep and work productivity in 155 full-time workers in Germany utilizing survey methodology. The effects varied with individual chronotype; that is, the "owls" are those that tend to stay up and wake up later than "larks," the early to bed and early to rise group. There's actually a tool to determine chronotype! The study found that us larks are less affected by the shift to DST.

Lots of evidence exists that the DST shift is associated with harmful effects, from medical illness to car crashes to work productivity. However, this is an extremely messy phenomenon. We have good evidence that the shifts are associated with poor circadian rhythms, a biologic plausibility for harmful outcomes, but only an epidemiologic association with these bad outcomes. With too many factors that can't be controlled or accounted for, probably the only way we will know if DST is bad is if the bad outcomes lessen when we quit using DST. I recall 2 prior instances where an epidemiologic association was likely confirmed to be causal: the association of aspirin use with Reye Syndrome in children, and the association of infant sleeping position with Sudden Infant Death Syndrome. The aspirin industry fought against the concept, but Reye Syndrome essentially disappeared when aspirin use for symptom relief in young children ended. SIDS rates plummeted with the Back-to-Sleep programs.

I don't recall ever seeing a lark, but apparently a subspecies of horned lark inhabits Maryland. I guess I'll need to rise early to spy one.

From CornellLab All About Birds.

Published on Leave a comment on The Future is Bright

2023 wasn't exactly the best of years, but at least we didn't slip back into pandemic circumstances. I fear we will see some "old" infections become new again in 2024. General immunization rates are falling; even before that, we saw plenty of pertussis and even some tetanus, but now we may become reacquainted with measles and varicella, among other vaccine-preventable diseases. Time for some of those younger pediatric healthcare providers who have never seen children with these infections to hit the textbooks again - how's that for a New Year's resolution!

Still, we have lots of reasons to hope for improvements in 2024. Maybe AI won't take over the world but instead will help us practice more effectively.

Short Course Therapy for Febrile UTI in Children

The literature just got a bit muddier with regard to treatment duration for pediatric UTI with a new study from Italy. Investigators in 8 pediatric emergency departments randomized 142 children ages 3 months to 5 years with fever and UTI to receive either 5 or 10 days of oral amoxicillin/clavulanate. The study wasn't blinded, and the randomization occurred on day 4 of therapy when urine culture results were available. UTI was defined as a single organism growing at >100,000 cfu/ml in clean catch urine or > 10,000 cfu/ml in catheterized urine, and subjects were followed for 30 days after completion of antibiotic. After a planned interim analysis the study was stopped early due to finding of noninferiority of the short course therapy.

As you can see, the short course group had numerically lower rates of UTI recurrences during this time period. However, this study's results contradict another study, with a somewhat more reliable study design and definitions, that showed short course therapy to be inferior. I reviewed this earlier study in my July 2, 2023 post. The editorial accompanying the new study is an excellent discussion of weighing the relative merits of the 2 studies. Suffice to say, the jury is still out, and I would stick with 10 days of therapy for febrile UTI in most children.

More Evidence for Using Nirsevimab to Ameliorate Bad Outcomes from RSV

Investigators in 3 European countries conducted a randomized trial of the long-acting monoclonal antibody nirsevimab showing benefits in preventing RSV-associated hospitalization, especially in younger infants. Note that subjects for this study were not eligible for receiving nirsevimab currently in these countries; they were all healthy infants less than 12 months of age, born at > 29 weeks gestation, who were entering their first RSV season.

This was a pragmatic trial, meaning that it was carried out under more "real-world" practice situations rather than within the strict confines of "explanatory" trials used with most therapeutic research studies. It lends more evidence to benefits of nirsevimab for young children.

WRIS (Winter Respiratory Illness Season)

Most pediatric healthcare providers across the country know that we are in the midst of a busy WRIS. This also is a time when data are least reliable due to the extended holiday season - reporting lags a bit, so trends seen now are more likely to be revised in the next few weeks. Still, it's worth a look.

Researchers in Stockholm, Sweden, looked at pediatric hospitalization rates for the 3 "tripledemic" viruses during the period 8/1/21 to 9/15/22 and found that rates were higher for RSV than for omicron covid (the time period was entirely omicron in Sweden) or influenza; note especially the numbers for younger children. I'll be interested to see if this pattern is seen in the US this winter.

CDC has a new (to me) section charting epidemic growth status for covid and influenza, i.e. it depicts, by locale, the growth rates but not the absolute numbers of these pathogens. Another interesting tidbit.

Along the same lines is a monthly crystal ball page from CDC, a bit of sticking their necks out to predict what's in our future for respiratory illnesses. The last report is from November 29:

Lots of uncertainties here, but I appreciate the attempt.

Now for a look at our usual sources for data.

FLUVIEW

Circulating strains are still well-matched to this year's vaccine.

Covid wastewater is increasing, and several healthcare facilities across the country have reinstituted masking and other mitigation practices due to high rates in their communities.

RSV is the one "tripledemic" component that seems to be decreasing in most areas.

So, WRIS this year seems to be a double-whammy rather than a tripledemic, still more than enough to strain healthcare resources. I can only dream how much better people's health would be with widespread vaccine acceptance.

We're Still Safe from the AI Bots

I tried to use an AI program, Microsoft Copilot's Suno, to compose a song about this blog. Specifically, I asked it to create a song about the Pediatric Infection Connection blog using the blues genre. Here's what I got.

Their link doesn't exist, nor is there a pediatric infectious disease specialist Dr. Sarah Jones certified by the American Board of Pediatrics. I did find a Sarah Jones infectious diseases pharmacist at Boston Children's Hospital, but she doesn't appear to have a blog and I don't know if she has children.

I think, for the next year, we'll still be able to keep AI from fooling all of us.

Have a Happy and Safe New Year!

Published on Leave a comment on Try to See It From Grendel’s Perspective

Ever read Beowulf? Me neither. Nor do I plan to ever read this epic poem consisting of 3182 lines of alliterative verse. Recently I did read Grendel by John Gardner. Grendel is the monster who was killed by Beowulf in the famous poem. Gardner's book is told entirely from Grendel's perspective, very different from how Beowulf and the other humans saw things of course.

Malaria Season

Practicing in the Washington, DC, area for almost 40 years meant that I had a steady diet of malaria. Our "malaria season" was towards the end of summer when vacationing families returned home after visiting relatives in malaria-endemic countries. This seasonality abated a bit during the pandemic when international travel was scarce, then came back with a vengeance. Now, however, autochthonous malaria has been reported in Florida and Texas.

Autochthonous, from the Greek autokhthon meaning "sprung from the land itself," in this instance refers to malaria acquired without visiting a malaria-endemic country. I didn't mention the initial CDC report a couple weeks ago, but now that a second state is involved and CDC issued a health alert advisory, I'll attempt to summarize what's happening.

We still have virtually no clinical details about any of the 5 cases, but CDC implied they are all due to Plasmodium vivax which is not as severe/deadly as P. falciparum. Autochthonous malaria in the US was common in the old days, but since effective mosquito control programs in the 1950s it has been scarce. Prior to the current reports, we hadn't seen autochthonous malaria since 2003. High risk areas in the US are those that have high population density, plenty of Anopheles mosquitoes (including favorable conditions for their reproduction), and a source of people who have recently traveled from malaria-endemic areas. So, it's not surprising that Florida and Texas are points of origin now.

Speaking of mosquitoes, climate change has greatly increased the range of various insect vectors of disease; for example, Lyme disease risk has expanded geographically in recent years as deer ticks broaden their range. Anopheles mosquitoes are present in virtually the entire US.

For frontline providers, malaria shouldn't be the first thing to suspect in a child with fever in the US, but recognize that in cases of prolonged fever it is a consideration even without a history of international travel. Look at the CDC's malaria website for more details, and read this article if you want to see a longer discussion of (prepandemic) autochthonous malaria.

Foodborne Disease is Back

Another sign that the pandemic is lifting is this CDC report of 2022 data. Certain foodborne illnesses such as Shiga toxin-producing Escherichia coli, Yersinia, Vibrio, and Cyclospora infections increased compared to 2016–2018 data; Campylobacter, Salmonella, Shigella, and Listeria incidences didn't change much. Although they didn't show the data in this report, foodborne diseases decreased in the 2020-2021 time period.

I was a bit disappointed that, although the report did mention increased use of culture-independent diagnostic testing rather than culture, it did not mention the fact that the highly sensitive CIDT methods can be more prone to false positives. This makes it difficult to compare trends across time periods.

Ideally one would perform a backup culture test for bacterial pathogens particularly to detect antimicrobial resistance; CIDT can not test for this.

Can We Shorten Treatment Duration for Pediatric Urinary Tract Infection?

The short answer is yes, but the more difficult question is how to decide which patients are appropriate for shortened therapy. Even this randomized controlled trial couldn't answer that question. The study compared 5 versus 10 days of therapy for UTI in children 2 months to 10 years of age. Children who showed clinical improvement at 5 days treatment were then randomized to another 5 days of antibiotic versus placebo. Failure rate in the 10-day treatment group was 0.6% versus 4.2% in the 5-day group.

Ultimately I think the details of study design doomed this trial to leave this question mostly unanswered. In particular the duration of followup after stopping antibiotic was too short for the 10-day group (which would have skewed results to a falsely low failure rate). Fundamentally the problem with UTI treatment in children is trying to determine which children have pyelonephritis versus just cystitis, much more difficult in children than in adults. Pyelonephritis likely requires more than 5 days of treatment.

This study definitely adds to our understanding of pediatric UTI but I don't think is immediately transferrable to clinical practice. The accompanying editorial offers some ideas in this regard.

'Demic Doldrums

We continue to enjoy relief from covid from the standpoint of no evidence of major surges around the world, just continued pockets of upswings in disease activity (tempered by the knowledge that we aren't tracking it very well now). Of course, the number of total cases in this WHO graph, as of June 28, is pretty depressing overall.

According to WHO, confirmed covid deaths now number 6,947,192.

Blood Group and Covid

I have blood group A positive. Should I be worried? It's been known for a while that individuals with type A blood have a slightly higher risk of SARS-CoV-2 infection, and this recent article lends some credence to these observations by supplying a biologic explanation. The A blood group antigen is very attractive to the receptor binding domain of the virus, including omicron variants. But no, I'm not concerned. The increase in infection risk attributable to blood group is very small, paling in comparison to other risk factors.

Whatever Happened to Wastewater Monitoring?

In the US, wastewater monitoring for viruses like SARS-CoV-2 has great potential but is ineffective because it involves voluntary reporting by states. Most people in the US live in areas that don't monitor wastewater. Our northern neighbors in Canada, specifically Peel, Ontario, provide evidence that wastewater monitoring truly can be an early warning for increased infections. Investigators reported that wastewater levels predicted very reliably 1 day before the rise in infections and 4 days before a rise in hospitalizations during the omicron period of November 2021 to June 2022. At this point I'm not sure if the US has the resources to implement wastewater virus monitoring on a larger scale.

Better Evidence for MIS-C Treatment

The multi-system inflammatory syndrome in children is still difficult to diagnose precisely. Thankfully MIS-C seems less common in today's covid era with omicron dominance and high levels of antibody in the population. Now we have some better guidance for immunomodulatory therapy for MIS-C. This meta-analysis suggests that the combination of intravenous immunoglobulin plus glucocorticoid therapy improved cardiovascular dysfunction better than either agent alone. The study was very well done but had to rely heavily on nonrandomized cohort studies which introduces a great degree of bias in the results. We missed a chance by not conducting large RCTs of MIS-C treatment early in the pandemic.

Understanding Grendel

I needed to consult Wikipedia and other Cliff Notes-like versions of Beowulf to understand Gardner's book. As with everything I read, I think about what, if anything, might apply to me. With Grendel and Beowulf it was relatively easy. When faced with dramatically different perspectives, say for example pandemic deniers or anti-vaxxers (Grendel) versus traditional science and medicine (Beowulf), it's a good idea to try to see things from the opposing perspective. If one can do this without resorting to raised voices or worse, it's possible to have a meaningful dialog and even occasionally change minds, even my own! Next time you see me, look for Grendel perched on my shoulder. For those less prone to wild fantasies I recognize this is quite a stretch, but regular readers are accustomed to my tangents.

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Published on 2 Comments on Watching My New Washing Machine

About 6 weeks ago, our washing machine's spin cycle started making noise and vibrations equivalent to the latest SpaceX rocket launch. After much hand-ringing and YouTube consulting, my wife and I decided it was time to move on from our elderly washer, initiating another round of internet searching. Our laundry space is very small. limiting our choice of washers. We ended up with a top-loading version equipped with a window in the top, making for some interesting entertainment better, than most of what's available on cable or streaming venues.

In the midst of all this upheaval, I somehow managed to keep an eye on infectious diseases.

Severe Neonatal Enteroviral Disease in France

In early May French authorities reported on several cases of severe enteroviral infections in neonates, summarized by the World Health Organization on May 31. Nine newborns developed late-onset sepsis syndromes with severe hepatitis and multi-organ involvement, resulting in 7 deaths. All had developed some symptoms by 7 days of age, typical of perinatal transmission from mothers. Cases were spread out since July 2022 and over 3 different regions but remarkably included 4 sets of twins.

ECHOvirus type 11 was detected in all 9 of the infants and in 4 of the 5 mothers tested. (A side note: I have capitalized ECHO because it is an acronym for Enteric Child Human Orphan. This came about because the original reports of ECHO viral isolation were from stool samples of human children; however, the children weren't orphans. Instead, it was the virus that was an orphan, because the children were asymptomatic. The virus was orphaned from any disease. This is a reminder that most enteroviral infections, even polio, are asymptomatic.)

Enteroviruses circulate worldwide all the time, with increases in the US usually in late summer. Enteroviral infection is always on the differential of neonatal sepsis syndromes.

Don't Work When You Are Sick

Easy to say, but in the past I've been guilty of toughing out a mild upper respiratory infection at work, trying to be diligent about hand washing, etc. Those days should be gone in our current covid era.

It's not surprising to see a new CDC report showing that a large number of foodborne illness outbreaks can be traced to sick restaurant workers. Almost 70% of 800 foodborne outbreaks reported to CDC from 2017-2019 had an identified etiology, and around 40% of those were traced to sick or infectious food workers. Norovirus was by far the most commonly identified at 47%, followed by Salmonella at 19%.

Handwashing, anyone?

Updated Hepatitis C Guidelines

We have updated hepatitis C management guidelines, including for children as young as 3 years of age. In pediatrics most of these cases will require subspecialty referral, but primary care providers should be aware of the key points. Thankfully, mother to child transmission of HCV is relatively uncommon, as I mentioned in my post last March 12.

Sonographic Testing in Febrile UTI

A group of investigators from Toronto and Ottawa, Ontario, Canada, performed a superb meta-analysis looking at the outcomes of obtaining renal ultrasound in children < 24 months of age at the time of first febrile UTI. I include it here because it demonstrates the most common outcome of a meta-analysis: no information that can be immediately incorporated into clinical practice.

The authors reviewed the varying guidance for when to obtain renal sonography in childhood UTI. The problem with sonography, in addition to the costs and inconvenience for families, primarily involve identification of trivial abnormalities that lead to unnecessary further tests and treatments, aka Ulysses Syndrome. I won't dwell at all on the complex statistical methods and only say that I was very impressed with the authors' thoughtfulness in constructing the approach.

Their initial literature search identified 2362 studies, culled down to 29 studies with an aggregate of 9170 subjects after applying predetermined study inclusion criteria. Nineteen of those studies were retrospective in design, with 10 involving prospective cohorts. None were randomized controlled trials or prospective comparisons of management strategies (e.g. comparing children who had sonogram after first febrile UTI versus obtaining after the second UTI). In this collection of studies, sonographic abnormalities were found in 22% of children. Most of these were clinically insignificant. In the 8 studies (2569 children total) that defined a population with clinically important abnormalities, the prevalence was 3.1% as seen in the forest plot below.

I include this figure to draw your attention to 2 things. First, look at the large variation in rates among the individual studies. Second, note the high numbers for heterogeneity. Heterogeneity refers to how different the designs of the individual studies were from one another, and high heterogeneity is a red flag for lower confidence in the results of a meta-analysis. It's sort of like a scale of comparing apples to apples (low heterogeneity) versus apples to oranges (high heterogeneity).

The end result of this study is a very clear roadmap for design of studies to decide if and when to perform renal ultrasonography in pediatric UTI. Most importantly, we must have prospective studies with comparison groups, to provide guidance to clinicians. The authors also highlighted the absence of any studies looking at parent-reported outcomes.

'Demic Doldrums

Last week saw a few noteworthy updates. CDC provided more information about covid transmission during the first in-person Epidemic Intelligence Service meeting since before the pandemic. In this meeting that occurred in late April, 1443 of 1800 in-person attendees responded to a CDC survey regarding covid infection. 181 (13%) tested positive, 49 received antiviral therapy, and thankfully none were hospitalized. 99.4% had received at least 1 vaccine dose prior to the conference.

An international group reported some success with a whole-blood transcriptional RNA "signature" to diagnose MIS-C. Using a discovery population of 38 children with MIS-C, 136 with Kawasaki Disease, 138 with viral infection, 188 with bacterial infection, and 134 healthy controls, they identified 5 genes to include in the signature. They then tested this in a validation study utilizing 37 MIS-C, 17 KD, 41 non-covid viral infections, 50 bacterial infections, and 24 healthy controls. They found reasonable correlations of the RNA signatures with the pre-established diagnoses, but of course the main problem is deciding whether the pre-established diagnoses were correct, i.e. we may not have a great gold standard for comparisons. I'll be watching closely for further studies on larger and more varied clinical populations.

The Washer Channel

Our laundry closet is microscopic, meaning we had few choices for what would fit in the space, not to mention our desire to have an ecologically sound machine. We ended up with an impeller model, new to us and therefore a source of curiosity. This week I finally finished watching the "Lucky Hank" series that I recorded and had mentioned in my April 23, 2023 post. It was interesting to see how Richard Ford's book was changed for the smallish screen. If you were thinking about watching "Lucky Hank," in my opinion you are better off reading the book, or even just watching your washing machine.

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