Background Telehealth (TH) practices among pediatric infectious disease specialists prior to the coronavirus disease 2019 (COVID-19) pandemic are largely unknown. Methods In 2019, the Pediatric Infectious Diseases Society (PIDS) Telehealth Working Group surveyed PIDS members to collect data on the use of TH modalities, adoption barriers, interest, extent of curbside consultations (CC), and reimbursement. Results Of 1,213 PIDS members, 161 (13.3%) completed the survey, and the responses of 154 (12.7%) from the US were included in our report. Medical school (63.6%) and hospital (44.8%) were the commonest work settings with 16.9% practicing in both of them. The most common TH modalities used were synchronous provider-patient virtual visits (20.8%) and synchronous provider-provider consultations (13.6%). TH services included outpatient consultations (48.1%), vaccine recommendations (43.5%), inpatient consultations (39.6%) and travel advice (39.6%). Barriers perceived by respondents included reimbursement (55.8%), lack of experience with TH (55.2%), lack of institutional support (52.6%), lack of administrative support (50%), and cost of implementation (48.7%). Most respondents (144, 93.5%) were interested in implementing a wide range of TH modalities. CCs accounted for 1-20 hours/week among 148 respondents. Conclusions Most of the PIDS survey respondents reported low utilization of TH and several perceived barriers to TH adoption before the COVID-19 pandemic. Nonetheless, they expressed a strong interest in adopting different TH modalities. They also reported spending considerable time on non-reimbursed CCs from within and outside their institutions. Results of this survey provide baseline information that will allow comparisons with post-COVID-19 changes in the adoption of TH in PID.
Background Rat-bite fever (RBF) is a rare, systemic illness caused by infection with Streptobacillus moniliformis. RBF has a case-fatality risk of 7%-10% among untreated patients. Over 200 cases of RBF have been documented in the United States, but this is likely a significant under-representation because RBF is not a reportable disease. The diagnosis of these infections can be limited by: (1) Streptobacillus moniliformis fastidious nature and difficulty to culture; (2) the nonspecific manifestations of the infections and clinical overlap with a broad differential diagnosis; and (3) the unreliability of rat exposure history. We demonstrate use of unbiased microbial cell free DNA (mcfDNA) next-generation sequencing (NGS) to overcome these diagnostic limitations. Method The Karius Test (KT) was developed and validated in Karius’s CLIA certified/CAP accredited lab (Redwood City, CA) to detect and interpret mcfDNA in plasma. After mcfDNA is extracted and NGS performed, mcfDNA sequences are aligned to a curated database of > 1000 organisms. McfDNA from organisms observed above background at statistical significance are reported and quantified in molecules/µL (MPM). KT detections of Streptobacillus moniliformis were reviewed from January 2017 - June 2021; clinical information was obtained with test requisition or consultation upon result reporting. Results KT detected 7 cases of Streptobacillus moniliformis at an average of 673 MPM (35-3078; SD 1185) with an average turnaround time of 28.5 hours (SD 8.4) from sample receipt from 6 unique institutions (Table 1). Six patients were children; all were immunocompetent. Fever and rash were the most common presentation in the majority of the cases. Five of seven patients had arthritis or osteomyelitis while the remaining two patients had arthralgia. A history of rat exposure was elicited in all cases (some after microbiological diagnosis). In all patients blood cultures were negative and mcfDNA NGS was the only means of microbiological diagnosis. Conclusion Unbiased plasma-based mcfDNA NGS provides a rapid, non-invasive test to diagnose diverse clinical infections by Streptobacillus moniliformis. These cases highlight the potential of the KT to effectively identify infections caused by fastidious/unculturable pathogens with non-specific clinical manifestations and broad differential diagnoses.
Background Children with nephrotic syndrome are at increased risk of infections, including bacterial peritonitis, pneumonia, and cellulitis. However, bacterial meningitis, a potentially life-threatening complication, has not been highlighted as an infectious complication of nephrotic syndrome in recent reviews. We report a very subtle and unusual presentation of bacterial meningitis in a child with nephrotic syndrome, which without a high index of suspicion, would have been missed. Case presentation A 9-year-old African-American male with a history of steroid-dependent nephrotic syndrome presented to the nephrology clinic for routine follow-up. His medications included mycophenolate mofetil and alternate-day steroids. His only complaint was neck pain and stiffness that the mother attributed to muscle tightness relieved by massage. There was no history of fever, vomiting, headache, photophobia, or altered mental status. On physical examination, he was afebrile (99 °F), but had mild periorbital swelling and edema on lower extremities. He appeared ill and exhibited neck rigidity, and demonstrated reflex knee flexion when the neck was bent. Laboratory evaluation revealed leukocytosis, elevated C-reactive protein, hypoalbuminemia, and proteinuria. Cerebrospinal fluid suggested bacterial meningitis. The patient was treated with ceftriaxone and vancomycin. Both cerebrospinal and blood cultures grew Streptococcus pneumoniae; vancomycin was discontinued. The child completed a 2-week course of ceftriaxone and was discharged home. Conclusions A high index of suspicion is necessary in children with nephrotic syndrome treated with corticosteroids, as symptoms may be masked, and thus, a life-threatening disease be missed. Bacterial meningitis should be highlighted as a serious infection complication in children with nephrotic syndrome.
Neonatal hyperpigmentation secondary to chikungunya infection is very common in tropical countries where chikungunya is endemic. Acquired infection in the perinatal period should be suspected in all neonates presenting with neurological or dermatological manifestations in the immediate postnatal period. We present a newborn baby who had hyperpigmentation which started from day 5 of life with lethargy and on extensive evaluation was found to have neonatal chikungunya. Babies with perinatal chikungunya infection are prone to developmental delay and require long term neuro-developmental follow-up. Hence the importance of following appropriate preventative vector measures and prompt diagnosis of infective conditions in tropical countries.
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BackgroundThere is a paucity of access to pediatric infectious diseases (PID) physicians in the United States. To improve access, PID clinicians spend significant time providing nonreimbursed curbside consultations (CCs) to community providers. While there is increasing utilization of telehealth technologies to increase access to PID physicians, there is limited knowledge regarding adoption of these technologies and how they may be used to improve care and reimbursement.MethodsThe PIDS Telehealth Working Group developed a 33-question online survey to collect individual- and practice-level data on the burden of CCs, current telehealth practices and barriers, and interest in providing future telehealth services. It was emailed to the PIDS Listserv (n = 1,213) in April 2019.ResultsA total of 161 (13%) providers completed the survey (100% MD/DO), representing 37 states; most are university- (n = 100, 62%) and/or hospital- (n = 74, 46%) employed. Respondents’ practices provide a mean of 1–10 CCs/week to outside institutions (median 3–5 hours/week), with a median of 6–10% resulting in referrals. Outside nonreimbursed CCs are performed by phone/paging systems (n = 156, 98%), secure email (n = 66, 42%), text messaging (n = 46, 29%), and EMR-messaging (n = 38, 24%); they include a variety of services (Figure 1). Only 46 (29%) of individual respondents provide any type of reimbursed telehealth at their practices (Figure 2). Reimbursement mechanisms include fee-for-service (31%), Medicaid/Medicare (25%), private insurance (24%), and internal institutional (i.e., internal RVU) payments (16%). The majority of respondents were unaware of credentialing (n = 90, 64%) and liability coverage needs for telehealth (n = 68, 47%). Though most respondents (n = 81, 57%) were not satisfied with their current telehealth program and barriers were significant (Figure 3), the majority (n = 144, 95%) were interested in implementing a variety of reimbursable telehealth services and modalities (Figure 4).ConclusionPID survey respondents indicated a lack of knowledge on key aspects of telehealth and perceive significant barriers to implementing telehealth at their institutions. Nonetheless, there is a strong interest in participating in a variety of telehealth services to increase access to care, with appropriate institutional support. Disclosures All authors: No reported disclosures.
BackgroundPositive peripheral blood culture results are essential in guiding antimicrobial therapy in patients with bacteremia. However, false-positive results may frequently pose diagnostic issues in interpreting the test. These results can lead to increased costs and patient harm through the administration of unnecessary antibiotics and prolongation of hospital stay. The maximum acceptable contamination rate for peripheral blood cultures as suggested by the College of American Pathologists is 3%.MethodsWe initiated a longitudinal quality improvement project to monitor peripheral blood contamination rates at our children’s hospital in Brooklyn, NY. We reviewed positive blood culture results on a monthly basis and assessed whether they represented true infections vs. contamination based on review of patient charts. Residents and nurses in the pediatric emergency department (ED), neonatal intensive care unit (NICU), pediatric intensive care unit (PICU), inpatient unit, and newborn nursery were educated on proper skin sterilization techniques using video demonstration; the importance of avoiding palpating the venipuncture site after sterilization and the importance of cleaning the port on the blood culture bottle were reinforced.ResultsThe pediatric ED and the PICU had the highest contamination rates in 2018 at 4.38% and 3.82%, respectively. The newborn nursery had the lowest contamination rate, at 0%. The NICU and pediatric inpatient units had contamination rates that met the goal as well, at 1.25% and 0.72%, respectively.ConclusionThe departments in need of targeted interventions are the pediatric ED and the PICU, both of which had contamination rates greater than the 3% goal rate set for our project. Future interventions currently being considered include re-education of nursing and resident staff as well as the creation of equipment bundles to facilitate adequate skin preparation prior to venipuncture. Disclosures All authors: No reported disclosures.
Introduction: Incidence of renal and bladder stones is increasing worldwide and many children presenting with pain abdomen are diagnosed to have renal calculi. There is high rate of recurrence of stones in children if full clearance is not achieved or metabolic evaluation is not performed. We analyzed the clinical profile of the children diagnosed to have Urolithiasis and admitted in pediatric ward of our institute over the period of 2 years (Jan 2015 to Dec 2016) Methods: We conducted an Observational study done in Children <15 years diagnosed to have Urolithiasis based on Ultrasound findings and admitted in pediatric ward of Velammal medical college hospital, Madurai, Tamilnadu between January 2015 to December 2016. A total of 30 children were enrolled in this study and their demographic details, clinical presentation, investigations and management were analyzed. Results: Pediatric urolithiasis was more common in boys (75%) with colicky pain abdomen (90%) as the predominant presenting symptom. Most of the children presented during the summer months. They had associated complications like urinary tract infection, hydronephrosis and Pelviureteric junction obstruction. Ureter was the commonest site of urolithiasis (18/30) and most of the children responded to medical management. The children who presented with recurrent symptoms during this study period were evaluated and diagnosed to have some underlying metabolic or genetic disorder. Conclusion: Rising incidence of renal stones with acute colicky pain in pediatric age group is a worrisome problem as it causes school absenteeism and mental stress to the entire family. Urolithiasis in children needs complete evaluation to rule out underlying metabolic disorder. Complete evaluation of the underlying etiology is essential to prevent recurrence and further complications.
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