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IMPORTANCE Staphylococcus aureus bacteremia (SAB) in children causes significant morbidity and mortality, but the epidemiology in children is not well characterized.OBJECTIVE To describe the epidemiology of SAB in children and adolescents younger than 18 years from Australia and New Zealand. DESIGN, SETTING, AND PARTICIPANTSA prospective cohort study, using data from the Australian New Zealand Cooperative on Outcomes in Staphylococcal Sepsis cohort for 1153 children with SAB from birth to less than 18 years in pediatric and general hospitals across Australia and New Zealand, collected between January 1, 2007, and December 31, 2012. Multivariate analysis was performed to identify risk factors for mortality. Incidence calculations were calculated separately for Australasian children younger than 15 years using postcode population denominator data from Australian and New Zealand census data.MAIN OUTCOMES AND MEASURES Demographic data, hospital length of stay, principal diagnosis, place of SAB onset (community or hospital), antibiotic susceptibility and principal antibiotic treatment, and 7-and 30-day mortality.RESULTS Of the 1153 children with SAB, complete outcome data were available for 1073 children (93.1%); of these, males accounted for 684 episodes (63.7%) of SAB. The median age was 57 months (interquartile range, 2 months to 12 years). The annual incidence of SAB for Australian children was 8.3 per 100 000 population and was higher in indigenous children (incident rate ratio, 3.0 [95% CI, 2.4-3.7]), and the incidence for New Zealand children was 14.4 per 100 000 population and was higher in Māori children (incident rate ratio, 5.4 [95% CI, 4.1-7.0]). Community-onset SAB occurred in 761 cases (70.9%), and 142 cases (13.2%) of the infections were methicillin-resistant S aureus (MRSA). Bone or joint infection was most common with 348 cases (32.4%), and endocarditis was uncommon with 30 cases (2.8%). Seven-and 30-day mortality rates were 2.6% (n = 28) and 4.7% (n = 50), respectively. Risk factors for mortality were age younger than 1 year; Māori or Pacific ethnicity; endocarditis, pneumonia, or sepsis; and receiving no treatment or treatment with vancomycin. Mortality was 14.0% (6 of 43) in children with methicillin-susceptible S aureus (MSSA) treated with vancomycin compared with 2.6% (22 of 851) in children treated with alternative agents (OR, 6.1 [95% CI, 1.9-16.7]). MRSA infection was associated with increased length of stay but not mortality. CONCLUSIONS AND RELEVANCEIn this large cohort study of the epidemiology of SAB in children, death was uncommon, but the incidence was higher for infants and varied by treatment, ethnicity, and clinical presentation. This study provides important information on the epidemiology of SAB in children and risk factors for mortality.

Antifungal agents may be associated with significant toxicity or drug interactions leading to sub-therapeutic antifungal drug concentrations and poorer clinical outcomes for patients with haematological malignancy. These risks may be minimised by clinical assessment, laboratory monitoring, avoidance of particular drug combinations and dose modification. Specific measures, such as the optimal timing of oral drug administration in relation to meals, use of pre-hydration and electrolyte supplementation may also be required. Therapeutic drug monitoring (TDM) of antifungal agents is warranted, especially where non-compliance, non-linear pharmacokinetics, inadequate absorption, a narrow therapeutic window, suspected drug interaction or unexpected toxicity are encountered. Recommended indications for voriconazole and posaconazole TDM in the clinical management of haematology patients are provided. With emerging knowledge regarding the impact of pharmacogenomics upon metabolism of azole agents (particularly voriconazole), potential applications of pharmacogenomic evaluation to clinical practice are proposed.

PurposeKingella kingae is an increasingly identified cause of musculoskeletal infections in young children. We report our experience with a recently developed polymerase chain reaction (PCR) method and review the clinical course of children diagnosed with K. kingae septic arthritis in a tertiary referral paediatric hospital.MethodsAll positive cases of K. kingae identified by PCR analysis of synovial fluid from August 2010 until July 2013 were included. A chart review was undertaken to determine history, presentation and management.Results27 Children (14 male, 13 female) had PCR positive synovial fluid samples for K. kingae with median age of 19 months (range 4 months to 5 years 3 months). The sites of infection were knee (17 cases), hip (2 cases), ankle (5 cases), shoulder (2 cases) and elbow. The median temperature on presentation was 37.1 °C, median peripheral white blood cell count 12.4 (9.9–13.8) × 109/L, erythrocyte sedimentation rate 55 (48–60) mm/h and C-reactive protein 24 (8–47) mg/L. The median synovial fluid white cell count was 21.8 (16.7–45.0) × 109/L. Routine cultures identified K. kingae in only two synovial fluid samples. Two samples were additionally positive for Staphylococcus aureus.ConclusionsKingella kingae is a significant cause of septic arthritis in young children. The authors recommend maintaining a high index of suspicion in young children presenting with joint inflammation, especially if indices of infection are mild. It appears likely that children historically treated with antibiotics for “culture negative” septic arthritis were infected with K. kingae. PCR techniques for detection of K. kingae should be encouraged.

A point prevalence survey is a useful cross-sectional method for quantifying antimicrobial use in paediatric populations. The value is significantly augmented by adding assessment of prescribing quality.

This is the first Australia-wide point prevalence survey of neonatal antimicrobial prescribing in tertiary children's hospitals. The findings highlight positive practices and potential targets for quality improvement.

Cryptococcosis caused by the Cryptococcus neoformans-Cryptococcus gattii complex is an important opportunistic infection in people with immunodeficiency, including in the haematology/oncology setting. This may manifest clinically as cryptococcal meningitis or pulmonary cryptococcosis, or be detected incidentally by cryptococcal antigenemia, a positive sputum culture or radiological imaging. Non-Candida, non-Cryptococcus spp. rare yeast fungaemia are increasingly common in this population. These consensus guidelines aim to provide clinicians working in the Australian and New Zealand haematology/oncology setting with clear guiding principles and practical recommendations for the management of cryptococcosis, while also highlighting important and emerging rare yeast infections and their recommended management.