Publications by authors named "Oded Scheuerman"

61 Publications

Peripheral Venous Catheter-related Bloodstream Infections in Hospitalized Children: The Role of Gram-negative Bacteria.

Pediatr Infect Dis J 2021 Jul 6. Epub 2021 Jul 6.

From the Department of Pediatrics A, Schneider Children's Medical Center, Petah Tikva, Israel Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel Infectious Diseases Unit Department of Pediatrics B Department of Pediatrics C Pediatric Heart Institute, Schneider Children's Medical Center, Petah Tikva, Israel Microbiology Laboratory, Rabin Medical Center, Petah Tikva, Israel.

Background: Peripheral venous catheter (PVC) is the most used vascular access device in medicine, allowing administration of intravenous fluids and medications. Known complications associated with PVC include extravasation, phlebitis and rarely bloodstream infection (BSI). Data regarding PVC-related BSI in children are lacking. Our aim was to evaluate the epidemiology, clinical and microbiologic characteristics of pediatric inpatients with PVC-related BSI.

Methods: A retrospective study was conducted in a pediatric tertiary care center. Children with BSI, admitted to general pediatric departments during 2010-2019, were identified and their medical records examined. Patients with BSI and phlebitis were further characterized and included in the analysis. We excluded patients with central venous catheters, other identified source of infection and with BSI upon admission. Data collected included patients' demographics and clinical and microbiologic characteristics.

Results: Twenty-seven children with PVC-related BSI were identified and included in the study, consisting of 0.2% of the total BSI cases. Patient's median age was 24 (range, 1.5-213) months, 14/27 (52%) were female and 6 (22%) were previously healthy while 21 (78%) had prior medical conditions. Sixteen (59.3%) patients had Gram-negative BSI and 6 (22.2%) Gram-positive bacteria. Polymicrobial infection occurred in 4 (14.8%) patients and Candida albicans in 1 (3.7%) patient. The most common isolated bacteria were Klebsiella spp and Staphylococcus aureus. Longer dwell-time was a predictor of Gram-negative bacteria.

Conclusions: PVC-related BSI due to Gram-negative bacteria was more common than to Gram-positive bacteria. Clinicians should consider an initial broad-spectrum antibiotic coverage for PVC-related BSI in hospitalized pediatric patients.
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http://dx.doi.org/10.1097/INF.0000000000003255DOI Listing
July 2021

COVID-19 in a Subset of Hospitalized Children in Israel.

J Pediatric Infect Dis Soc 2021 Jun 15. Epub 2021 Jun 15.

Infectious Disease and Infection Control Unit, Hillel Yaffe Medical Center, Hadera, Israel.

Background: Most pediatric coronavirus disease 2019 (COVID-19) is mild. We assessed nationally severe COVID-19, including pediatric inflammatory multisystem syndrome (PIMS), in hospitalized children.

Methods: An ongoing, prospective, national surveillance was conducted from March 2020 through March 2021, at 20 hospitals treating children <18 years across Israel (~75% of Israeli hospitals).

Results: Overall, 1007 cases (439 outpatients and 568 hospitalized) identified represent 0.35% of pediatric COVID-19 nationwide (n = 291 628). Of hospitalized cases, 464 (82%), 48 (8%), and 56 (10%) had mild, moderate/severe, and PIMS disease, respectively. The mean ± SD age was 5.6 ± 6.4 years. In mild, moderate/severe, and PIMS disease, 55%, 23%, and 4% of patients were <1 year old, respectively. Obesity was reported in 1%, 4%, and 13% of patients, respectively (P < .001). The most common symptom was fever in 67%, 60%, and 100%, respectively, whereas respiratory symptoms were documented in 33%, 41%, and 38% of patients, respectively. Lymphopenia was recorded in 25%, 60%, and 86% of cases, respectively. PIMS diagnosis was mainly serology-based (in 59%). Gastrointestinal symptoms, cardiovascular involvement, rash, and conjunctivitis were noted in 82%, 61%, 57%, and 34% of PIMS episodes, respectively. Elevated C-reactive protein (100%), ferritin, troponin, D-dimer, low albumin, and thrombocytopenia were common in PIMS. Echocardiography revealed pathological findings in 33% of patients. PIMS mainstay treatment included corticosteroids (77%) and intravenous immunoglobulin (53%). No mortality was recorded.

Conclusions: At a national level, pediatric COVID-19 is mild, even in hospitalized cases, with only a third presenting with respiratory involvement. PIMS is rare, but necessitates a high index of suspicion, and with suitable treatment prognosis is favorable.
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http://dx.doi.org/10.1093/jpids/piab035DOI Listing
June 2021

COVID-19 in advanced Duchenne/Becker muscular dystrophy patients.

Neuromuscul Disord 2021 Apr 6. Epub 2021 Apr 6.

Sackler Faculty of Medicine, Tel Aviv University, Ramat Aviv, Tel Aviv, Israel; Department of Pediatrics B, Schneider Children's Medical Center, Petah-Tikva, Israel; Pediatric Infectious Disease Unit, Schneider Children's Medical Center.

Duchenne muscular dystrophy (DMD) is the most common childhood muscular dystrophy. As a result of progressive muscle weakness, pulmonary function decreases during the second decade of life and lung disease contributes significantly to morbidity and mortality in these patients. Corticosteroids are the current standard of care for patients with DMD, despite known adverse effects such as obesity and immunosuppression. Over the past year (2020), the novel coronavirus (COVID-19/SARS-CoV2) outbreak has caused a global pandemic. Restrictive lung disease due to low lung volumes, chronic immunosuppressive treatment with corticosteroids, and obesity are potential risk factors that may contribute to a more severe course of the disease. Out of 116 Duchenne/Becker muscular dystrophy patients treated in our tertiary neuromuscular center, six patients with DMD and one with advanced Becker muscular dystrophy were found to be positive for COVID-19 infection. Two of the DMD patients were admitted for hospitalization, of whom one was dependent on daily nocturnal non-invasive ventilation. All patients recovered without complications despite obesity, steroid treatment and severe restrictive lung disease.
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http://dx.doi.org/10.1016/j.nmd.2021.03.011DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8021445PMC
April 2021

Unilateral Choanal Atresia Presenting With Congenital Respiratory Distress and Recurrent Cyanotic Episodes.

Ear Nose Throat J 2021 May 28:1455613211020978. Epub 2021 May 28.

Pediatric Otorhinolaryngology Unit, 36739Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Congenital unilateral choanal atresia (CA) is not considered an emergent condition and should not cause respiratory distress in the newborn. Therefore, surgical repair of unilateral CA is usually delayed. This description of a newborn with congenital unilateral CA that caused significant respiratory distress, recurrent cyanotic episodes, and severe feeding difficulties highlights an exception to that rule.
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http://dx.doi.org/10.1177/01455613211020978DOI Listing
May 2021

SARS-CoV-2 Infection Among Health Care Workers Despite the Use of Surgical Masks and Physical Distancing-the Role of Airborne Transmission.

Open Forum Infect Dis 2021 Mar 27;8(3):ofab036. Epub 2021 Jan 27.

Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is transmitted mainly via respiratory droplets. A key question in the coronavirus disease 2019 pandemic is whether SARS-CoV-2 could be transmitted via the airborne route as well. We report for the first time SARS-CoV-2 nosocomial infections despite using surgical masks and physical distancing. This report may provide possible evidence for airborne transmission of SARS-CoV-2.
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http://dx.doi.org/10.1093/ofid/ofab036DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7928680PMC
March 2021

Clinical Features and Comparison of Kingella and Non-Kingella Endocarditis in Children, Israel.

Emerg Infect Dis 2021 03;27(3):703-709

Kingella spp. have emerged as an important cause of invasive pediatric diseases. Data on Kingella infective endocarditis (KIE) in children are scarce. We compared the clinical features of pediatric KIE cases with those of Streptococcus species IE (StIE) and Staphylococcus aureus IE (SaIE). A total of 60 patients were included in the study. Throughout the study period, a rise in incidence of KIE was noted. KIE patients were significantly younger than those with StIE and SaIE, were predominately boys, and had higher temperature at admission, history of oral aphthae before IE diagnosis, and higher lymphocyte count (p<0.05). Pediatric KIE exhibits unique features compared with StIE and SaIE. Therefore, in young healthy children <36 months of age, especially boys, with or without a congenital heart defect, with a recent history of oral aphthae, and experiencing signs and symptoms compatible with endocarditis, Kingella should be suspected as the causative pathogen.
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http://dx.doi.org/10.3201/eid2703.203022DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7920667PMC
March 2021

Performance of 2019 EULAR/ACR classification criteria for Systemic Lupus Erythematosus in a pediatric population - a multicenter study.

Rheumatology (Oxford) 2021 02 9. Epub 2021 Feb 9.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objectives: The "European League Against Rheumatism" and "American College of Rheumatology" 2019 (EULAR/ACR-19) criteria for the diagnosis of Systemic Lupus Erythematosus (SLE) were recently published, with the stated goal of maintaining the level of sensitivity and raising the level of specificity for classification of SLE in adults. The aim of this study is to examine their application to juvenile SLE (jSLE) patients.

Methods: In this multicenter study the charts of jSLE patients from three tertiary medical centers were reviewed and compared to patients with non-jSLE diagnosis. Pediatric rheumatologists, blinded to the original diagnosis, reviewed and diagnosed all cases. Pediatric patients' clinical and laboratory data were retrospectively extracted and then examined with regard to how they met the new and old criteria.

Results: Included were 225 patients (112 jSLE, 113 non-SLE). When applied to juvenile SLE classification, the sensitivity of the new EULAR/ACR-19 criteria was 0.96 (0.9-.0.99) and the specificity was 0.89 (0.82-0.94). These were comparable to the Systemic Lupus International Collaborating Clinics (SLICC) criteria. . The sensitivity of the EULAR/ACR-19 criteria improves over time and was 0.83 twelve months following disease onset, reaching 0.96 after longer than 24 months.

Conclusion: Among a cohort of jSLE patients, sensitivity of the new EULAR/ACR-19 criteria was found to be high and specificity may have improved slightly compared to the SLICC-12 criteria. We support the use of the new classification criteria for pediatric patients in future jSLE studies, but it should be noted that its specificity is lower than for adults.
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http://dx.doi.org/10.1093/rheumatology/keab140DOI Listing
February 2021

Trend in women representation among authors of high rank rheumatology journals articles, 2002-2019.

Rheumatology (Oxford) 2021 02 9. Epub 2021 Feb 9.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: The representation of women among authors of peer reviewed scientific papers is gradually increasing. The aims of this study were to examine the trend of the proportion of women among authors in the field of rheumatology during the last two decades.

Methods: Articles published in journals ranked in the top quartile of the field of rheumatology in the years 2002-2019 were analyzed. The authorship positions of all authors, country of the article's source and manuscript type were retrieved by specifically designed software.

Results: Overall, 153,856 author names were included in the final analysis. Of them, 55,608 (36.1%) were women. There was a significant rise in the percentage of women authors over time (r = 0.979, P < 0.001) from 30.9% in 2002 to 41.2% in 2018, with a slight decline to 39.8% in 2019. There were significantly fewer women in the senior author positions compared to the first author positions (24.3% in senior position Vs. 40.9% as first author, p < 0.001).

Conclusion: The proportion of women among authors of rheumatology articles has increased over the years, both in general and as a first or senior author, however, their proportion is still less than 50% and there is still a gap between the proportion of women among first authors and the proportion of women among senior authors.
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http://dx.doi.org/10.1093/rheumatology/keab134DOI Listing
February 2021

The COVID-19 pandemic dramatically reduced admissions of children with and without chronic conditions to general paediatric wards.

Acta Paediatr 2021 07 10;110(7):2212-2217. Epub 2021 Feb 10.

Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel.

Aim: We examined the impact of the COVID-19 pandemic on how many children were admitted to Israel's largest tertiary paediatric hospital and why they were admitted.

Methods: Israel declared COVID-19 a national emergency on 19 March 2020. This study examined daily hospital admissions to our three general paediatric wards during the COVID-19 lockdown period from 20 March to 18 April 2020. These 258 admissions were compared with the 4217 admissions from the period immediately before this, 1 February to 19 March 2020, plus 1 February to 18 April in 2018 and 2019. We also compared why patients were admitted during the study period, and any pre-existing conditions, with 638 children hospitalised during the same period in 2019.

Results: The mean number of daily hospitalisations during the COVID-19 lockdown period was 8.6, which was 59% lower than the 20.9 recorded during the other three periods before COVID-19. There was a significant decrease in the number of patients admitted with infectious (74%) and non-infectious (44%) aetiologies from 2019 to 2020, and these occurred among patients with (58%), and without (55%), pre-existing medical conditions.

Conclusion: The Israeli COVID-19 lockdown had a dramatic effect on admissions to the paediatric wards of a tertiary hospital.
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http://dx.doi.org/10.1111/apa.15792DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8013809PMC
July 2021

Minor Clinical Impact of COVID-19 Pandemic on Patients With Primary Immunodeficiency in Israel.

Front Immunol 2020;11:614086. Epub 2021 Jan 14.

The Jeffrey Modell Foundation Israeli Network for Primary Immunodeficiency, New York, NY, United States.

In the last few months the world has witnessed a global pandemic due to severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) infection causing coronavirus disease 2019 (COVID-19). Obviously, this pandemic affected individuals differently, with a significant impact on populations considered to be at high-risk. One such population, was assumed to be patients with primary genetic defect involving components or pathways of the immune system. While human immunity against COVID-19 is not fully understood, it is, so far, well documented, that both adaptive and innate cells have a critical role in protection against SARS-CoV-2. Here, we aimed to summarize the clinical and laboratory data on primary immunodeficiency (PID) patients in Israel, who were tested positive for SARS-CoV-2, in order to estimate the impact of COVID-19 on such patients. Data was collected from mid-February to end-September. During this time Israel experienced two "waves" of COVID-19 diseases; the first, from mid-February to mid-May and the second from mid-June and still ongoing at the end of data collection. A total of 20 PID patients, aged 4 months to 60 years, were tested positive for SARS-CoV-2, all but one, were detected during the second wave. Fourteen of the patients were on routine monthly IVIG replacement therapy at the time of virus detection. None of the patients displayed severe illness and none required hospitalization; moreover, 7/20 patients were completely asymptomatic. Possible explanations for the minimal clinical impact of COVID-19 pandemic observed in our PID patients include high level of awareness, extra-precautions, and even self-isolation. It is also possible that only specific immune pathways (e.g. type I interferon signaling), may increase the risk for a more severe course of disease and these are not affected in many of the PID patients. In some cases, lack of an immune response actually may be a protective measure against the development of COVID-19 sequelae.
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http://dx.doi.org/10.3389/fimmu.2020.614086DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7840610PMC
February 2021

Factors predicting efficacy of ethanol lock therapy as catheter salvage strategy for pediatric catheter-related infections.

Pediatr Blood Cancer 2021 May 22;68(5):e28856. Epub 2020 Dec 22.

Pediatric Infectious Diseases Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Aim: Catheter-related infections are difficult to cure, and failure rates are high. We aimed to evaluate the efficacy and safety of ethanol lock therapy (ELT) as catheter salvage strategy in children with central-line-associated bloodstream infection (CLABSI), and to identify factors associated with treatment failure.

Methods: Data were collected of all the children who received ELT for treatment of CLABSI during 2013-2018 due to failure of standard therapy or multiple catheter-related infections. Univariate and multivariate analyses of risk-factors for ELT failure were performed. Catheter salvage rates were compared to those achieved using systemic antimicrobials alone in an historical control group.

Results: A total of 123 ELT episodes among 95 patients were analyzed. The majority of patients had underlying hemato-oncological disorders. Approximately half the episodes occurred in patients with implantable ports. Early and late treatment failure rates of ELT were 16% (20/123) and 7% (9/123), respectively. Overall, successful catheter salvage was achieved in 78% (96/123) of episodes, compared to 54% using systemic antimicrobials alone (P < .001), including mycobacterium, candida, and most staphylococcus aureus infections. Adverse events were reported in 9% (11/123) of episodes and were mostly mechanical. Multivariate analysis identified four risk factors for ELT failure: Gram-positive bacteria, elevated C-reactive protein, signs of tunnel infection, and low absolute neutrophil counts.

Conclusions: Our findings support the use of ELT for catheter salvage in children with CLABSI who failed standard therapy or had multiple catheter-related infections. The identified variables associated with ELT failure may help identify patients who can most benefit from ELT.
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http://dx.doi.org/10.1002/pbc.28856DOI Listing
May 2021

A Drop in Number of Hospitalizations Among Children with Bacterial Infections During the COVID-19 Pandemic.

Pediatr Infect Dis J 2021 01;40(1):e39-e41

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

A significant drop was found in the number of hospitalizations due to bacterial infections among children during the first peak period of COVID-19 in Israel. There was a 77% decrease in serious bacterial infections, and ≥50% decrease in most types of bacterial infections, especially osteoarticular and skin infections, followed by pneumonia and ENT infections.
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http://dx.doi.org/10.1097/INF.0000000000002963DOI Listing
January 2021

Diagnostic value of sputum cultures in children under 2 years of age with chronic suppurative lung diseases.

Pediatr Pulmonol 2020 12 12;55(12):3421-3428. Epub 2020 Oct 12.

Graub CF Center Pulmonary Institute, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Background: Acquiring sputum cultures from infants is considered challenging. We describe their yield in infants with cystic fibrosis (CF) and other chronic suppurative lung diseases (CSLDs).

Methods: Retrospective medical record review over a 4-year period, for infants aged 0-2 years with ≥2 airway bacterial cultures acquired by deep suction or induced sputum ≥4 weeks apart. Data included demographics, culture results, and clinical status.

Results: A total of 98 infants (16 CF) were evaluated and 534 sputum cultures acquired, 201 in CF and 333 in CSLD. There were 12 (2-23), median (range) cultures/CF infant, and 3 (2-21)/CSLD infant. Age at first culture was 3.8 (1-19.5) months for CF and 10.4 (0.5-22) months for CSLD; p = .016. In total, 360 cultures (67%) were positive for any bacteria, with 170/234 (73%) positive during exacerbations, compared with 190/300 (63%) during routine visits; p = .05. More infants with CF than CSLD had cultures positive for Staphylococcus aureus (SA; 75% vs. 34%; p = .004) throughout the period. Pseudomonas aeruginosa (PA) was common in both CF and CSLD (56% and 44%, respectively; p = .42) and increased over time for CF but was high throughout for CSLD. The number of hospital days before PA acquisition was 6 (10.2) for CF and 28.8 (38.7) for CSLD (p = .003). No CF but 6/82 (7%) CSLD infants had chronic PA (p = .56).

Conclusions: Sputum cultures showed that infection, in particular PA, is common in CF and CSLD whereas SA is more common in CF. Prospective studies are warranted to elucidate the role of active surveillance in guiding antibiotic therapy.
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http://dx.doi.org/10.1002/ppul.25103DOI Listing
December 2020

Medical and surgical characteristics of fusobacterium necrophorum mastoiditis in children.

Int J Pediatr Otorhinolaryngol 2020 Nov 18;138:110324. Epub 2020 Aug 18.

Pediatric Ear-Nose-Throat Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel; Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objectives: To evaluate and compare characteristics of Fusobacterium necrophorum mastoiditis (FnM) to characteristics of acute mastoiditis (AM) caused by other bacteria in tertiary children hospital Methods : Children with FnM (N=43) and non FnM (N=88). Assess medical, microbiologic and imaging characteristics, surgical findings and postoperative recovery.

Results: Children with FnM had a positive history of otitis media, ear discharge and sub-periosteal abscess (p=0.0004, 0.09, 0.0003, respectively) at presentation. Their temperature, WBC and CRP were significantly higher (39.8 vs. 37.9, 19.4K vs. 16.1K, 21 vs. 8.7, p=0.0001). Positive culture was found in 46% of patients; 64% were diagnosed by PCR. CT scan was indicated in 95% and surgical intervention in 93% of children with FnM, compared to 15% and 9.7% of children in the non-FnM group (p=0.0001). Complex post-operative course was frequent for the FnM group: 88% of children had persistent fever, 46% had additional imaging and 14% additional surgical intervention. Children with FnM were treated with IV antibiotics for an average of 22 compared to seven days for non-FnM children (p=0.0001).

Conclusions: Fusobacterium should be suspect in a child presenting with AM, a septic appearance, high fever and increased inflammation markers. A regimen of two antibiotics should be empirically started, then proceed to imaging and early surgical intervention. A relatively slow post-operative recovery process should be expected; however, prognosis is good.
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http://dx.doi.org/10.1016/j.ijporl.2020.110324DOI Listing
November 2020

Frequency of Multifocal Disease and Pyogenic Arthritis of the Hip in Infants with Osteoarticular Infection in Three Neonatal Intensive Care Units.

J Pediatr 2020 12 22;227:157-162. Epub 2020 Jul 22.

St. Christopher's Hospital for Children and Drexel University College of Medicine, Philadelphia, PA.

Objective: To describe the clinical features of osteoarticular infection in infants cared for in neonatal intensive care units (NICUs) and to assess the presence of multifocal infection.

Study Design: Retrospective medical record review with structured data abstraction of infants with osteomyelitis or pyogenic arthritis or both in NICUs at 3 children's hospitals over a 29-year period.

Results: Of the 45 cases identified, 87% occurred in prematurely born infants, with a median gestational age of 27.4 weeks (IQR, 26, 31 weeks). Median postnatal age at diagnosis of infection was 33 days (IQR, 20, 50 days). Osteomyelitis was present without joint involvement in 53% and with joint involvement in 44% of cases. Methicillin-susceptible Staphylococcus aureus (71%) was the predominant pathogen, despite prevalent methicillin-resistant S aureus in community-associated infections. More than 1 bone was infected in 34% of cases. The femur (in 50% of patients) was the most frequently involved bone and the hip (in 20% of patients) was the most frequently involved joint. Bacteremia persisted for 4 or more days in 54% of patients with a positive blood culture despite active antimicrobial therapy.

Conclusions: Among infants with osteoarticular infection in NICUs, multifocal disease is common and frequently is unsuspected. Search for additional sites of infection including the hip is warranted following the diagnosis of osteoarticular infection at a single site. Involvement of contiguous joints should be suspected in cases of osteomyelitis; conversely the presence of pyogenic arthritis usually indicates extant osteomyelitis in a contiguous bone.
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http://dx.doi.org/10.1016/j.jpeds.2020.07.055DOI Listing
December 2020

Pediatrician, watch out for corona-phobia.

Eur J Pediatr 2021 Jan 13;180(1):201-206. Epub 2020 Jul 13.

Department of Pediatrics C, Schneider Children's Medical Center of Israel, Petah Tikva, Israel.

The current outbreak of COVID-19 raging globally is taking a heavy toll on the adult population, with a rapidly growing number of newly infected and critically ill patients. However, to date, mortality rate among children is low as they mostly suffer from a mild disease. Yet, other more routinely encountered childhood diseases do not stand still and continue to be the main share of pediatricians' everyday challenges. Here we describe a case series of routinely seen pediatric diseases with delayed diagnosis due to different aspects of what we call "Corona-phobia". These cases were easily collected within a 1-week period which implies that this is a more widespread phenomenon.In conclusion, this raises the possibility that measures taken to mitigate this pandemic may be more damaging to children overall than the virus itself. We believe that pediatricians as well as policy makers should take this important aspect into consideration. What is Known: • COVID-19 manifests as a mild disease in most children; however, children are an important reservoir and may become spreaders of the disease. • Social distancing and isolation are important tools in mitigating COVID-19 transmission. What is New: • This case series describes 7 cases with delayed diagnosis of every-day pediatric diseases that were not caused by COVID-19 but were highly influenced by different aspects of "Corona-phobia". • Our objective is to highlight the possibility that measures taken to mitigate this pandemic may lead to a substantial delay in the diagnosis of other non-COVID-19 related diseases.
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http://dx.doi.org/10.1007/s00431-020-03736-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7357258PMC
January 2021

Altered slow-wave sleep activity in children with rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation syndrome.

J Clin Sleep Med 2020 10;16(10):1731-1735

Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel.

Study Objectives: Rapid-onset obesity with hypothalamic dysregulation, hypoventilation, and autonomic dysregulation (ROHHAD) is a rare condition. Little is known about sleep/wake and slow-wave activity in this condition, although the central hypothalamic dysfunction associated with autonomic dysregulation would make the occurrence of SWA deregulation most likely.

Methods: Two children with clinical presentation of ROHHAD syndrome were evaluated, diagnosed, and treated. Their polysomnographic studies were compared with 4 matched children with obstructive sleep apnea and 6 controls.

Results: Children that were clinically diagnosed with ROHHAD exhibited significantly weaker slow-wave activity power and shallower slow-wave activity slopes during the first 2 sleep cycles compared with children with obstructive sleep apnea or controls.

Conclusions: This study shows that children with ROHHAD have suppressed slow-wave activity, possibly because of hypothalamic dysregulation that may contribute to their rapid-onset obesity and excessive daytime sleepiness.
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http://dx.doi.org/10.5664/jcsm.8678DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954010PMC
October 2020

Acute mastoiditis in infants younger than 6 months: is an alternative treatment protocol needed?

Eur Arch Otorhinolaryngol 2021 Feb 4;278(2):339-344. Epub 2020 Jun 4.

Department of Otorhinolaryngology and Head and Neck Surgery, Schneider Children's Medical Center of Israel and Rabin Medical Center, Beilinson Campus, 49202, Petah Tikva, Israel.

Objectives: Several studies have reported that younger children suffer from increased incidence and more severe episodes of acute mastoiditis (AM) than older children, whereas other researchers have found the opposite. The aim of our study was to describe the occurrence, clinical, and microbiological aspects of AM in children 6 months or younger, and compare them with the results in an older reference age band.

Methods: The medical files of children hospitalized with a diagnosis of AM during 2001-2016 were retrospectively reviewed. Diagnosis of AM was based on the presence of clinical signs of acute otitis media (AOM) accompanied by two or more of the following: auricle protrusion, retro-auricular erythema, swelling, and local tenderness. Children were divided into two age bands, 6 months or younger, and older than 6 months.

Results: Fifty patients in the young age band and 335 in the older reference age band were included. Bilateral AOM was identified in 14 (28%) children under 6 months, and 50 (14.9%) in the reference age band (p < 0.001). Fever, mean WBC, and CRP values were similar in both age bands; 4 (8%) children under 6 months had pre-auricular/zygomatic area swelling, as compared to 1(0.02%) in the reference age band (p < 0.001). Complication rates (subperiosteal abscess, sinus vein thrombosis, and epidural abscess) were similar in both age bands. All children were treated with myringotomy and IV antibiotics. Cortical mastoidectomy with the insertion of ventilation tube was performed in 10 (20%) children in the younger age band and 58(17.3%) in the reference age band. Streptococcus pneumoniae was the most common (38%) isolated bacteria in the younger age band, and Group A streptococcous (GAS) (20.6%) in the reference age band.

Conclusions: AM in children 6 months or younger has similar presentation and characteristics as in older children. Pre-auricular swelling and bilateral AOM are more typical in the younger age band; Streptococcus pneumoniae is the most common pathogen in the younger children. We suggest that the treatment approach should be the same for both groups.
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http://dx.doi.org/10.1007/s00405-020-06088-3DOI Listing
February 2021

Changing epidemiology and resistance patterns of pathogens causing neonatal bacteremia.

Eur J Clin Microbiol Infect Dis 2020 Oct 15;39(10):1879-1884. Epub 2020 May 15.

Department of Neonatology, Schneider Children's Medical Center of Israel, Petach Tikvah, Israel.

To conduct a survey of the local prevalent bacteria and antibiotic resistance in a referral tertiary neonatal intensive care unit (NICU), in order to assess the efficacy of local antibiotic policies. We reviewed all positive blood and cerebrospinal fluid cultures obtained between January 2007 and December 2017 in the NICU of Schneider Children's Medical Center of Israel. Early and late-onset bacteremia were defined as episodes occurring within or after the first 3 calendar days of life respectively. Empiric treatment included ampicillin and gentamicin or piperacillin-tazobactam and amikacin for early or late-onset bacteremia respectively. The prevalence and antibiotic resistance of the bacteria were described and compared over time. Eight hundred and twenty nine of 15,947 (5.2%) newborns had at least one episode of bacteremia; 81 had multiple episodes. The most common bacteria were Escherichia coli (32.35%) and group B Streptococcus (19.11%) or coagulase negative Staphylococcus (CoNS) (60.5%) and Klebsiella sp. (12.4%) in early or late-onset bacteremia respectively. Overall, all Gram-positive bacteria were susceptible to vancomycin and most non-CoNS to ampicillin. Nosocomial vs. vertical bacteremia had increased resistance to ampicillin and cephalosporins. Resistance of nosocomial bacteria to piperacillin-tazobactam was 22.4%, to amikacin 3.3%, and to meropenem 1.8%. Changes over time: Gram-negative bacteria had a significant increase in resistance to cotrimoxazole and piperacillin. The resistance to gentamicin doubled. Our empiric antibiotic regimen covers the most frequent isolates. Amikacin may replace gentamicin for selected sick patients in early-onset bacteremia. Piperacillin-tazobactam should be combined with amikacin until susceptibility is available.
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http://dx.doi.org/10.1007/s10096-020-03921-9DOI Listing
October 2020

Isavuconazole As Successful Salvage Therapy for Mucormycosis in Pediatric Patients.

Pediatr Infect Dis J 2020 08;39(8):718-724

From the Day Hospitalization Department, Infectious Diseases Unit, Hemato-Oncology Department, Intensive Care Unit, Schneider Children's Medical Center of Israel, Petah Tikva.

Background: Mucormycosis is a rare but emerging life-threatening fungal disease with limited treatment options. Isavuconazole is a new triazole that has shown efficacy in adults for primary and salvage treatment of mucormycosis. However, data in children are scarce.

Methods: The demographic and clinical data of pediatric patients with proven mucormycosis who were treated with isavuconazole in 2015 to 2019 at 2 centers were collected.

Results: Four children of median age 10.5 years (range 7-14) met the study criteria. Three had underlying hematologic malignancies, and 1 had sustained major trauma. Isavuconazole was used as salvage therapy in all: in 3 patients for refractory disease, and in 1 after intolerance to another antifungal drug. Isavuconazole was administered alone or combined with other antifungal agents. Following treatment and surgical intervention, complete clinical, radiologic and mycologic responses were documented in all patients. A literature review identified 8 children with mucormycosis who were successfully treated with isavuconazole, as salvage therapy in the majority.

Conclusion: Our limited experience supports the use of isavuconazole as salvage therapy in pediatric mucormycosis.
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http://dx.doi.org/10.1097/INF.0000000000002671DOI Listing
August 2020

Can we improve early identification of neonatal late-onset sepsis? A validated prediction model.

J Perinatol 2020 09 20;40(9):1315-1322. Epub 2020 Mar 20.

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Objective: No single test can accurately identify neonatal late-onset sepsis (LOS). Our aim was to use clinical evaluation with laboratory tests to rapidly assess sepsis risk.

Study Design: A retrospective case-control study was performed in a tertiary Neonatal Center during the years 2016-2019. Infants with bacteriologically confirmed LOS were compared with control infants. A clinical health evaluation score was assigned to each infant. A prediction model was developed and validated by multivariable analysis.

Results: The study included 145 infants, 48 with sepsis, and 97 controls. LOS was independently associated with: sick appearance (OR: 5.7, 95% CI: 1.1-29.1), C-reactive protein > 0.75 (OR: 5.4, 95% CI: 1.1-26.3), and neutrophil-to-lymphocyte ratio > 1.5 (OR: 6.7, 95% CI: 1.2-38.5). Our model had an area under the receiver operating characteristic curve of 0.92 (95% CI: 0.86-0.97).

Conclusions: Clinical evaluation with neutrophil-to-lymphocyte ratio and C-reactive protein can rapidly identify LOS enabling decreased health costs and antibiotic use.
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http://dx.doi.org/10.1038/s41372-020-0649-6DOI Listing
September 2020

Q Fever and Kingella kingae Endocarditis in a Toddler: A Rare Coinfection Case.

Pediatr Infect Dis J 2019 12;38(12):e336-e337

From the Department of Pediatrics B.

A toddler after tetralogy of Fallot graft repair in infancy was diagnosed with endocarditis. Blood cultures were positive for Kingella kingae and serology was positive Coxiella burnetii. He was treated medically and surgically. A postoperative specimen polymerase chain reaction confirmed a coinfection. A comprehensive patient history was imperative for identification of an unlikely infection at this age.
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http://dx.doi.org/10.1097/INF.0000000000002469DOI Listing
December 2019

Vacuum-Assisted Closure for the Treatment of Deep Sternal Wound Infection After Pediatric Cardiac Surgery.

Pediatr Crit Care Med 2020 02;21(2):150-155

Infectious Disease Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

Objectives: Vacuum-assisted closure is being increasingly used to treat deep sternal wound infection following cardiac surgery, but most of the data refer to adults. This study investigated the safety and efficacy of vacuum-assisted closure in pediatric patients.

Design: Retrospective file review.

Setting: Tertiary pediatric medical center.

Patients: All children with deep sternal wound infection treated with vacuum-assisted closure in 2003-2016.

Interventions: Epidemiological, clinical, and microbiological data were collected from the medical records.

Measurements And Main Results: The cohort included 50 patients (0.9% of cardiac patients operated during the study period) of median age 6.5 months (interquartile range, 2-12.75 mo; range, 1 wk to 14 yr) and median weight 5.1 kg (interquartile range, 4-9.75 kg). The most frequent heart defects were tetralogy of Fallot (22%) and ventricular septal defect (20%); 38% of patients had cyanotic heart disease. Deep sternal wound infections appeared a median of 10 days postoperatively (interquartile range, 7-14 d; range 3-100 d). Vacuum-assisted closure was applied a median of 13 days postoperatively (interquartile range, 10-18.5 d; range, 5-103 d) for a median duration of 10 days (interquartile range, 7-13.25 d; range, 1-21 d). Wound cultures were positive in 48 patients (96%); most isolates were Gram-positive (76%). The main bacterial pathogen was methicillin-susceptible Staphylococcus aureus (61%). Most patients were treated with cloxacillin for a median of 38 days (interquartile range, 28-42 d; range, 9-189 d). There were no statistically significant differences in clinical or treatment characteristics between bacteremic (56%) and nonbacteremic patients. Compared with older patients, infants less than 3 months old (36%) had a significantly longer hospitalization time (41 vs 25 d; p = 0.001) and higher Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery Mortality Category (3 vs 2; p = 0.003). All cases except one (contact dermatitis) were uneventful. In 10 patients, wounds were closed surgically after vacuum-assisted closure. Two patients required a pectoralis flap, both treated before 2005. One of the two deaths was infection-related.

Conclusions: Vacuum-assisted closure is a feasible treatment option of deep sternal wound infection after pediatric cardiac surgery and was not associated with independent morbidity.
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http://dx.doi.org/10.1097/PCC.0000000000002131DOI Listing
February 2020

Flavobacteriaceae Bacteremia in Children: A Multicenter Study.

Pediatr Infect Dis J 2019 11;38(11):1096-1099

From the Department of Pediatrics B, Schneider Children's Medical Center, Petach Tikva, Israel.

Background: The Flavobacteriaceae family includes rare pathogens in children; Chryseobacterium indologenes and Elizabethkingia meningosepticum are the most common pathogenic species, with a wide range of clinical presentations and high mortality rate. Although rare, diagnosis is important due to inherent resistance to multiple antibiotics, especially those typically prescribed for empiric treatment of aerobic Gram-negative bacterial infections.

Methods: A multicenter retrospective study conducted in 5 Israeli hospitals, describing Flavobacteriaceae bacteremia confirmed by positive blood culture from 1998 to 2018.

Results: Thirteen cases were included; 9 isolates were C. indologenes. Bacteremia was nosocomial or healthcare-associated in all cases. Bacteremia was associated with young age (median, 1 year, range 24 days-17 years), with only 2 (15.4%) cases in neonates, Central line-associated bloodstream infection as a source (5/13, 38%) and malignancy (7/13, 54.8%). Thirty-day all-cause mortality was 23% (3/13). Ninety-one percent of isolates were susceptible to trimethoprim-sulfamethoxazole, 82% to piperacillin-tazobactam and 92% to ciprofloxacin.

Conclusions: C. indologenes and E. meningosepticum are rare, nosocomial- or healthcare-associated pediatric bacteremia pathogens. Bacteremia was associated with young age, but in contrast to the literature, the majority of our cases were older than the neonatal age period. In addition, they were associated with central line-associated bloodstream infection and malignancy. The most adequate antibiotics according to resistance patterns were ciprofloxacin, trimethoprim-sulfamethoxazole and piperacillin-tazobactam.
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http://dx.doi.org/10.1097/INF.0000000000002449DOI Listing
November 2019

Efficacy and Safety of a Weight-based Dosing Regimen of Valganciclovir for Cytomegalovirus Prophylaxis in Pediatric Solid-organ Transplant Recipients.

Transplantation 2019 08;103(8):1730-1735

Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.

Background: Valganciclovir has been widely used for cytomegalovirus (CMV) prophylaxis in solid-organ transplant recipients. However, the optimal dosing protocol and target exposure in children are still unclear. Specific data as to the efficacy and safety of low-dose/low-exposure regimens are lacking and urgently needed.

Methods: During 2010 to 2015, the clinical efficacy and safety of a weight-based regimen of valganciclovir of 17 mg/kg/day, with a stratified dose reduction for impaired creatinine clearance, given as a CMV prophylaxis for 3 to 6 months, was retrospectively evaluated among pediatric kidney and liver transplant recipients, 12 months posttransplantation. Incidence of CMV infection was assessed by periodic measurements of viral load; adverse events were evaluated.

Results: Eighty-three children who had undergone 86 transplantations and were treated with 17 mg/kg of valganciclovir were included. Median age was 9.77 years (range, 0.6 to 18.9). Twelve (14%) developed CMV infection: 1 during prophylaxis and 11 during follow-up. These events comprised 6 cases of asymptomatic viremia and 6 cases of a clinically significant disease without occurrences of tissue-invasive disease. Treatment-related adverse effects occurred in 7 patients (8%), mostly hematological, resulting in premature drug cessation.

Conclusions: Our results support the use of 17 mg/kg of valganciclovir for CMV prophylaxis in liver and kidney transplanted children as it showed satisfactory long-term efficacy and a good safety profile.
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http://dx.doi.org/10.1097/TP.0000000000002632DOI Listing
August 2019

Atypical presentation of human ehrlichiosis and anaplasmosis in children in Israel.

Acta Paediatr 2019 09 17;108(9):1727-1728. Epub 2019 Jun 17.

Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petach Tikva, Israel.

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http://dx.doi.org/10.1111/apa.14882DOI Listing
September 2019

Pediatric Infectious Sacroiliitis: Characterization and Differentiation from Noninfectious Etiologies.

Pediatr Infect Dis J 2019 07;38(7):e134-e137

From the Department of Pediatrics B, Schneider Children's Medical Center of Israel, Petach Tikva.

Background: Pediatric sacroiliitis (SI) is an uncommon entity of infectious or inflammatory etiology. Recent data regarding pediatric SI are scarce. The study objective was to describe and compare the clinical features of pediatric infectious and noninfectious SI.

Methods: We reviewed files of children ≤18 years of age, admitted with SI in 2004-2017. Patients were grouped by etiology, infectious versus noninfectious. Clinical and laboratory indices, imaging, treatment protocols and outcome were compared.

Results: Study population included 40 patients with infectious SI (range: 3-192 months, median age: 15 months, 45% female) and 13 patients with noninfectious SI (range: 30-216 months, median age: 168 months, 62% females). Duration of symptoms before admission averaged 5.9 ± 7.5 days in the infectious group and 54.2 ± 96 days in the noninfectious group (P = 0.003). Symptoms observed solely in the infectious group included refusal to stand (n = 27, 77%); walk or crawl (n = 24, 65%); irritability (n = 20, 50%) and recent constipation event (n = 8, 20%). No significant differences in laboratory results were found. Infectious SI patients had uneventful medical history, rapid response to antibiotics and a higher rate of complete resolution of symptoms without recurrences.

Conclusions: An acute unilateral presentation in young patients ≤2 years of age, without chronic medical conditions, suggests an infectious etiology of SI anticipated to completely resolve with antibiotic treatment, not necessitating further workup for noninfectious etiologies.
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http://dx.doi.org/10.1097/INF.0000000000002340DOI Listing
July 2019

Corrigendum to "Influence of GeneXpert MRSA/SA test implementation on clinical outcomes of Staphylococcus aureus bacteremia - A before-after retrospective study" [Diagn Microbiol Infect Dis 2019;93(2):120-124].

Diagn Microbiol Infect Dis 2019 05 8;94(1):107. Epub 2019 Mar 8.

Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel.

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http://dx.doi.org/10.1016/j.diagmicrobio.2019.02.003DOI Listing
May 2019

Influence of GeneXpert MRSA/SA test implementation on clinical outcomes of Staphylococcus aureus bacteremia - a before-after retrospective study.

Diagn Microbiol Infect Dis 2019 02 29;93(2):120-124. Epub 2018 Aug 29.

Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel; Infectious Diseases Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel. Electronic address:

Use of GeneXpert MRSA/SA in diagnostic algorithms of Staphylococcus aureus bacteremia may influence both patients' clinical outcomes and antibiotic stewardship. We evaluated these outcomes in a retrospective cohort before (1/6/2015-31/5/2016) and after (1/6/2016-31/8/2017) the introduction of the test in adult patients with Gram-positive cocci in clusters in blood cultures. We included 254 patients (125 preintervention, 129 postintervention). No significant difference in 30-day mortality or clinical success was demonstrated between periods. Appropriate antibiotic therapy rates were significantly higher in the postintervention group, and vancomycin use was significantly reduced (80.6% vs 53.6%, P < 0.01; 2.3±0.38 vs 2.98±1.02 defined daily doses/100 patient days, P = 0.026, respectively). Appropriate beta-lactam use was also significantly higher (56.7% postintervention vs 23.1% preintervention, P < 0.01). Use of GeneXpert MRSA/SA test has a positive effect on antibiotic stewardship measures, though it has no significant effect on clinical outcomes including mortality in this fatal infection.
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http://dx.doi.org/10.1016/j.diagmicrobio.2018.08.011DOI Listing
February 2019
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