Mary Anne Jackson, MD

Last year, there were five predictions made that appeared to be on the money – but there is more to the story!

1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.

This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.

2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.

3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.

4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.

5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.

So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!

1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.

2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).

3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.

4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).

5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Last year, there were five predictions made that appeared to be on the money – but there is more to the story!

1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.

This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.

2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.

3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.

4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.

5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.

So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!

1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.

2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).

3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.

4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).

5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Last year, there were five predictions made that appeared to be on the money – but there is more to the story!

1. The approach to diagnosis and treatment of influenza was essential knowledge for clinicians. Last year, we started seeing influenza activity early – with disease confirmed in mid-November, peaking during the week ending December 28, 2013 and trending downward in early January 2014. Hospitalizations were most common in young and middle aged adults and the 2009 H1N1 virus predominated.

This year, again we are seeing influenza early – with nearly all states reporting at least sporadic and local activity, and several states (Alaska, Florida, Louisiana, Massachusetts, and Texas) reporting regional activity as of the week ending November 24, 2014. At my institution, we’ve already tested over 500 children and over 100 were positive – influenza A (H3N2) strains are predominating. That may be important for the two reasons you’ll read below.

2. Invasive staphylococcal disease caused by methicillin-susceptible Staphylococcus aureus (MSSA) was more common than methicillin-resistant Staphylococcus aureus (MRSA), as the national burden of MRSA disease decreased (JAMA 2014;311:1438-9). The rates of clindamycin resistance continue to be pretty steady at approximately 15%-18%, but higher for MSSA than for MRSA – a point that is important to consider when empirically treating suspected invasive staphylococcal infection.

3. Multidrug resistant uropathogens took an increasingly prominent role in 2014, requiring careful approach to diagnosis (every child treated for urinary tract infection should have an appropriately obtained urine culture with an identified pathogen) and treatment (the drug used should be based on antibiotic susceptibility testing results). Particularly concerning is the emergence of carbapenem-resistant Enterobacteriaceae, which cause infection more commonly in hospitalized patients, those with indwelling devices, and those who have received long courses of antibiotics.

4. It was an outbreak year for parechovirus (HPeV), a viral pathogen causing meningitis in very young infants. Such infants present with signs and symptoms of meningitis but rarely show CSF pleocytosis. Diagnosis relies on the detection of the virus by polymerase chain reaction testing in CSF – a test which is not routinely available in many laboratories. At my institution this season, we saw nearly as many cases of parechovirus meningitis (n = 43) as we saw cases of enterovirus meningitis (n = 63). The parechovirus virus we detected was HPeV type 3, which can cause particularly severe disease in neonates.

5. Data confirmed that making human papillomavirus (HPV) vaccine a standard recommendation increased vaccine uptake and coverage. In February of 2014, a “Dear Colleague” letter that was endorsed by six leading medical organizations encouraged providers to promote HPV vaccination by giving a strong recommendation, citing data based on research conducted by the Centers for Disease Control and Prevention. We still have a long way to go as HPV vaccine coverage for teens remains at 35% for the three-dose series while meningococcal and Tdap vaccine (both vaccines that generally receive a standard recommendation by physicians) coverage is at nearly 90%.

So for 2015, I’ll start the discussion by saying there are five major developments I did not see coming for this past year, but that will remain relevant for the year 2015!

1. In June of 2014, live attenuated influenza vaccine (LAIV) was announced by the Advisory Committee on Immunization Practices to be the preferred vaccine in children aged 2-8 years. The American Academy of Pediatrics followed with a recommendation that either inactivated influenza vaccine (IIV) or LAIV be used for children, including children aged 2-8 years – the key being to give the vaccine as soon as one had it available. What was not known then and I did not predict was that newer data would confirm that in children aged 2-8 years who received LAIV last year when 2009 H1N1 strains predominated, there was essentially no coverage against 2009 H1N1 virus. This was in contrast to data from the prior 2 years and is as yet unexplained. The AAP continues to recommend that either vaccine be given and all children be immunized. That may be especially important this year as the influenza season started early. Disease will likely have been widespread by Christmas in many parts of the United States, and it looks like influenza A H3N2 strains will be most commonly noted. So the good news for young children who received LAIV is that 2009 H1N1 strains so far have not been seen this year. The bad news is that there are two H3N2 strains circulating, and potentially only one will be covered by the 2014-2015 seasonal vaccine. Staffing your office and hospital for a likely high census respiratory viral season is going to be essential.

2. The largest U.S. outbreak ever of enterovirus (EV) D-68 respiratory infection occurred between August and October of 2014. This virus – which had been identified in 1962 but was rarely described over the next 36 years except in small clusters of disease – was reported in nearly every state and characterized by unusually severe respiratory tract infection. Many, but not all children, had a history of asthma or prior wheezing, and the clinical presentation was that of severe bronchospasm that was generally resistant to standard bronchodilator therapy. The spectrum of infection likely ranged from mild upper respiratory infection to severe bronchospasm with respiratory failure, and the burden of disease resulting in hospitalization was substantial at many children’s hospitals. The big question now is what will enterovirus season 2015 bring us? The good news here is that we now have a test to rapidly diagnose EV D-68, which will allow us to more clearly understand the burden of disease – and potentially to define antiviral treatment (none of the current antivirals is effective) and prevention (there is no vaccine against EV D-68).

3. The etiology of the neurologic illness, which appeared to mimic polio and presented during the same time frame during which EV D-68 was circulating, is as yet unknown. As of Nov. 26, 2014, the CDC has received reports of 90 children in 32 states who meet a case definition consistent with acute flaccid myelitis. While certain viruses – including West Nile virus, herpes virus, adenovirus, and certain enterovirus types (for example, enterovirus 71, and the classic being polio) – may cause acute flaccid paralysis and can be confirmed by detecting the virus in cerebrospinal fluid and stool, to date virus testing for all viruses, including EV D-68, has been negative in all of the patients reported. Hopefully, 2015 will be the year that will allow us to more clearly understand this neurologic illness – and this is important because so far most children have shown minimal recovery of function.

4. If you see a child (or adult) who recently traveled to the Caribbean and returns with fever, rash, and joint pain, especially with severe pain of the hands and feet, think chikungunya virus infection. As of the end of October 2014, local transmission had been identified in 37 countries or territories in the Caribbean (including Puerto Rico and the U.S. Virgin Islands), with a total of 780,206 suspected cases and over 15,000 confirmed cases reported from these areas. Consider this in contrast to the numbers from 2006 through 2011, when 117 cases of chikungunya fever were reported in returning travelers. As of Dec. 2, a total of 1,911 chikungunya virus disease cases have been reported to ArboNET from U.S. states. The mosquito that transmits chikungunya virus can bite in day and night, and prevention relies on appropriate use of mosquito repellents. Physicians should be prepared to discuss the risks of this virus with travelers who plan a trip to the Caribbean, especially those at high risk, including those with underlying medical conditions, preexisting arthritis diagnoses, and pregnant women (because of the potential risk to newborns whose mothers develop intrapartum infection).

5. And lastly, Ebola. While there were reports that Ebola virus disease had emerged in West Africa as early as December of 2013, the scope of the outbreak and extent of loss of human life has been unbelievably huge. Dr. Carrie Byington, who is the current chair of the AAP Committee on Infectious Diseases, wrote an article in AAP News in October 2014 describing the needs of children who have been impacted by Ebola virus disease (EVD). She noted that UNICEF estimated there were at that time, over 4,000 Ebola orphans in the countries most affected by EVD, including Sierra Leone, Liberia, and Guinea, and that these countries urgently needed medical infrastructure for treatment and prevention of this disease. It appears that at least two Ebola vaccines will be deployed in West Africa in 2015, and it is not a moment too soon. While cases in Liberia seemed to be decreasing, it looks like Sierra Leone cases continue to mount.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled “Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions,” but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Recently the American Academy of Pediatrics issued recommendations that address management of asymptomatic newborns whose mothers have active herpes simplex virus (HSV) lesions noted at the time of delivery. Implementing these recommendations requires proactive coordination between the director of the laboratory and the obstetrical and pediatric providers to ensure success (Pediatrics 2013;131:e635-46).

Approximately 1,500 infants are diagnosed and treated for neonatal HSV infection each year in the United States. Most pediatricians are knowledgeable about the three forms of neonatal HSV infection and the role of prompt diagnosis and utilization of acyclovir. Even so, the outcomes of this disease may be devastating. Skin–eye–mucous membrane disease has the best prognosis (98% neurologically normal), as finding the culprit lesion generally ensures timely diagnosis and treatment. With central nervous system infection or disseminated disease, a skin lesion is not noted in 25%-40% of cases. So the diagnosis is sometimes delayed or missed initially because the initial presentations (seizures in CNS infection; sepsis picture or liver failure in disseminated disease) may sidetrack the provider into considering other working diagnoses, such as bacterial sepsis or metabolic disease. Neurologic sequelae occur in 25% of those with disseminated infection, but in upward of 70% in those with CNS disease.

Ideally, both the obstetrician and the pediatric provider play a role in ensuring appropriate care for the baby whose mother has active HSV lesions at time of delivery. Appropriate care includes preemptive treatment for neonatal HSV infection, which has the potential to improve outcomes and so should be a high priority for all providers.

The new guidance is evidence based and predicated on the availability of HSV typing of the HSV from the maternal lesion and type-specific serology. It allows the provider to define the newborn risk of acquiring HSV infection more explicitly and utilize preemptive evaluation/therapy. Providers should ensure that their hospital laboratory can perform such testing with reasonable turnaround time for results.

Obstetrical role and implications of testing

The obstetric provider should swab the maternal lesion for HSV polymerase chain reaction (PCR) assay/culture and typing (HSV-1 or HSV-2). These data can be utilized with maternal history and serologic results to calculate the neonatal risk for infection.

Calculation of relative neonatal risk

• First episode, primary infection. Defined as the first maternal HSV episode with type-specific serology being negative, this makes the risk of neonatal infection approximately 50%. If maternal history of prior disease is negative AND either the maternal lesion test results or serology results are unavailable, follow the plan of care for first episode primary infection.

• First episode, nonprimary infection. Defined as the first maternal episode but antibody to detected HSV type is not present (e.g., HSV-2 confirmed from lesion, with type 1 but NOT type 2 maternal antibody present; OR HSV-1 confirmed, with type 2 but NOT type 1 maternal antibody present), the risk of neonatal infection is approximately 25%.

• Recurrent. If the mother has a history of genital herpes and the mother’s type-specific antibody is the same as the type detected in the lesions, the risk for neonatal infection is lower and approximately 2%.

Pediatrician’s role and plan of care

The first order of business is to identify neonates who demonstrate signs or symptoms suggestive of HSV infection at birth or in the perinatal period (whether or not any lesions were noted at time of delivery). In this case, all infants should undergo full evaluation for both viral and bacterial causes and should have prompt initiation of preemptive antiviral and antibacterial therapy. The evaluation of an ill-appearing infant at birth should include CBC; liver function studies; blood, urine, and cerebrospinal fluid examination with bacterial cultures of blood, urine, and cerebrospinal fluid, plus blood and cerebrospinal fluid HSV PCR. Also, HSV surface (conjunctivae, nasopharynx, and rectum) and lesion cultures are needed. Infectious disease consultation is recommended if HSV infection is confirmed. Acyclovir should continue for 14 days for skin–eye–mucous membrane disease or 21 days for CNS or disseminated infection. Further evaluation toward the end of therapy can determine if a longer course of therapy should be considered.

The recent guideline addresses care for those infants who are born to mothers with active HSV lesions noted at time of delivery, and should be initiated only if the infant is asymptomatic at birth.

In this situation, for babies whose mothers have primary infection (risk 50% for neonatal infection) or first episode, nonprimary infection (risk 25% for neonatal infection):

• Approximately 24 hours after the infant’s birth, obtain blood HSV DNA PCR and HSV surface cultures of conjunctivae, nasopharynx, and rectum as well as from the scalp electrode site if there was one.

• Cerebrospinal fluid examination with HSV DNA PCR testing should be obtained.

• Acyclovir (20 mg/kg per dose every 8 hours IV) should be initiated. Preemptive therapy (acyclovir 20 mg/kg per dose every 8 hours IV) should be continued for 10 days and until all studies are negative.

For babies whose mothers have recurrent infection:

• Cerebrospinal fluid examination may be deferred.

• But the rest of the workup should be completed and IV acyclovir initiated.

• IV acyclovir can be stopped at the time that studies are negative (usually at 48 hours, assuming negative results of blood PCR and preliminary negative surface cultures), with close follow-up of the infant.

Use of this guideline can improve care of infants only when the laboratory and the obstetrical and pediatric providers have established a good working relationship. This ensures the availability of necessary HSV studies, complete implementation, and proper interpretation of testing to guide the newborn’s care.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled "Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions," but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Recently the American Academy of Pediatrics issued recommendations that address management of asymptomatic newborns whose mothers have active herpes simplex virus (HSV) lesions noted at the time of delivery. Implementing these recommendations requires proactive coordination between the director of the laboratory and the obstetrical and pediatric providers to ensure success (Pediatrics 2013;131:e635-46).

Approximately 1,500 infants are diagnosed and treated for neonatal HSV infection each year in the United States. Most pediatricians are knowledgeable about the three forms of neonatal HSV infection and the role of prompt diagnosis and utilization of acyclovir. Even so, the outcomes of this disease may be devastating. Skin–eye–mucous membrane disease has the best prognosis (98% neurologically normal), as finding the culprit lesion generally ensures timely diagnosis and treatment. With central nervous system infection or disseminated disease, a skin lesion is not noted in 25%-40% of cases. So the diagnosis is sometimes delayed or missed initially because the initial presentations (seizures in CNS infection; sepsis picture or liver failure in disseminated disease) may sidetrack the provider into considering other working diagnoses, such as bacterial sepsis or metabolic disease. Neurologic sequelae occur in 25% of those with disseminated infection, but in upward of 70% in those with CNS disease.

Ideally, both the obstetrician and the pediatric provider play a role in ensuring appropriate care for the baby whose mother has active HSV lesions at time of delivery. Appropriate care includes preemptive treatment for neonatal HSV infection, which has the potential to improve outcomes and so should be a high priority for all providers.

The new guidance is evidence based and predicated on the availability of HSV typing of the HSV from the maternal lesion and type-specific serology. It allows the provider to define the newborn risk of acquiring HSV infection more explicitly and utilize preemptive evaluation/therapy. Providers should ensure that their hospital laboratory can perform such testing with reasonable turnaround time for results.

Obstetrical role and implications of testing

The obstetric provider should swab the maternal lesion for HSV polymerase chain reaction (PCR) assay/culture and typing (HSV-1 or HSV-2). These data can be utilized with maternal history and serologic results to calculate the neonatal risk for infection.

Calculation of relative neonatal risk

• First episode, primary infection. Defined as the first maternal HSV episode with type-specific serology being negative, this makes the risk of neonatal infection approximately 50%. If maternal history of prior disease is negative AND either the maternal lesion test results or serology results are unavailable, follow the plan of care for first episode primary infection.

• First episode, nonprimary infection. Defined as the first maternal episode but antibody to detected HSV type is not present (e.g., HSV-2 confirmed from lesion, with type 1 but NOT type 2 maternal antibody present; OR HSV-1 confirmed, with type 2 but NOT type 1 maternal antibody present), the risk of neonatal infection is approximately 25%.

• Recurrent. If the mother has a history of genital herpes and the mother’s type-specific antibody is the same as the type detected in the lesions, the risk for neonatal infection is lower and approximately 2%.

Pediatrician’s role and plan of care

The first order of business is to identify neonates who demonstrate signs or symptoms suggestive of HSV infection at birth or in the perinatal period (whether or not any lesions were noted at time of delivery). In this case, all infants should undergo full evaluation for both viral and bacterial causes and should have prompt initiation of preemptive antiviral and antibacterial therapy. The evaluation of an ill-appearing infant at birth should include CBC; liver function studies; blood, urine, and cerebrospinal fluid examination with bacterial cultures of blood, urine, and cerebrospinal fluid, plus blood and cerebrospinal fluid HSV PCR. Also, HSV surface (conjunctivae, nasopharynx, and rectum) and lesion cultures are needed. Infectious disease consultation is recommended if HSV infection is confirmed. Acyclovir should continue for 14 days for skin–eye–mucous membrane disease or 21 days for CNS or disseminated infection. Further evaluation toward the end of therapy can determine if a longer course of therapy should be considered.

The recent guideline addresses care for those infants who are born to mothers with active HSV lesions noted at time of delivery, and should be initiated only if the infant is asymptomatic at birth.

In this situation, for babies whose mothers have primary infection (risk 50% for neonatal infection) or first episode, nonprimary infection (risk 25% for neonatal infection):

• Approximately 24 hours after the infant’s birth, obtain blood HSV DNA PCR and HSV surface cultures of conjunctivae, nasopharynx, and rectum as well as from the scalp electrode site if there was one.

• Cerebrospinal fluid examination with HSV DNA PCR testing should be obtained.

• Acyclovir (20 mg/kg per dose every 8 hours IV) should be initiated. Preemptive therapy (acyclovir 20 mg/kg per dose every 8 hours IV) should be continued for 10 days and until all studies are negative.

For babies whose mothers have recurrent infection:

• Cerebrospinal fluid examination may be deferred.

• But the rest of the workup should be completed and IV acyclovir initiated.

• IV acyclovir can be stopped at the time that studies are negative (usually at 48 hours, assuming negative results of blood PCR and preliminary negative surface cultures), with close follow-up of the infant.

Use of this guideline can improve care of infants only when the laboratory and the obstetrical and pediatric providers have established a good working relationship. This ensures the availability of necessary HSV studies, complete implementation, and proper interpretation of testing to guide the newborn’s care.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled "Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions," but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Recently the American Academy of Pediatrics issued recommendations that address management of asymptomatic newborns whose mothers have active herpes simplex virus (HSV) lesions noted at the time of delivery. Implementing these recommendations requires proactive coordination between the director of the laboratory and the obstetrical and pediatric providers to ensure success (Pediatrics 2013;131:e635-46).

Approximately 1,500 infants are diagnosed and treated for neonatal HSV infection each year in the United States. Most pediatricians are knowledgeable about the three forms of neonatal HSV infection and the role of prompt diagnosis and utilization of acyclovir. Even so, the outcomes of this disease may be devastating. Skin–eye–mucous membrane disease has the best prognosis (98% neurologically normal), as finding the culprit lesion generally ensures timely diagnosis and treatment. With central nervous system infection or disseminated disease, a skin lesion is not noted in 25%-40% of cases. So the diagnosis is sometimes delayed or missed initially because the initial presentations (seizures in CNS infection; sepsis picture or liver failure in disseminated disease) may sidetrack the provider into considering other working diagnoses, such as bacterial sepsis or metabolic disease. Neurologic sequelae occur in 25% of those with disseminated infection, but in upward of 70% in those with CNS disease.

Ideally, both the obstetrician and the pediatric provider play a role in ensuring appropriate care for the baby whose mother has active HSV lesions at time of delivery. Appropriate care includes preemptive treatment for neonatal HSV infection, which has the potential to improve outcomes and so should be a high priority for all providers.

The new guidance is evidence based and predicated on the availability of HSV typing of the HSV from the maternal lesion and type-specific serology. It allows the provider to define the newborn risk of acquiring HSV infection more explicitly and utilize preemptive evaluation/therapy. Providers should ensure that their hospital laboratory can perform such testing with reasonable turnaround time for results.

Obstetrical role and implications of testing

The obstetric provider should swab the maternal lesion for HSV polymerase chain reaction (PCR) assay/culture and typing (HSV-1 or HSV-2). These data can be utilized with maternal history and serologic results to calculate the neonatal risk for infection.

Calculation of relative neonatal risk

• First episode, primary infection. Defined as the first maternal HSV episode with type-specific serology being negative, this makes the risk of neonatal infection approximately 50%. If maternal history of prior disease is negative AND either the maternal lesion test results or serology results are unavailable, follow the plan of care for first episode primary infection.

• First episode, nonprimary infection. Defined as the first maternal episode but antibody to detected HSV type is not present (e.g., HSV-2 confirmed from lesion, with type 1 but NOT type 2 maternal antibody present; OR HSV-1 confirmed, with type 2 but NOT type 1 maternal antibody present), the risk of neonatal infection is approximately 25%.

• Recurrent. If the mother has a history of genital herpes and the mother’s type-specific antibody is the same as the type detected in the lesions, the risk for neonatal infection is lower and approximately 2%.

Pediatrician’s role and plan of care

The first order of business is to identify neonates who demonstrate signs or symptoms suggestive of HSV infection at birth or in the perinatal period (whether or not any lesions were noted at time of delivery). In this case, all infants should undergo full evaluation for both viral and bacterial causes and should have prompt initiation of preemptive antiviral and antibacterial therapy. The evaluation of an ill-appearing infant at birth should include CBC; liver function studies; blood, urine, and cerebrospinal fluid examination with bacterial cultures of blood, urine, and cerebrospinal fluid, plus blood and cerebrospinal fluid HSV PCR. Also, HSV surface (conjunctivae, nasopharynx, and rectum) and lesion cultures are needed. Infectious disease consultation is recommended if HSV infection is confirmed. Acyclovir should continue for 14 days for skin–eye–mucous membrane disease or 21 days for CNS or disseminated infection. Further evaluation toward the end of therapy can determine if a longer course of therapy should be considered.

The recent guideline addresses care for those infants who are born to mothers with active HSV lesions noted at time of delivery, and should be initiated only if the infant is asymptomatic at birth.

In this situation, for babies whose mothers have primary infection (risk 50% for neonatal infection) or first episode, nonprimary infection (risk 25% for neonatal infection):

• Approximately 24 hours after the infant’s birth, obtain blood HSV DNA PCR and HSV surface cultures of conjunctivae, nasopharynx, and rectum as well as from the scalp electrode site if there was one.

• Cerebrospinal fluid examination with HSV DNA PCR testing should be obtained.

• Acyclovir (20 mg/kg per dose every 8 hours IV) should be initiated. Preemptive therapy (acyclovir 20 mg/kg per dose every 8 hours IV) should be continued for 10 days and until all studies are negative.

For babies whose mothers have recurrent infection:

• Cerebrospinal fluid examination may be deferred.

• But the rest of the workup should be completed and IV acyclovir initiated.

• IV acyclovir can be stopped at the time that studies are negative (usually at 48 hours, assuming negative results of blood PCR and preliminary negative surface cultures), with close follow-up of the infant.

Use of this guideline can improve care of infants only when the laboratory and the obstetrical and pediatric providers have established a good working relationship. This ensures the availability of necessary HSV studies, complete implementation, and proper interpretation of testing to guide the newborn’s care.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. Dr. Jackson was a member of the AAP Committee on Infectious Diseases who wrote the AAP clinical report entitled "Guidance on Management of Asymptomatic Neonates Born to Women With Active Genital Herpes Lesions," but said she had no other conflicts of interest to disclose. E-mail her at [email protected].

Are you prepared to manage the infectious disease challenges you’ll be facing in 2014? Here are my Top 5 predictions for what lies ahead in infectious diseases for the next year with pearls to help you in your practice. The first addresses a series of concerns around influenza. Others target diagnoses you might not have encountered or considered in the past. The last will hopefully improve HPV vaccination rates in your practice.

1. Expect an especially busy influenza season and the possibility that you may encounter patients with life-threatening influenza. We’ve already detected influenza in over 1,000 children at my institution, almost all 2009 pandemic H1N1 influenza A viruses, which is consistent with the national data from the Centers for Disease Control and Prevention. We are really just a month into influenza season, and we are seeing a significant number of children admitted to our pediatric intensive care unit with life-threatening disease presentations, and we’ve also seen unusual influenza complications. Talk to your ID colleagues about the potential for intravenous zanamivir in critically ill children who do not respond to oseltamivir. While pulmonary complications of influenza are most common, unusual presentations you may encounter include influenza encephalopathy (altered mental status, seizures, and mutism) and bacterial superinfection (when fever recurs or recrudesces after initial improvement, often 3-5 days into the course, think Staphylococcus aureus or Group A streptococcal disease). The CDC is alerting practitioners to the potential for increased morbidity and mortality in young/middle aged adults so the parents of your patients are at increased risk this year.

• False-negative testing can happen if the sensitivity of the rapid test is low, but a false-negative test can occur if the specimen is collected late in the clinical course. (This is especially true in the adult population in which testing may be negative at just 4-5 days into the course of disease.)

• Recognize that all hospitalized children should be treated with oseltamivir, as well as children who are immunocompromised; have chronic cardiopulmonary conditions, including hemodynamically significant heart disease and asthma; renal disease; metabolic disease, including diabetes; pregnant teens; morbidly obese patients; patients with neuromuscular/neurodevelopmental conditions (especially those with difficulty controlling airway secretions); and children under 2 years of age.

• I predict you may be hearing about oseltamivir shortages, but for now this relates to the sporadic difficulty in finding the oseltamivir suspension, in part, because of the lack of early season availability of this product at retail pharmacies, many of which are just getting in their stock. Prescribe the suspension for children aged younger than 1 year and be explicit about the mL dosage that should be dispensed. For children over 1 year of age, capsules can be opened and placed in pudding for those who cannot swallow capsules. Lexicomp Online offers guidelines for easy use of 30-mg, 45-mg and 75-mg capsules for different weight categories. If the suspension is necessary for an infant and is not available, the drug can be compounded by your pharmacy using capsules. You may find some pharmacies are reluctant to compound, so be prepared to contact your local children’s hospital for help. And keep offering vaccine throughout the season to healthy patients!

2. Most practitioners are aware of the importance of methicillin-resistant S. aureus (MRSA) as a pathogen that causes bacteremia and musculoskeletal and pulmonary disease in otherwise healthy children. I suspect there is less awareness that, in many locales, methicillin-sensitive S. aureus (MSSA) is being seen just as often, if not slightly more often than MRSA, as a bloodstream pathogen. The inclusion of vancomycin (which covers MRSA) with cefepime should be considered for empiric coverage in the otherwise healthy child with suspected sepsis. Cefepime is a fourth-generation cephalosporin with good gram-negative and gram-positive coverage and also has bactericidal activity against MSSA strains. Clindamycin should be considered as an adjunct to vancomycin and cefepime in those with toxin-mediated disease/toxic shock syndrome. Of course, modification of the empiric regimen should follow identification of the specific pathogen and the site(s) of infection.

3. E. coli remains the most common cause of urinary tract infections in children, but infections caused by multiple drug resistant (MDR) Escherichia coli strains are increasingly being seen. Consider infection caused by extended spectrum beta-lactamase–producing organisms in children with underlying renal anomalies, especially if they have been previously exposed to third-generation cephalosporins. Most strains are also resistant to fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides as well as to non–carbapenem beta-lactams. Speaking of antibiotic resistance, look for many hospital microbiology laboratories to begin using advanced molecular detection methodology to more quickly identify bacterial and fungal isolates; such methods could reduce the time of identification from over 24 hours with conventional techniques to less than one hour. The use of newer systems to identify microbes and confirm susceptibility testing has the potential to transform care and improve outcomes.

4. Consider the diagnosis of human parechovirus (HPeV) infection in young febrile infants with sepsis/meningitis presentation but negative bacterial cultures. Detection of HPeV by polymerase chain reaction testing in serum or cerebrospinal fluid is diagnostic. Exclusion of herpes simplex virus and enterovirus disease is key, as similar clinical presentations may be seen. HPeV infections are more commonly noted in late spring and early summer in contrast to enteroviral infections, which tend to occur from July to September.

5. The strength of your vaccine recommendation continues to be the most important factor affecting the parental decision to vaccinate a child. Nowhere is this more obvious than with human papillomavirus vaccine (HPV), where practitioners often simply offer the vaccine rather than recommend it. In terms of teenage vaccines, when practitioners recommend Tdap (tetanus, diphtheria, and pertussis vaccine) and meningococcal conjugate vaccine as standard for their patients ("Today your child will receive whooping cough vaccine and the meningitis vaccine."), vaccine uptake is very high. But when it comes to the HPV vaccine, some practitioners feel they first must establish whether the parents are aware of HPV vaccine; then discuss their questions regarding the safety of the vaccine; and finally, explain that the vaccine prevents cancer. Some practitioners offer the option of "thinking about" the vaccine for the next visit, but in such cases, the patient generally leaves without receiving the vaccine. Add HPV vaccine into your standard teen vaccine recommendation and make it a goal to get the first vaccine initiated in all eligible patients. The three-dose HPV vaccine schedule is still recommended, but I predict that simplification of the schedule may occur as early as 2014 in the United States. We’ll keep you posted.

Dr. Jackson is director of the division of infectious disease and associate director of the infectious disease fellowship program at the University of Missouri, Kansas City.

Are you prepared to manage the infectious disease challenges you’ll be facing in 2014? Here are my Top 5 predictions for what lies ahead in infectious diseases for the next year with pearls to help you in your practice. The first addresses a series of concerns around influenza. Others target diagnoses you might not have encountered or considered in the past. The last will hopefully improve HPV vaccination rates in your practice.

1. Expect an especially busy influenza season and the possibility that you may encounter patients with life-threatening influenza. We’ve already detected influenza in over 1,000 children at my institution, almost all 2009 pandemic H1N1 influenza A viruses, which is consistent with the national data from the Centers for Disease Control and Prevention. We are really just a month into influenza season, and we are seeing a significant number of children admitted to our pediatric intensive care unit with life-threatening disease presentations, and we’ve also seen unusual influenza complications. Talk to your ID colleagues about the potential for intravenous zanamivir in critically ill children who do not respond to oseltamivir. While pulmonary complications of influenza are most common, unusual presentations you may encounter include influenza encephalopathy (altered mental status, seizures, and mutism) and bacterial superinfection (when fever recurs or recrudesces after initial improvement, often 3-5 days into the course, think Staphylococcus aureus or Group A streptococcal disease). The CDC is alerting practitioners to the potential for increased morbidity and mortality in young/middle aged adults so the parents of your patients are at increased risk this year.

• False-negative testing can happen if the sensitivity of the rapid test is low, but a false-negative test can occur if the specimen is collected late in the clinical course. (This is especially true in the adult population in which testing may be negative at just 4-5 days into the course of disease.)

• Recognize that all hospitalized children should be treated with oseltamivir, as well as children who are immunocompromised; have chronic cardiopulmonary conditions, including hemodynamically significant heart disease and asthma; renal disease; metabolic disease, including diabetes; pregnant teens; morbidly obese patients; patients with neuromuscular/neurodevelopmental conditions (especially those with difficulty controlling airway secretions); and children under 2 years of age.

• I predict you may be hearing about oseltamivir shortages, but for now this relates to the sporadic difficulty in finding the oseltamivir suspension, in part, because of the lack of early season availability of this product at retail pharmacies, many of which are just getting in their stock. Prescribe the suspension for children aged younger than 1 year and be explicit about the mL dosage that should be dispensed. For children over 1 year of age, capsules can be opened and placed in pudding for those who cannot swallow capsules. Lexicomp Online offers guidelines for easy use of 30-mg, 45-mg and 75-mg capsules for different weight categories. If the suspension is necessary for an infant and is not available, the drug can be compounded by your pharmacy using capsules. You may find some pharmacies are reluctant to compound, so be prepared to contact your local children’s hospital for help. And keep offering vaccine throughout the season to healthy patients!

2. Most practitioners are aware of the importance of methicillin-resistant S. aureus (MRSA) as a pathogen that causes bacteremia and musculoskeletal and pulmonary disease in otherwise healthy children. I suspect there is less awareness that, in many locales, methicillin-sensitive S. aureus (MSSA) is being seen just as often, if not slightly more often than MRSA, as a bloodstream pathogen. The inclusion of vancomycin (which covers MRSA) with cefepime should be considered for empiric coverage in the otherwise healthy child with suspected sepsis. Cefepime is a fourth-generation cephalosporin with good gram-negative and gram-positive coverage and also has bactericidal activity against MSSA strains. Clindamycin should be considered as an adjunct to vancomycin and cefepime in those with toxin-mediated disease/toxic shock syndrome. Of course, modification of the empiric regimen should follow identification of the specific pathogen and the site(s) of infection.

3. E. coli remains the most common cause of urinary tract infections in children, but infections caused by multiple drug resistant (MDR) Escherichia coli strains are increasingly being seen. Consider infection caused by extended spectrum beta-lactamase–producing organisms in children with underlying renal anomalies, especially if they have been previously exposed to third-generation cephalosporins. Most strains are also resistant to fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides as well as to non–carbapenem beta-lactams. Speaking of antibiotic resistance, look for many hospital microbiology laboratories to begin using advanced molecular detection methodology to more quickly identify bacterial and fungal isolates; such methods could reduce the time of identification from over 24 hours with conventional techniques to less than one hour. The use of newer systems to identify microbes and confirm susceptibility testing has the potential to transform care and improve outcomes.

4. Consider the diagnosis of human parechovirus (HPeV) infection in young febrile infants with sepsis/meningitis presentation but negative bacterial cultures. Detection of HPeV by polymerase chain reaction testing in serum or cerebrospinal fluid is diagnostic. Exclusion of herpes simplex virus and enterovirus disease is key, as similar clinical presentations may be seen. HPeV infections are more commonly noted in late spring and early summer in contrast to enteroviral infections, which tend to occur from July to September.

5. The strength of your vaccine recommendation continues to be the most important factor affecting the parental decision to vaccinate a child. Nowhere is this more obvious than with human papillomavirus vaccine (HPV), where practitioners often simply offer the vaccine rather than recommend it. In terms of teenage vaccines, when practitioners recommend Tdap (tetanus, diphtheria, and pertussis vaccine) and meningococcal conjugate vaccine as standard for their patients ("Today your child will receive whooping cough vaccine and the meningitis vaccine."), vaccine uptake is very high. But when it comes to the HPV vaccine, some practitioners feel they first must establish whether the parents are aware of HPV vaccine; then discuss their questions regarding the safety of the vaccine; and finally, explain that the vaccine prevents cancer. Some practitioners offer the option of "thinking about" the vaccine for the next visit, but in such cases, the patient generally leaves without receiving the vaccine. Add HPV vaccine into your standard teen vaccine recommendation and make it a goal to get the first vaccine initiated in all eligible patients. The three-dose HPV vaccine schedule is still recommended, but I predict that simplification of the schedule may occur as early as 2014 in the United States. We’ll keep you posted.

Dr. Jackson is director of the division of infectious disease and associate director of the infectious disease fellowship program at the University of Missouri, Kansas City.

Are you prepared to manage the infectious disease challenges you’ll be facing in 2014? Here are my Top 5 predictions for what lies ahead in infectious diseases for the next year with pearls to help you in your practice. The first addresses a series of concerns around influenza. Others target diagnoses you might not have encountered or considered in the past. The last will hopefully improve HPV vaccination rates in your practice.

1. Expect an especially busy influenza season and the possibility that you may encounter patients with life-threatening influenza. We’ve already detected influenza in over 1,000 children at my institution, almost all 2009 pandemic H1N1 influenza A viruses, which is consistent with the national data from the Centers for Disease Control and Prevention. We are really just a month into influenza season, and we are seeing a significant number of children admitted to our pediatric intensive care unit with life-threatening disease presentations, and we’ve also seen unusual influenza complications. Talk to your ID colleagues about the potential for intravenous zanamivir in critically ill children who do not respond to oseltamivir. While pulmonary complications of influenza are most common, unusual presentations you may encounter include influenza encephalopathy (altered mental status, seizures, and mutism) and bacterial superinfection (when fever recurs or recrudesces after initial improvement, often 3-5 days into the course, think Staphylococcus aureus or Group A streptococcal disease). The CDC is alerting practitioners to the potential for increased morbidity and mortality in young/middle aged adults so the parents of your patients are at increased risk this year.

• False-negative testing can happen if the sensitivity of the rapid test is low, but a false-negative test can occur if the specimen is collected late in the clinical course. (This is especially true in the adult population in which testing may be negative at just 4-5 days into the course of disease.)

• Recognize that all hospitalized children should be treated with oseltamivir, as well as children who are immunocompromised; have chronic cardiopulmonary conditions, including hemodynamically significant heart disease and asthma; renal disease; metabolic disease, including diabetes; pregnant teens; morbidly obese patients; patients with neuromuscular/neurodevelopmental conditions (especially those with difficulty controlling airway secretions); and children under 2 years of age.

• I predict you may be hearing about oseltamivir shortages, but for now this relates to the sporadic difficulty in finding the oseltamivir suspension, in part, because of the lack of early season availability of this product at retail pharmacies, many of which are just getting in their stock. Prescribe the suspension for children aged younger than 1 year and be explicit about the mL dosage that should be dispensed. For children over 1 year of age, capsules can be opened and placed in pudding for those who cannot swallow capsules. Lexicomp Online offers guidelines for easy use of 30-mg, 45-mg and 75-mg capsules for different weight categories. If the suspension is necessary for an infant and is not available, the drug can be compounded by your pharmacy using capsules. You may find some pharmacies are reluctant to compound, so be prepared to contact your local children’s hospital for help. And keep offering vaccine throughout the season to healthy patients!

2. Most practitioners are aware of the importance of methicillin-resistant S. aureus (MRSA) as a pathogen that causes bacteremia and musculoskeletal and pulmonary disease in otherwise healthy children. I suspect there is less awareness that, in many locales, methicillin-sensitive S. aureus (MSSA) is being seen just as often, if not slightly more often than MRSA, as a bloodstream pathogen. The inclusion of vancomycin (which covers MRSA) with cefepime should be considered for empiric coverage in the otherwise healthy child with suspected sepsis. Cefepime is a fourth-generation cephalosporin with good gram-negative and gram-positive coverage and also has bactericidal activity against MSSA strains. Clindamycin should be considered as an adjunct to vancomycin and cefepime in those with toxin-mediated disease/toxic shock syndrome. Of course, modification of the empiric regimen should follow identification of the specific pathogen and the site(s) of infection.

3. E. coli remains the most common cause of urinary tract infections in children, but infections caused by multiple drug resistant (MDR) Escherichia coli strains are increasingly being seen. Consider infection caused by extended spectrum beta-lactamase–producing organisms in children with underlying renal anomalies, especially if they have been previously exposed to third-generation cephalosporins. Most strains are also resistant to fluoroquinolones, trimethoprim-sulfamethoxazole, and aminoglycosides as well as to non–carbapenem beta-lactams. Speaking of antibiotic resistance, look for many hospital microbiology laboratories to begin using advanced molecular detection methodology to more quickly identify bacterial and fungal isolates; such methods could reduce the time of identification from over 24 hours with conventional techniques to less than one hour. The use of newer systems to identify microbes and confirm susceptibility testing has the potential to transform care and improve outcomes.

4. Consider the diagnosis of human parechovirus (HPeV) infection in young febrile infants with sepsis/meningitis presentation but negative bacterial cultures. Detection of HPeV by polymerase chain reaction testing in serum or cerebrospinal fluid is diagnostic. Exclusion of herpes simplex virus and enterovirus disease is key, as similar clinical presentations may be seen. HPeV infections are more commonly noted in late spring and early summer in contrast to enteroviral infections, which tend to occur from July to September.

5. The strength of your vaccine recommendation continues to be the most important factor affecting the parental decision to vaccinate a child. Nowhere is this more obvious than with human papillomavirus vaccine (HPV), where practitioners often simply offer the vaccine rather than recommend it. In terms of teenage vaccines, when practitioners recommend Tdap (tetanus, diphtheria, and pertussis vaccine) and meningococcal conjugate vaccine as standard for their patients ("Today your child will receive whooping cough vaccine and the meningitis vaccine."), vaccine uptake is very high. But when it comes to the HPV vaccine, some practitioners feel they first must establish whether the parents are aware of HPV vaccine; then discuss their questions regarding the safety of the vaccine; and finally, explain that the vaccine prevents cancer. Some practitioners offer the option of "thinking about" the vaccine for the next visit, but in such cases, the patient generally leaves without receiving the vaccine. Add HPV vaccine into your standard teen vaccine recommendation and make it a goal to get the first vaccine initiated in all eligible patients. The three-dose HPV vaccine schedule is still recommended, but I predict that simplification of the schedule may occur as early as 2014 in the United States. We’ll keep you posted.

Dr. Jackson is director of the division of infectious disease and associate director of the infectious disease fellowship program at the University of Missouri, Kansas City.

Mycoplasma pneumoniae is a cell wall–deficient pleomorphic bacterium and well-reported cause of respiratory tract infection in the school-aged child. Symptoms are variable, and clinical presentations run the gamut from upper respiratory (usually self-limited) and lower respiratory tract involvement (pneumonia) to unusual manifestations including nervous system disease (encephalitis, cerebellar ataxia, transverse myelitis), hemolytic anemia, Stevens-Johnson syndrome, and myocarditis/pericarditis.

Pneumonia occurs in 10% of infected school-aged children, and cough can persist for 3-4 weeks; some children wheeze in the setting of Mycoplasma infection. Radiographic patterns of disease are variable; patchy alveolar infiltrates with small pleural effusions are often described. Consolidated pneumonia, large effusions, and hilar adenopathy are uncommonly reported, and severe disease has been described in certain patient populations, including those with sickle cell disease, children with Down syndrome, and those with immunodeficiencies. The acute chest presentation has been associated with M. pneumoniae in children with sickle cell anemia and prolonged hospitalizations (mean, 10 days), and the need for transfusion and mechanical ventilation was noted in 82% and 6%, respectively, in one study (Pediatrics 2003;112(1 Pt 1):87-95). Community clusters of pneumonia are reported in school-aged children, and in Rhode Island, an outbreak was reported in children from four schools; 76 had pneumonia and 3 had encephalitis (J. Infect. Dis. 2008;198:1365-74).

Considering this is a common pathogen, there are a number of questions regarding the scope of disease and impact of treatment that are incompletely answered. The first problem is that it is hard to confirm diagnostically. Culture is technically difficult, the organism takes up to 3 weeks to grow, and the diagnostic test is offered in very few labs. The old-fashioned cold agglutinin test has a low sensitivity and specificity; an increase in titers can be seen during a variety of viral infections. Polymerase chain reaction (PCR) on respiratory secretions is increasingly available; sensitivity and specificity are said to be 80% and 100%, respectively. The organism can persist in the respiratory tract for several weeks though, even after treatment, so PCR can remain positive for 2-3 weeks. This makes it hard to use PCR to confirm M. pneumoniae as the etiologic agent, especially in the setting of unusual clinical presentations. Serologic testing is often ordered and hard to interpret. False positive IgM antibody tests are not uncommon, and IgM antibody can persist for months. Outside of PCR and culture, acute and convalescent specimens can be used diagnostically, and a fourfold IgG antibody rise is consistent with acute infection.

Macrolides are regarded as the preferred treatment for M. pneumoniae pneumonia, but several studies question whether treatment impacts the clinical course. This may be due to the inherent difficulty of confirming M. pneumoniae as the etiologic agent, as most studies used serology to confirm the diagnosis. In countries outside the United States, macrolide resistance is well reported, and this may be underappreciated in the United States. We recently cared for a teenager with Down syndrome with pneumonia caused by M. pneumoniae who had a protracted clinical course. Fever and hypoxemia were persistent over a several-week period despite two courses of azithromycin and exclusion of virus, bacteria, and fungal pathogens. Bronchoalveolar lavage was performed, M. pneumoniae was detected by PCR, and macrolide resistance was confirmed. Levofloxacin was given, and she recovered over the next week.

Macrolide resistance is commonly reported outside the United States; rates in China are reported to be greater than 90%, in Japan 80%, and in Europe, between 15% and 25%. A recent study from Greg Storch and his colleagues (Pediatr. Infect. Dis. J. 2012;31:409-10) documented macrolide resistance in 8% of respiratory samples collected between 2007 and 2010 (49 patients; mean age, 10 years), noting the resistance rate was 3% in 2007-2008 and 15% in 2009-2010. A recently published study of data from Canada reported that 12.1% of M. pneumoniae–positive specimens collected between 2010 and January 2012 carried nucleotide mutations associated with macrolide resistance in the 23S rRNA gene (Emerg. Infect. Dis. 2013 September [doi: 10.3201/eid1909.121466]). Anecdotal studies suggest that patients with macrolide-resistant M. pneumoniae infection clinically improve when given doxycycline (or minocycline) or levofloxacin.

A number of clinical questions regarding M. pneumoniae may be answered more definitively in the future, but we need more easily available diagnostics (PCR is a good start), routinely accessible susceptibility data, and a good randomized controlled study to investigate the question of whether treatment shortens the course of disease.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri-Kansas City. She said she has no conflicts of interest to disclose. E-mail her at [email protected].

Mycoplasma pneumoniae is a cell wall–deficient pleomorphic bacterium and well-reported cause of respiratory tract infection in the school-aged child. Symptoms are variable, and clinical presentations run the gamut from upper respiratory (usually self-limited) and lower respiratory tract involvement (pneumonia) to unusual manifestations including nervous system disease (encephalitis, cerebellar ataxia, transverse myelitis), hemolytic anemia, Stevens-Johnson syndrome, and myocarditis/pericarditis.

Pneumonia occurs in 10% of infected school-aged children, and cough can persist for 3-4 weeks; some children wheeze in the setting of Mycoplasma infection. Radiographic patterns of disease are variable; patchy alveolar infiltrates with small pleural effusions are often described. Consolidated pneumonia, large effusions, and hilar adenopathy are uncommonly reported, and severe disease has been described in certain patient populations, including those with sickle cell disease, children with Down syndrome, and those with immunodeficiencies. The acute chest presentation has been associated with M. pneumoniae in children with sickle cell anemia and prolonged hospitalizations (mean, 10 days), and the need for transfusion and mechanical ventilation was noted in 82% and 6%, respectively, in one study (Pediatrics 2003;112(1 Pt 1):87-95). Community clusters of pneumonia are reported in school-aged children, and in Rhode Island, an outbreak was reported in children from four schools; 76 had pneumonia and 3 had encephalitis (J. Infect. Dis. 2008;198:1365-74).

Considering this is a common pathogen, there are a number of questions regarding the scope of disease and impact of treatment that are incompletely answered. The first problem is that it is hard to confirm diagnostically. Culture is technically difficult, the organism takes up to 3 weeks to grow, and the diagnostic test is offered in very few labs. The old-fashioned cold agglutinin test has a low sensitivity and specificity; an increase in titers can be seen during a variety of viral infections. Polymerase chain reaction (PCR) on respiratory secretions is increasingly available; sensitivity and specificity are said to be 80% and 100%, respectively. The organism can persist in the respiratory tract for several weeks though, even after treatment, so PCR can remain positive for 2-3 weeks. This makes it hard to use PCR to confirm M. pneumoniae as the etiologic agent, especially in the setting of unusual clinical presentations. Serologic testing is often ordered and hard to interpret. False positive IgM antibody tests are not uncommon, and IgM antibody can persist for months. Outside of PCR and culture, acute and convalescent specimens can be used diagnostically, and a fourfold IgG antibody rise is consistent with acute infection.

Macrolides are regarded as the preferred treatment for M. pneumoniae pneumonia, but several studies question whether treatment impacts the clinical course. This may be due to the inherent difficulty of confirming M. pneumoniae as the etiologic agent, as most studies used serology to confirm the diagnosis. In countries outside the United States, macrolide resistance is well reported, and this may be underappreciated in the United States. We recently cared for a teenager with Down syndrome with pneumonia caused by M. pneumoniae who had a protracted clinical course. Fever and hypoxemia were persistent over a several-week period despite two courses of azithromycin and exclusion of virus, bacteria, and fungal pathogens. Bronchoalveolar lavage was performed, M. pneumoniae was detected by PCR, and macrolide resistance was confirmed. Levofloxacin was given, and she recovered over the next week.

Macrolide resistance is commonly reported outside the United States; rates in China are reported to be greater than 90%, in Japan 80%, and in Europe, between 15% and 25%. A recent study from Greg Storch and his colleagues (Pediatr. Infect. Dis. J. 2012;31:409-10) documented macrolide resistance in 8% of respiratory samples collected between 2007 and 2010 (49 patients; mean age, 10 years), noting the resistance rate was 3% in 2007-2008 and 15% in 2009-2010. A recently published study of data from Canada reported that 12.1% of M. pneumoniae–positive specimens collected between 2010 and January 2012 carried nucleotide mutations associated with macrolide resistance in the 23S rRNA gene (Emerg. Infect. Dis. 2013 September [doi: 10.3201/eid1909.121466]). Anecdotal studies suggest that patients with macrolide-resistant M. pneumoniae infection clinically improve when given doxycycline (or minocycline) or levofloxacin.

A number of clinical questions regarding M. pneumoniae may be answered more definitively in the future, but we need more easily available diagnostics (PCR is a good start), routinely accessible susceptibility data, and a good randomized controlled study to investigate the question of whether treatment shortens the course of disease.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri-Kansas City. She said she has no conflicts of interest to disclose. E-mail her at [email protected].

Mycoplasma pneumoniae is a cell wall–deficient pleomorphic bacterium and well-reported cause of respiratory tract infection in the school-aged child. Symptoms are variable, and clinical presentations run the gamut from upper respiratory (usually self-limited) and lower respiratory tract involvement (pneumonia) to unusual manifestations including nervous system disease (encephalitis, cerebellar ataxia, transverse myelitis), hemolytic anemia, Stevens-Johnson syndrome, and myocarditis/pericarditis.

Pneumonia occurs in 10% of infected school-aged children, and cough can persist for 3-4 weeks; some children wheeze in the setting of Mycoplasma infection. Radiographic patterns of disease are variable; patchy alveolar infiltrates with small pleural effusions are often described. Consolidated pneumonia, large effusions, and hilar adenopathy are uncommonly reported, and severe disease has been described in certain patient populations, including those with sickle cell disease, children with Down syndrome, and those with immunodeficiencies. The acute chest presentation has been associated with M. pneumoniae in children with sickle cell anemia and prolonged hospitalizations (mean, 10 days), and the need for transfusion and mechanical ventilation was noted in 82% and 6%, respectively, in one study (Pediatrics 2003;112(1 Pt 1):87-95). Community clusters of pneumonia are reported in school-aged children, and in Rhode Island, an outbreak was reported in children from four schools; 76 had pneumonia and 3 had encephalitis (J. Infect. Dis. 2008;198:1365-74).

Considering this is a common pathogen, there are a number of questions regarding the scope of disease and impact of treatment that are incompletely answered. The first problem is that it is hard to confirm diagnostically. Culture is technically difficult, the organism takes up to 3 weeks to grow, and the diagnostic test is offered in very few labs. The old-fashioned cold agglutinin test has a low sensitivity and specificity; an increase in titers can be seen during a variety of viral infections. Polymerase chain reaction (PCR) on respiratory secretions is increasingly available; sensitivity and specificity are said to be 80% and 100%, respectively. The organism can persist in the respiratory tract for several weeks though, even after treatment, so PCR can remain positive for 2-3 weeks. This makes it hard to use PCR to confirm M. pneumoniae as the etiologic agent, especially in the setting of unusual clinical presentations. Serologic testing is often ordered and hard to interpret. False positive IgM antibody tests are not uncommon, and IgM antibody can persist for months. Outside of PCR and culture, acute and convalescent specimens can be used diagnostically, and a fourfold IgG antibody rise is consistent with acute infection.

Macrolides are regarded as the preferred treatment for M. pneumoniae pneumonia, but several studies question whether treatment impacts the clinical course. This may be due to the inherent difficulty of confirming M. pneumoniae as the etiologic agent, as most studies used serology to confirm the diagnosis. In countries outside the United States, macrolide resistance is well reported, and this may be underappreciated in the United States. We recently cared for a teenager with Down syndrome with pneumonia caused by M. pneumoniae who had a protracted clinical course. Fever and hypoxemia were persistent over a several-week period despite two courses of azithromycin and exclusion of virus, bacteria, and fungal pathogens. Bronchoalveolar lavage was performed, M. pneumoniae was detected by PCR, and macrolide resistance was confirmed. Levofloxacin was given, and she recovered over the next week.

Macrolide resistance is commonly reported outside the United States; rates in China are reported to be greater than 90%, in Japan 80%, and in Europe, between 15% and 25%. A recent study from Greg Storch and his colleagues (Pediatr. Infect. Dis. J. 2012;31:409-10) documented macrolide resistance in 8% of respiratory samples collected between 2007 and 2010 (49 patients; mean age, 10 years), noting the resistance rate was 3% in 2007-2008 and 15% in 2009-2010. A recently published study of data from Canada reported that 12.1% of M. pneumoniae–positive specimens collected between 2010 and January 2012 carried nucleotide mutations associated with macrolide resistance in the 23S rRNA gene (Emerg. Infect. Dis. 2013 September [doi: 10.3201/eid1909.121466]). Anecdotal studies suggest that patients with macrolide-resistant M. pneumoniae infection clinically improve when given doxycycline (or minocycline) or levofloxacin.

A number of clinical questions regarding M. pneumoniae may be answered more definitively in the future, but we need more easily available diagnostics (PCR is a good start), routinely accessible susceptibility data, and a good randomized controlled study to investigate the question of whether treatment shortens the course of disease.

Dr. Jackson is chief of pediatric infectious diseases at Children’s Mercy Hospital, Kansas City, Mo., and professor of pediatrics at the University of Missouri-Kansas City. She said she has no conflicts of interest to disclose. E-mail her at [email protected].

It is that time of year when 2013 predictions come your way, with insights into upcoming changes and/or developments in the specialty of pediatric infectious diseases. The theme this year: drugs, bugs, and the new immunization schedule.

Antimicrobial resistance for Gram negative organisms will reach new heights in 2013, new antibiotics will not likely appear on the market, and you will see an increase in emphasis on judicious antibiotic use in other venues such as the animal industry.

Particularly worrisome is the increased rate of hospital acquired carbapenem-resistant Klebsiella pneumoniae infections as few good therapeutic options currently exist for these pathogens. Judicious use of antibiotics in all instances is key, and pediatricians should particularly focus on their practice patterns for common infections (streptococcal pharyngitis, otitis media, and sinusitis), and avoiding antibiotics for upper respiratory infections and bronchitis.

The United States is the fifth greatest user of antibiotics in the world (France, Greece, Italy, and Belgium exceed us), and Kentucky, West Virginia, Tennessee, Mississippi, and Louisiana are the states with the highest use. Check out the map of this data to see antibiotic use for your state.

The winter scourge of rotavirus infection has virtually disappeared following the introduction of rotavirus vaccine but two diarrheal pathogens you’ll likely hear more about in 2013 are norovirus and cryptosporidia.

Norovirus (think cruise ship diarrhea) moves front and center as the most important cause of diarrheal outbreaks in the United States. While foodborne disease occurs, most outbreaks relate to person-to-person transmission, and you are most likely to see disease this time of year (November through April). This might be explained by the fact that infected individuals shed billions of norovirus particles, and it only takes 18 particles to infect another, plus folks are more likely to be closely quartered in winter months.

In terms of cryptosporidiosis, famous outbreaks have followed contamination of drinking water, and sporadic cases are often seen in summer following recreational water exposure. While self-limited in the healthy child, cryptosporidiosis is hard to treat and causes significant morbidity in immunocompromised individuals, such as organ transplant patients. Pediatricians should alert parents to the risk related to recreational water exposure for high-risk patients who should avoid ingesting such water, and particularly avoid pools where diapered children may contaminate the water.

Speaking of diarrhea, as rates for Clostridium difficile associated disease (CDAD) in children have been increasing over the last decade, I suspect clinicians will need to gain a better understanding of the specifics regarding newer C. difficile tests. Many institutions have gone to molecular assays. Polymerase chain reaction (PCR) testing, for instance, has been introduced, which is very sensitive, and doubled the rate of positivity (compared with enzyme immunoassay) in some studies. We know that asymptomatic carriage of C. difficile is common in infants younger than 12 months of age, but several studies suggest that 25%-33% of 0- to 36-month control patients had stools that were positive for C. difficile toxin. Take a highly sensitive test, high rates of asymptomatic colonization, and the overall low prevalence CDAD, and you are likely to see diagnosis and treatment instituted inappropriately in some cases. The key to diagnosis of CDAD is to perform testing only on liquid stools and to make sure that other etiologies of diarrhea have been excluded in those less than 3 years of age. Don’t test young infants younger than 1 year (unless they have Hirschsprung’s disease), and do not perform tests to check for cure. See the new guideline published in the January issue of Pediatrics (2013; 131:196-200).

We may still be months away from knowing the full extent of the 2012 national fungal meningitis outbreak; however, based on what we know now, there is a clear need for legislation to ensure safe practices in compounding pharmacies, and I predict this will come in 2013. The first case of fungal meningitis cases was reported Sept. 18, 2012, in a man in Tennessee, and within a week, seven other cases were diagnosed; all had epidural steroid injections at the same center (N. Engl. J. Med. 2012 Dec. 19 [doi: 10.1056/NEJMoa1213978]).

Since then, a Centers for Disease Control and Prevention investigation has found that more than 600 infected patients and 39 patients have died. Three lots of methylprednisolone products from a compounding pharmacy in New England were found to be the source, and the CDC investigation found that more than 14,000 individuals in 70-plus clinics in 22 states were exposed to the products, mostly adult patients with chronic back pain. The organism in all but one case is an unusual environmental fungus (Exserohilum rostratum) that likely was introduced into the products during drug preparation. The Food and Drug Administration has since inspected the company’s processing room and noted a number of different issues that may have resulted in contamination. Products have been recalled from the implicated pharmacy (New England Compounding Center), and a sister pharmacy (Ameridose) has voluntarily recalled its products. This is not the first time that an outbreak has been tracked to contamination at a compounding pharmacies, but the extent of this outbreak emphasizes the need for definitive action to prevent this from ever happening again.

The 2013 Immunization Schedule will be out soon, and I predict practitioners may be happy to see a comprehensive footnote table, a harmonized schedule for those 0-18 years, and separate tables for the high-risk patient and for those requiring catch-up schedules.

In terms of vaccines, an important goal for practitioners may be to increase vaccine coverage in teens. Human papillomavirus (HPV) coverage rates are still dismal; 35% of girls and 1% of boys completed three vaccines in 2011, according to the National Immunization Survey–Teen. Parents who refused HPV vaccines in their daughters more likely cited safety concerns, but those who refused for their sons were more likely not to be aware of the recommendation for vaccination, according to data from the NIS-Teen. Geographic disparities also have been noted, with the southeastern U.S. states having lowest rates for immunization and some of the highest rates for cervical cancer. Recommend HPV vaccine every time another teen platform vaccine is recommended, and use a standing order in your practice so every encounter is an opportunity to immunize.

I wish you blessings in the coming year and hope that at least some of my predictions have utility for those of you in practice.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

It is that time of year when 2013 predictions come your way, with insights into upcoming changes and/or developments in the specialty of pediatric infectious diseases. The theme this year: drugs, bugs, and the new immunization schedule.

Antimicrobial resistance for Gram negative organisms will reach new heights in 2013, new antibiotics will not likely appear on the market, and you will see an increase in emphasis on judicious antibiotic use in other venues such as the animal industry.

Particularly worrisome is the increased rate of hospital acquired carbapenem-resistant Klebsiella pneumoniae infections as few good therapeutic options currently exist for these pathogens. Judicious use of antibiotics in all instances is key, and pediatricians should particularly focus on their practice patterns for common infections (streptococcal pharyngitis, otitis media, and sinusitis), and avoiding antibiotics for upper respiratory infections and bronchitis.

The United States is the fifth greatest user of antibiotics in the world (France, Greece, Italy, and Belgium exceed us), and Kentucky, West Virginia, Tennessee, Mississippi, and Louisiana are the states with the highest use. Check out the map of this data to see antibiotic use for your state.

The winter scourge of rotavirus infection has virtually disappeared following the introduction of rotavirus vaccine but two diarrheal pathogens you’ll likely hear more about in 2013 are norovirus and cryptosporidia.

Norovirus (think cruise ship diarrhea) moves front and center as the most important cause of diarrheal outbreaks in the United States. While foodborne disease occurs, most outbreaks relate to person-to-person transmission, and you are most likely to see disease this time of year (November through April). This might be explained by the fact that infected individuals shed billions of norovirus particles, and it only takes 18 particles to infect another, plus folks are more likely to be closely quartered in winter months.

In terms of cryptosporidiosis, famous outbreaks have followed contamination of drinking water, and sporadic cases are often seen in summer following recreational water exposure. While self-limited in the healthy child, cryptosporidiosis is hard to treat and causes significant morbidity in immunocompromised individuals, such as organ transplant patients. Pediatricians should alert parents to the risk related to recreational water exposure for high-risk patients who should avoid ingesting such water, and particularly avoid pools where diapered children may contaminate the water.

Speaking of diarrhea, as rates for Clostridium difficile associated disease (CDAD) in children have been increasing over the last decade, I suspect clinicians will need to gain a better understanding of the specifics regarding newer C. difficile tests. Many institutions have gone to molecular assays. Polymerase chain reaction (PCR) testing, for instance, has been introduced, which is very sensitive, and doubled the rate of positivity (compared with enzyme immunoassay) in some studies. We know that asymptomatic carriage of C. difficile is common in infants younger than 12 months of age, but several studies suggest that 25%-33% of 0- to 36-month control patients had stools that were positive for C. difficile toxin. Take a highly sensitive test, high rates of asymptomatic colonization, and the overall low prevalence CDAD, and you are likely to see diagnosis and treatment instituted inappropriately in some cases. The key to diagnosis of CDAD is to perform testing only on liquid stools and to make sure that other etiologies of diarrhea have been excluded in those less than 3 years of age. Don’t test young infants younger than 1 year (unless they have Hirschsprung’s disease), and do not perform tests to check for cure. See the new guideline published in the January issue of Pediatrics (2013; 131:196-200).

We may still be months away from knowing the full extent of the 2012 national fungal meningitis outbreak; however, based on what we know now, there is a clear need for legislation to ensure safe practices in compounding pharmacies, and I predict this will come in 2013. The first case of fungal meningitis cases was reported Sept. 18, 2012, in a man in Tennessee, and within a week, seven other cases were diagnosed; all had epidural steroid injections at the same center (N. Engl. J. Med. 2012 Dec. 19 [doi: 10.1056/NEJMoa1213978]).

Since then, a Centers for Disease Control and Prevention investigation has found that more than 600 infected patients and 39 patients have died. Three lots of methylprednisolone products from a compounding pharmacy in New England were found to be the source, and the CDC investigation found that more than 14,000 individuals in 70-plus clinics in 22 states were exposed to the products, mostly adult patients with chronic back pain. The organism in all but one case is an unusual environmental fungus (Exserohilum rostratum) that likely was introduced into the products during drug preparation. The Food and Drug Administration has since inspected the company’s processing room and noted a number of different issues that may have resulted in contamination. Products have been recalled from the implicated pharmacy (New England Compounding Center), and a sister pharmacy (Ameridose) has voluntarily recalled its products. This is not the first time that an outbreak has been tracked to contamination at a compounding pharmacies, but the extent of this outbreak emphasizes the need for definitive action to prevent this from ever happening again.

The 2013 Immunization Schedule will be out soon, and I predict practitioners may be happy to see a comprehensive footnote table, a harmonized schedule for those 0-18 years, and separate tables for the high-risk patient and for those requiring catch-up schedules.

In terms of vaccines, an important goal for practitioners may be to increase vaccine coverage in teens. Human papillomavirus (HPV) coverage rates are still dismal; 35% of girls and 1% of boys completed three vaccines in 2011, according to the National Immunization Survey–Teen. Parents who refused HPV vaccines in their daughters more likely cited safety concerns, but those who refused for their sons were more likely not to be aware of the recommendation for vaccination, according to data from the NIS-Teen. Geographic disparities also have been noted, with the southeastern U.S. states having lowest rates for immunization and some of the highest rates for cervical cancer. Recommend HPV vaccine every time another teen platform vaccine is recommended, and use a standing order in your practice so every encounter is an opportunity to immunize.

I wish you blessings in the coming year and hope that at least some of my predictions have utility for those of you in practice.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

It is that time of year when 2013 predictions come your way, with insights into upcoming changes and/or developments in the specialty of pediatric infectious diseases. The theme this year: drugs, bugs, and the new immunization schedule.

Antimicrobial resistance for Gram negative organisms will reach new heights in 2013, new antibiotics will not likely appear on the market, and you will see an increase in emphasis on judicious antibiotic use in other venues such as the animal industry.

Particularly worrisome is the increased rate of hospital acquired carbapenem-resistant Klebsiella pneumoniae infections as few good therapeutic options currently exist for these pathogens. Judicious use of antibiotics in all instances is key, and pediatricians should particularly focus on their practice patterns for common infections (streptococcal pharyngitis, otitis media, and sinusitis), and avoiding antibiotics for upper respiratory infections and bronchitis.

The United States is the fifth greatest user of antibiotics in the world (France, Greece, Italy, and Belgium exceed us), and Kentucky, West Virginia, Tennessee, Mississippi, and Louisiana are the states with the highest use. Check out the map of this data to see antibiotic use for your state.

The winter scourge of rotavirus infection has virtually disappeared following the introduction of rotavirus vaccine but two diarrheal pathogens you’ll likely hear more about in 2013 are norovirus and cryptosporidia.

Norovirus (think cruise ship diarrhea) moves front and center as the most important cause of diarrheal outbreaks in the United States. While foodborne disease occurs, most outbreaks relate to person-to-person transmission, and you are most likely to see disease this time of year (November through April). This might be explained by the fact that infected individuals shed billions of norovirus particles, and it only takes 18 particles to infect another, plus folks are more likely to be closely quartered in winter months.

In terms of cryptosporidiosis, famous outbreaks have followed contamination of drinking water, and sporadic cases are often seen in summer following recreational water exposure. While self-limited in the healthy child, cryptosporidiosis is hard to treat and causes significant morbidity in immunocompromised individuals, such as organ transplant patients. Pediatricians should alert parents to the risk related to recreational water exposure for high-risk patients who should avoid ingesting such water, and particularly avoid pools where diapered children may contaminate the water.

Speaking of diarrhea, as rates for Clostridium difficile associated disease (CDAD) in children have been increasing over the last decade, I suspect clinicians will need to gain a better understanding of the specifics regarding newer C. difficile tests. Many institutions have gone to molecular assays. Polymerase chain reaction (PCR) testing, for instance, has been introduced, which is very sensitive, and doubled the rate of positivity (compared with enzyme immunoassay) in some studies. We know that asymptomatic carriage of C. difficile is common in infants younger than 12 months of age, but several studies suggest that 25%-33% of 0- to 36-month control patients had stools that were positive for C. difficile toxin. Take a highly sensitive test, high rates of asymptomatic colonization, and the overall low prevalence CDAD, and you are likely to see diagnosis and treatment instituted inappropriately in some cases. The key to diagnosis of CDAD is to perform testing only on liquid stools and to make sure that other etiologies of diarrhea have been excluded in those less than 3 years of age. Don’t test young infants younger than 1 year (unless they have Hirschsprung’s disease), and do not perform tests to check for cure. See the new guideline published in the January issue of Pediatrics (2013; 131:196-200).

We may still be months away from knowing the full extent of the 2012 national fungal meningitis outbreak; however, based on what we know now, there is a clear need for legislation to ensure safe practices in compounding pharmacies, and I predict this will come in 2013. The first case of fungal meningitis cases was reported Sept. 18, 2012, in a man in Tennessee, and within a week, seven other cases were diagnosed; all had epidural steroid injections at the same center (N. Engl. J. Med. 2012 Dec. 19 [doi: 10.1056/NEJMoa1213978]).

Since then, a Centers for Disease Control and Prevention investigation has found that more than 600 infected patients and 39 patients have died. Three lots of methylprednisolone products from a compounding pharmacy in New England were found to be the source, and the CDC investigation found that more than 14,000 individuals in 70-plus clinics in 22 states were exposed to the products, mostly adult patients with chronic back pain. The organism in all but one case is an unusual environmental fungus (Exserohilum rostratum) that likely was introduced into the products during drug preparation. The Food and Drug Administration has since inspected the company’s processing room and noted a number of different issues that may have resulted in contamination. Products have been recalled from the implicated pharmacy (New England Compounding Center), and a sister pharmacy (Ameridose) has voluntarily recalled its products. This is not the first time that an outbreak has been tracked to contamination at a compounding pharmacies, but the extent of this outbreak emphasizes the need for definitive action to prevent this from ever happening again.

The 2013 Immunization Schedule will be out soon, and I predict practitioners may be happy to see a comprehensive footnote table, a harmonized schedule for those 0-18 years, and separate tables for the high-risk patient and for those requiring catch-up schedules.

In terms of vaccines, an important goal for practitioners may be to increase vaccine coverage in teens. Human papillomavirus (HPV) coverage rates are still dismal; 35% of girls and 1% of boys completed three vaccines in 2011, according to the National Immunization Survey–Teen. Parents who refused HPV vaccines in their daughters more likely cited safety concerns, but those who refused for their sons were more likely not to be aware of the recommendation for vaccination, according to data from the NIS-Teen. Geographic disparities also have been noted, with the southeastern U.S. states having lowest rates for immunization and some of the highest rates for cervical cancer. Recommend HPV vaccine every time another teen platform vaccine is recommended, and use a standing order in your practice so every encounter is an opportunity to immunize.

I wish you blessings in the coming year and hope that at least some of my predictions have utility for those of you in practice.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

Although the 2011-2012 influenza season was milder than usual and associated with fewer outpatient visits, lower hospitalization rates, and fewer pediatric deaths, practitioners should be aware that this virus is still the leading cause of vaccine-preventable deaths in children. Hopefully, practitioners are already providing influenza immunization utilizing the 2012-2013 vaccine, which contains the same influenza A (H1N1) antigen as the 2011-2012 seasonal vaccine but new influenza A (H3N2) and B antigens: These are A/California/7/2009 (H1N1)–like antigen, A/Victoria/361/2011(H3N2)–like antigen, and B/Wisconsin/1/2010–like antigen.

Here are the answers to some of the most common questions related to this year’s influenza season:

• How many doses are recommended this year for children between 6 months through 8 years of age?

For a child in this age group who had two or more doses of seasonal vaccine since July 1, 2010, or in whom you can document one dose of a pandemic H1N1–containing vaccine and at least two seasonal vaccines from any season, only one dose is needed. All others in this age group should receive two doses. As always, those 9 years of age and older receive one dose of vaccine.

• Given recent data that suggested a slight increased risk of a febrile seizure following trivalent inactivated vaccine (TIV) in children less than 4 years, have vaccine recommendations changed?

A suggestion of an increased risk for febrile seizures in young children after TIV was noted in the United States in 2010-2011. This followed enhanced monitoring after the observation in Australia in 2010 of an association with an increased risk of febrile seizures (greater than or equal to nine per 1,000 doses) that were related to a particular influenza vaccine. (Afluria vaccine is approved for use in those greater than age 5 years, but current recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) state this vaccine should not be used in those less than 9 years of age. It could be considered for a high-risk patient between 5 through 8 years if no alternative TIV is available and after discussion of the seizure risk with parents.)

To further study this potential association, the CDC tracked more than 200,000 children in the United States who received TIV or PCV13 (Prevnar) vaccine at different visits or both together at the same visit. Rarely, a febrile seizure was noted in children less than 5 years who got TIV or PCV13 vaccine given at separate visits. Those 12- to 23-month-olds who received both at the same visit had a slightly increased risk for an uncomplicated febrile seizure in the 24 hours following vaccine receipt. This is the age group where febrile seizures peak in general and is equivalent to one excess seizure for every 2,000-3,000 vaccine doses. Based on this low risk and the uncomplicated course in such patients, coupled with the benefits of immunization, both the AAP and ACIP recommended no change in either the TIV or PCV13 vaccine policies. And remember that neither a prior febrile seizure history nor a preexisting seizure disorder is considered a contraindication for influenza vaccine.

• Who can get the intradermal formulation of influenza vaccine?

Fluzone Intradermal, which made its debut in the 2011-2012 season, is licensed for those 18-64 years of age, and is a preservative-free, trivalent inactivated influenza vaccine. It comes in a prefilled microinjection syringe, which for those who require TIV and are needle averse, may be preferred. Local reactions seen with intramuscular TIV (with the exception of pain), including redness, swelling, and itching at the site seem to be a bit more common with the intradermal product, but such reactions abate in 3-7 days. This vaccine could be utilized in an older adolescent who might opt for a vaccine that has a needle that is 90% shorter than the needle used for intramuscular injection of TIV.

• Is oseltamivir still the drug of choice to treat influenza?

Last year only 1.4% of strains were resistant to oseltamivir, and this year is expected to be the same. Treatment and prophylaxis dosing is the same as last year. The AAP and ACIP continue to emphasize early treatment for all children in high-risk groups who develop influenza, regardless of influenza immunization status. Treatment is also recommended for all who are ill enough to require hospitalization. For patients with influenzalike illness, the decision to treat should not be based on rapid antigen testing results. A negative test does not "rule out" influenza as commercially available tests are not sufficiently sensitive. You might want to check with your hospital to find out what other influenza testing is available in your locale.

• Which of my "egg-allergic" patients can receive influenza vaccine?

Decision making related to TIV depends on the type of prior reaction the patient had. Those with mild reactions, defined as hives alone, may receive TIV followed by a 30-minute observation period. Use the same vaccine for those who require a second dose, if at all possible. Consult an allergist for those with severe reactions including cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that required the use of epinephrine. An algorithm is available from the CDC that can be used to guide decision making in such cases.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

Although the 2011-2012 influenza season was milder than usual and associated with fewer outpatient visits, lower hospitalization rates, and fewer pediatric deaths, practitioners should be aware that this virus is still the leading cause of vaccine-preventable deaths in children. Hopefully, practitioners are already providing influenza immunization utilizing the 2012-2013 vaccine, which contains the same influenza A (H1N1) antigen as the 2011-2012 seasonal vaccine but new influenza A (H3N2) and B antigens: These are A/California/7/2009 (H1N1)–like antigen, A/Victoria/361/2011(H3N2)–like antigen, and B/Wisconsin/1/2010–like antigen.

Here are the answers to some of the most common questions related to this year’s influenza season:

• How many doses are recommended this year for children between 6 months through 8 years of age?

For a child in this age group who had two or more doses of seasonal vaccine since July 1, 2010, or in whom you can document one dose of a pandemic H1N1–containing vaccine and at least two seasonal vaccines from any season, only one dose is needed. All others in this age group should receive two doses. As always, those 9 years of age and older receive one dose of vaccine.

• Given recent data that suggested a slight increased risk of a febrile seizure following trivalent inactivated vaccine (TIV) in children less than 4 years, have vaccine recommendations changed?

A suggestion of an increased risk for febrile seizures in young children after TIV was noted in the United States in 2010-2011. This followed enhanced monitoring after the observation in Australia in 2010 of an association with an increased risk of febrile seizures (greater than or equal to nine per 1,000 doses) that were related to a particular influenza vaccine. (Afluria vaccine is approved for use in those greater than age 5 years, but current recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) state this vaccine should not be used in those less than 9 years of age. It could be considered for a high-risk patient between 5 through 8 years if no alternative TIV is available and after discussion of the seizure risk with parents.)

To further study this potential association, the CDC tracked more than 200,000 children in the United States who received TIV or PCV13 (Prevnar) vaccine at different visits or both together at the same visit. Rarely, a febrile seizure was noted in children less than 5 years who got TIV or PCV13 vaccine given at separate visits. Those 12- to 23-month-olds who received both at the same visit had a slightly increased risk for an uncomplicated febrile seizure in the 24 hours following vaccine receipt. This is the age group where febrile seizures peak in general and is equivalent to one excess seizure for every 2,000-3,000 vaccine doses. Based on this low risk and the uncomplicated course in such patients, coupled with the benefits of immunization, both the AAP and ACIP recommended no change in either the TIV or PCV13 vaccine policies. And remember that neither a prior febrile seizure history nor a preexisting seizure disorder is considered a contraindication for influenza vaccine.

• Who can get the intradermal formulation of influenza vaccine?

Fluzone Intradermal, which made its debut in the 2011-2012 season, is licensed for those 18-64 years of age, and is a preservative-free, trivalent inactivated influenza vaccine. It comes in a prefilled microinjection syringe, which for those who require TIV and are needle averse, may be preferred. Local reactions seen with intramuscular TIV (with the exception of pain), including redness, swelling, and itching at the site seem to be a bit more common with the intradermal product, but such reactions abate in 3-7 days. This vaccine could be utilized in an older adolescent who might opt for a vaccine that has a needle that is 90% shorter than the needle used for intramuscular injection of TIV.

• Is oseltamivir still the drug of choice to treat influenza?

Last year only 1.4% of strains were resistant to oseltamivir, and this year is expected to be the same. Treatment and prophylaxis dosing is the same as last year. The AAP and ACIP continue to emphasize early treatment for all children in high-risk groups who develop influenza, regardless of influenza immunization status. Treatment is also recommended for all who are ill enough to require hospitalization. For patients with influenzalike illness, the decision to treat should not be based on rapid antigen testing results. A negative test does not "rule out" influenza as commercially available tests are not sufficiently sensitive. You might want to check with your hospital to find out what other influenza testing is available in your locale.

• Which of my "egg-allergic" patients can receive influenza vaccine?

Decision making related to TIV depends on the type of prior reaction the patient had. Those with mild reactions, defined as hives alone, may receive TIV followed by a 30-minute observation period. Use the same vaccine for those who require a second dose, if at all possible. Consult an allergist for those with severe reactions including cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that required the use of epinephrine. An algorithm is available from the CDC that can be used to guide decision making in such cases.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].

Although the 2011-2012 influenza season was milder than usual and associated with fewer outpatient visits, lower hospitalization rates, and fewer pediatric deaths, practitioners should be aware that this virus is still the leading cause of vaccine-preventable deaths in children. Hopefully, practitioners are already providing influenza immunization utilizing the 2012-2013 vaccine, which contains the same influenza A (H1N1) antigen as the 2011-2012 seasonal vaccine but new influenza A (H3N2) and B antigens: These are A/California/7/2009 (H1N1)–like antigen, A/Victoria/361/2011(H3N2)–like antigen, and B/Wisconsin/1/2010–like antigen.

Here are the answers to some of the most common questions related to this year’s influenza season:

• How many doses are recommended this year for children between 6 months through 8 years of age?

For a child in this age group who had two or more doses of seasonal vaccine since July 1, 2010, or in whom you can document one dose of a pandemic H1N1–containing vaccine and at least two seasonal vaccines from any season, only one dose is needed. All others in this age group should receive two doses. As always, those 9 years of age and older receive one dose of vaccine.

• Given recent data that suggested a slight increased risk of a febrile seizure following trivalent inactivated vaccine (TIV) in children less than 4 years, have vaccine recommendations changed?

A suggestion of an increased risk for febrile seizures in young children after TIV was noted in the United States in 2010-2011. This followed enhanced monitoring after the observation in Australia in 2010 of an association with an increased risk of febrile seizures (greater than or equal to nine per 1,000 doses) that were related to a particular influenza vaccine. (Afluria vaccine is approved for use in those greater than age 5 years, but current recommendations from the American Academy of Pediatrics and the Centers for Disease Control and Prevention’s Advisory Committee on Immunization Practices (ACIP) state this vaccine should not be used in those less than 9 years of age. It could be considered for a high-risk patient between 5 through 8 years if no alternative TIV is available and after discussion of the seizure risk with parents.)

To further study this potential association, the CDC tracked more than 200,000 children in the United States who received TIV or PCV13 (Prevnar) vaccine at different visits or both together at the same visit. Rarely, a febrile seizure was noted in children less than 5 years who got TIV or PCV13 vaccine given at separate visits. Those 12- to 23-month-olds who received both at the same visit had a slightly increased risk for an uncomplicated febrile seizure in the 24 hours following vaccine receipt. This is the age group where febrile seizures peak in general and is equivalent to one excess seizure for every 2,000-3,000 vaccine doses. Based on this low risk and the uncomplicated course in such patients, coupled with the benefits of immunization, both the AAP and ACIP recommended no change in either the TIV or PCV13 vaccine policies. And remember that neither a prior febrile seizure history nor a preexisting seizure disorder is considered a contraindication for influenza vaccine.

• Who can get the intradermal formulation of influenza vaccine?

Fluzone Intradermal, which made its debut in the 2011-2012 season, is licensed for those 18-64 years of age, and is a preservative-free, trivalent inactivated influenza vaccine. It comes in a prefilled microinjection syringe, which for those who require TIV and are needle averse, may be preferred. Local reactions seen with intramuscular TIV (with the exception of pain), including redness, swelling, and itching at the site seem to be a bit more common with the intradermal product, but such reactions abate in 3-7 days. This vaccine could be utilized in an older adolescent who might opt for a vaccine that has a needle that is 90% shorter than the needle used for intramuscular injection of TIV.

• Is oseltamivir still the drug of choice to treat influenza?

Last year only 1.4% of strains were resistant to oseltamivir, and this year is expected to be the same. Treatment and prophylaxis dosing is the same as last year. The AAP and ACIP continue to emphasize early treatment for all children in high-risk groups who develop influenza, regardless of influenza immunization status. Treatment is also recommended for all who are ill enough to require hospitalization. For patients with influenzalike illness, the decision to treat should not be based on rapid antigen testing results. A negative test does not "rule out" influenza as commercially available tests are not sufficiently sensitive. You might want to check with your hospital to find out what other influenza testing is available in your locale.

• Which of my "egg-allergic" patients can receive influenza vaccine?

Decision making related to TIV depends on the type of prior reaction the patient had. Those with mild reactions, defined as hives alone, may receive TIV followed by a 30-minute observation period. Use the same vaccine for those who require a second dose, if at all possible. Consult an allergist for those with severe reactions including cardiovascular changes, respiratory and/or gastrointestinal tract symptoms, or reactions that required the use of epinephrine. An algorithm is available from the CDC that can be used to guide decision making in such cases.

Dr. Jackson is the chief of infectious diseases at Children’s Mercy Hospitals and Clinics in Kansas City, Mo., and professor of pediatrics at the University of Missouri–Kansas City. She said she has no relevant financial disclosures. E-mail her at [email protected].