Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine June 10-12, 2011

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1 10 Recent Publications That Have or Should Have Changed Your Practice The 48th Annual Pediatrics for the Practitioner San Antonio, TX; June 10, 2011 Russell Steele, M.D. Ochsner s Children s Health Center and Tulane University School of Medicine New Orleans, Louisiana Russell Steele, M.D. has no relevant financial relationships with commercial interests to disclose. OBJECTIVES To incorporate into practice new observations for patient management To carefully evaluate recent publications related to infectious diseases To update standards of care for treating infections To improve diagnostic approaches to potential severe infectious processes

2 DISCLOSURES NONE ALL OF MY MONEY WENT TO COLLEGE AND MEDICAL SCHOOL TUITIONS FOR THE KIDS Triatoma rubida 40-60% of Kissing Bugs are infected with Trypanosoma cruzi in Tucson, AZ (Emerg. Inf. Dis. March :400-5) Chagas Disease A 19 y/o healthy adolescent, a college student in Arizona, was notified by the blood bank after donating blood that his screen for Chagas disease was positive and advised to contact you. Your management is: a. contact CDC b. no treatment is indicated c. treat with nifurtimox d. treat if there are cardiac or GI symptoms e. treat if immunosuppressed

3 Most Recent U.S. Case New Orleans 2006 Emerg Infect Dis. 2007;13:605-7 Testing began in December positive tests 12/06 through 9/07 >300,000 T. cruzi infected individuals of Hispanic origin currently live in the U.S. Only 11% of Chagas seropositive blood donors have contacted CDC Physician lack of awareness Treatment is nifurtimox 15 mg/kg/d div. q 8-12 hr. x 90 days Chagas Disease Kissing Bugs with Trypanosoma cruzi 7.7 million infected in Mexico, Central and South America Cardiomyopathy in 25-30% Treatment now recommended for: 1. acute infections 2. congenital infections 3. immunosuppressed 4. children Kissing bugs and Anaphylaxis Clin. Infect. Dis.; 50:1629 (15 June) Severe allergic reactions Widespread occurrence amongst vertebrate hosts T. crusi infects > 50% of kissing bugs Seen mainly in the Southwest U.S. 5 cases presented: Case #1 : March 2008; 57 y/o/ woman who lived near coastal marches in southern Louisiana Other cases: 3 Arizona, one California.

4 Immunizations: #1 Medical Achievement VACCINES 2010 Meningococcal conjugate Menactra/Menveo Booster pertussis Adacel/Boostrix Rotavirus RotaTeq/Rotarix HPV Gardasil, Cervarix Zoster Zostavax Influenza COMBINATION MMR-VZ ProQuad DTap/Hib/Polio Pentacel Hep A,B Twinrix NEW RECOMMENDATIONS HPV males Prevnar-13 Influenza universal; high dose (4X) for >65 H1N1 in seasonal flu product Varicella booster for high risk Meningococcal booster for high risk Status of Vaccines Cervarix HPV YEARS Menveo yr.; 2-10 yrs. Pending licensure MenHibrix MenCY-Hib ; 2, 4, 6 mo. pending licensure; filing 6/10;?booster at 12 mo. Prevnar 13-2 mo. 6 years; Gardasil HPV4 males 9-26 yr; covered by Aetna, BC/BS, Cigna ; not by Humana, Coventry, Health Plus of LA, United Health Care, Vantage Health Care

5 Prevnar 13 Types 4, 6B,9V,14, 18C, 19F, and 23F also 1,3,5,6A,7F, and 19A Licensed 6wk-71 mo. VFC in April Cost $ Return PCV 7 and company will replace with PCV mo. should receive one dose May Administer PCV 13 to Children 6-18 Years of Age Sickle cell disease HIV Immunocompromising conditions Also give 23-valent polysaccharide vaccine Rotavirus Diarrhea

6 Rotavirus Vaccines March 22, 2010: FDA News Release Extraneous virus detected Porcine Circovirus (PCV l) Present since early stages of development Not known to cause illness in humans Manufactured by GlaxoSmithKline Rotarix has an excellent safety profile RotaTeq does not contain PCV l FDA temporarily suspends use of Rotarix Rotavirus Vaccine Updates May 7, 2010: Merck identified porcine circovirus in Rotateq using a highly sensitive PCR assay May 14, 2010: FDA advises to resume the use of Rotarix How many doses of rabies vaccine are recommended following an animal bite when the animal escaped or could not be examined? Rabies Exposure a. 23 b. 5 c. 4 d. 1 e. none-treat with Rocephin (it works for other viral infections)

7 Rabies Exposure Treatment ACIP June 24, doses over 14 days: 0,3,7,14 days Of 20-40,000 rabies exposures, 1000 get only 3-4 doses Cost: $ /dose Novartis (manufacturer) disagrees Booster of Meningococcal Vaccine Serogroup C vaccine, United Kingdom Antibody Persistence: (CID 15 June 2010;50:1601) Antibody sustained in adolescents but rapid waning in children immunized between 2 months and 6 years Booster at 6-12 years highly effective

8 Congenital CMV If CNS disease, I.V. ganciclovir 12 mg/kg/d div. q. 12 hr. X 6 wks. Would you do this for an otherwise normal neonate with thrombocytopenia and a single calcification? Screening and Treatment of Congenital CMV (J Peds in press) Only 10% of newborns have signs or symptoms 10-15% with no signs/symptoms have hearing loss CNS disease should be treated I.V. for 6 wks., an incredible burden on management. Screening for CMV in dried blood (J Peds 2010) P.O. Valganciclovir 16 mg/kg twice daily achieves concentrations equivalent to I.V. Longer therapy may be needed. SCID Newborn Screening Jan. 2010: Recommended Uniform Screening Panel PCR for T-cell receptor incision circles Prevalence of SCIDS: 1 in 50, ,000 newborns Wisconsin implemented screening in January 2008, screening 71,000 infants in 2008; 8 cases of lymphopenia dx., one receiving a BM transplant

9 Mask and Hand Hygiene for Seasonal Influenza J Infect Dis (Feb) 2010;201: college students in dorms; influenza outbreak; Study continued for 6 weeks 3 groups: face mask; face mask+hand hygiene; control 35-51% reduction in influenza illness for the mask plus hand hygiene group Face mask alone showed a similar reduction but adjusted estimates (vaccination and other covariants) were not statistically significant. CONCLUSION: face masks and hand hygiene reduce illness in shared living settings; potential impact on H1N1 pandemic Influenza Vaccine in Children and Benefit to Unimmunized Adults JAMA March 10, : Hutterite Communities in Canada 979 children received vaccine; 2326 controls Dx. By PCR and serum antibody Nonrecipients: 7.6% vs. 3.1% had influenza Protective efficacy 61% in the vaccine colonies No serious adverse events

10 Mastitis during Lactation Lactobacilli for the Treatment of Mastitis during Lactation Clin. Infect. Dis. 2010; 50: , 15 June 3%-33% of lactating mothers have mastitis Staph., streptococci, and/or corynebacterium Chronic mastitis Staphylococcus epidermidis STUDY: Lactobacillus fermentum or L. Salivarius Strains isolated from breast milk 352 women: 3 groups 1) L.f. 2) L.s. 3) antibiotic RESULTS: day 21 bacti. counts lower with probiotic improved more and lower recurrence with probiotic