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.