Table of Contents
Credits
Host: Sara Dong
Guests: Sumanth Cherukumilli, Emma Mohr, Paul Spearman
Content Editing, Cover Art: Sara Dong
Audio Editing: Bentley Brown
Produced by Sara Dong with support from the Infectious Diseases Society of America (IDSA)
Our Guests
Sumanth Cherukumilli, MD
Dr. Sumanth Cherukumilli is a second-year pediatric infectious diseases fellow at the University of Maryland. He completed his medical schooling at the American University of Antigua and completed his pediatrics residency at the Marshfield Clinic in Marshfield, Wisconsin. His main research interest is AMR in low- and middle-income countries. Sumanth was selected as the Top Abstract for this meeting, and his project was entitled: High mortality rates and antimicrobial resistance in children with invasive bacterial infections in a tertiary care facility in West Africa
Emma Mohr, MD, PhD
Dr. Emma Mohr is an Assistant Professor of Pediatrics, the Director of Physician Scientist Development Pathway, and Pediatric ID fellowship program associate director at the University of Wisconsin School of Medicine and Public Health. Dr. Mohr completed her undergraduate degree (B.A. in Biology and Biochemistry) at Gustavus Adolphus College in Minnesota. She earned her medical degree (M.D.) and graduate degree (Ph.D. in cellular and molecular biology) at the University of Iowa, as part of the Medical Scientist Training Program. She completed her pediatrics residency at Emory University and her pediatric infectious diseases fellowship at the University of Wisconsin-Madison. In addition to caring for pediatric patients with complex infections, she leads a research laboratory defining immune correlates of protection, neuropathogenesis and early predictors of developmental outcomes in congenital Zika virus infection. Lab is linked in the Bacteria icon below!
Paul Spearman, MD
Dr. Paul Spearman is the Vice Chair for Clinical and Translational Research and Education for the Department of Pediatrics and the Albert B. Sabin Professor and Director of Infectious Diseases at Cincinnati Children’s Hospital Medical Center in Cincinnati, OH. He earned his medical degree from the University of Texas Southwestern. He completed his Med-Peds training at Ohio State University followed by infectious diseases fellowship at Washington University, St. Louis. His laboratory studies fundamental aspects of HIV biology and develops new vaccines for human pathogens.
Culture
Sumanth enjoys watching Love is Blind
Emma loves running
Paul shared that he has been into sculpture
Consult Notes
This episode was recorded live at the St. Jude / PIDS Pediatric Infectious Diseases Research Conference held March 6-8, 2024 in Memphis, TN
- This annual conference features leaders in the field of ID and features pediatric ID research, transplant/immunocompromised host ID, career development, and global health.
- You can find the full agenda on the website
- Thank you to the meeting organizers for the invitation and support!
Emma and Paul provided an overview of initial evaluation and management of early onset sepsis
- Early-onset neonatal sepsis is generally defined as within 72 hrs vs 7 days of birth (there isn’t a clear consensus definition of neonatal sepsis, so you may hear both time frames)
- Typically due to vertical transmission by ascending contaminated amniotic fluid or during vaginal delivery due to bacteria in from maternal GU or GI tract
- Risk factors
- Well recognized: maternal chorioamnionitis or intra-amniotic infection
- Maternal Group B Streptococcus (GBS) colonization
- Use of forceps during delivery and electrodes have been implicated
- Pathogen ddx for early onset neonatal infection (in North America) typically includes:
- GBS
- E.coli
- Other less common bacterial: Other GNs, Enterococcus, Listeria, Nontypeable H.flu, S.aureus, etc
- Nonbacterial considerations: HSV, Enterovirus, Parechovirus, Candida
- The incidence of EOS in the US has decreased, primarily from the reduction in GBS infections with use of intrapartum antibiotic prophylaxis. Neonatal sepsis rates vary widely with associated mortality rates reported in some pooled studies as high as 11-19%
- We discussed the typical US empiric therapy of ampicillin + aminoglycoside vs ampicillin + 3rd or 4th gen cephalosporin, but ultimately the best empiric regimen will be based on your local epidemiology
CHAMPS: Sumanth provided some additional perspective on empiric therapy and management related to his research
- He shared information about the CHAMPS (Child Health and Mortality Prevention Surveillance) Network, which is a program/network of disease surveillance sites in Sub-Saharan Africa and South Asia gathering data about why children under the age of 5 die
- Areas covered by the sites experience high mortality rates. You can see the CHAMPS sites on their website
- Minimally invasive tissue sampling (post-mortem needle biopsies) on deceased children are gathered to determine causes of death, and the ultimate goal of the program is to use the data to inform policies to reduce childhood mortality in these regions
- Their webpage is available here: https://champshealth.org/
- There is also information available from this CDC NCEZID feature
- As discussed, the mortality burden and high rates of Gram negative organisms are important to consider when talking about empiric regimens in settings outside of the US and Europe. Sumanth discussed some data from published CHAMPS studies that noted Klebsiella pneumoniae as the most common pathogen identified in neonatal deaths:
- Analysis of deaths enrolled in CHAMPS sites between 2016-2021; see Figure 8 for pathogens: Mahtab S, Madhi SA, Baillie VL, et al. Causes of death identified in neonates enrolled through Child Health and Mortality Prevention Surveillance (CHAMPS), December 2016 -December 2021. PLOS Glob Public Health. 2023;3(3):e0001612. Published 2023 Mar 20. doi:10.1371/journal.pgph.0001612
- This recent paper examining causes of stillbirth and death among children in Ethiopia; see Table 3 for pathogens identified in the causal chain leading to death. In neonates, half of the isolates identified in neonatal deaths were K.pneumonia: Madrid L, Alemu A, Seale AC, et al. Causes of stillbirth and death among children younger than 5 years in eastern Hararghe, Ethiopia: a population-based post-mortem study. Lancet Glob Health. 2023;11(7):e1032-e1040. doi:10.1016/S2214-109X(23)00211-5
- This paper took a look at the susceptibility patterns, mechanisms of resistance, and virulence profile of Klebsiella spp and found MDR Klebsiella harboring genes associated with hyperviscosity in Mozambique: Massinga AJ, Garrine M, Messa A Jr, et al. Klebsiella spp. cause severe and fatal disease in Mozambican children: antimicrobial resistance profile and molecular characterization. BMC Infect Dis. 2021;21(1):526. Published 2021 Jun 5. doi:10.1186/s12879-021-06245-x
- Some other CHAMPS publications:
- Madrid L, Vyas KJ, Kancherla V, et al. Neural tube defects as a cause of death among stillbirths, infants, and children younger than 5 years in sub-Saharan Africa and southeast Asia: an analysis of the CHAMPS network. Lancet Glob Health. 2023;11(7):e1041-e1052. doi:10.1016/S2214-109X(23)00191-2
- Gonçalves BP, Procter SR, Paul P, et al. Group B streptococcus infection during pregnancy and infancy: estimates of regional and global burden [published correction appears in Lancet Glob Health. 2022 May 12;:]. Lancet Glob Health. 2022;10(6):e807-e819. doi:10.1016/S2214-109X(22)00093-6
- Ngere SH, Akelo V, Ondeng’e K, et al. Traditional Medicine Beliefs and Practices among Caregivers of Children under Five Years-The Child Health and Mortality Prevention Surveillance (CHAMPS), Western Kenya: A qualitative study. PLoS One. 2022;17(11):e0276735. Published 2022 Nov 2. doi:10.1371/journal.pone.0276735
- Madewell ZJ, Whitney CG, Velaphi S, et al. Prioritizing Health Care Strategies to Reduce Childhood Mortality. JAMA Netw Open. 2022;5(10):e2237689. Published 2022 Oct 3. doi:10.1001/jamanetworkopen.2022.37689
- Salzberg NT, Sivalogan K, Bassat Q, et al. Mortality Surveillance Methods to Identify and Characterize Deaths in Child Health and Mortality Prevention Surveillance Network Sites. Clin Infect Dis. 2019;69(Suppl 4):S262-S273. doi:10.1093/cid/ciz599
- Raghunathan PL, Madhi SA, Breiman RF. Illuminating Child Mortality: Discovering Why Children Die. Clin Infect Dis. 2019;69(Suppl 4):S257-S259. doi:10.1093/cid/ciz562
- Breiman RF, Blau DM, Mutevedzi P, et al. Postmortem investigations and identification of multiple causes of child deaths: An analysis of findings from the Child Health and Mortality Prevention Surveillance (CHAMPS) network. PLoS Med. 2021;18(9):e1003814. Published 2021 Sep 30. doi:10.1371/journal.pmed.1003814
- Onyango DO, Akelo V, van der Sande MAB, et al. Causes of death in HIV-infected and HIV-uninfected children aged under-five years in western Kenya. AIDS. 2022;36(1):59-68. doi:10.1097/QAD.0000000000003086
- Sumanth talked about challenges of managing infection in young children in certain settings in a few buckets: diagnostics, presentation, antibiotics, and supportive care
- He specifically mentioned the FEAST trial from 2011 that looked at the impact of fluid boluses on patient mortality in Easter Africa in settings without mechanical ventilation: Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-2495. doi:10.1056/NEJMoa1101549
- Authors found fluid boluses significantly increased 48-hr mortality in critically ill children with impaired perfusion in resource-limited settings in Africa
- He specifically mentioned the FEAST trial from 2011 that looked at the impact of fluid boluses on patient mortality in Easter Africa in settings without mechanical ventilation: Maitland K, Kiguli S, Opoka RO, et al. Mortality after fluid bolus in African children with severe infection. N Engl J Med. 2011;364(26):2483-2495. doi:10.1056/NEJMoa1101549
- The secondary analysis: Levin M, Cunnington AJ, Wilson C, et al. Effects of saline or albumin fluid bolus in resuscitation: evidence from re-analysis of the FEAST trial. Lancet Respir Med. 2019;7(7):581-593. doi:10.1016/S2213-2600(19)30114-6
Infographics
Goal
Listeners will be able to understand the variable epidemiology of early onset neonatal sepsis
Learning Objectives
After listening to this episode, listeners will be able to:
- List the top pathogens that cause early onset neonatal sepsis in the US
- Describe the CHAMPS network/study
- Discuss some of the challenges in management of infection in young children in resource limited settings
Disclosures
Drs. Dong, Mohr, and Spearman received a speaker honorarium for other presentations at this conference (St. Jude/PIDS Pediatric ID Research Conference). Our guests as well as Febrile podcast and hosts report no other relevant financial disclosures
Citation
Cherukumilli, S., Mohr, E., Spearman, P., Dong, S. “#95: Viva Pediatric ID! Live from Memphis”. Febrile: A Cultured Podcast. https://player.captivate.fm/episode/fa44c812-8061-48af-97fb-b417382225e0