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Deer tick

Lyme disease: When will pediatric symptoms resolve?

Deer tick

Over a 13-year period that began in 2004, cases of illness transmitted by ticks, mosquitoes and fleas have more than tripled, the CDC found.

The summer of 2018 was a bad summer for Lyme disease, the tick-borne disease that was first documented in the 1970s in the town of Lyme, Connecticut. While about 30,000 cases of this disease had been reported annually in recent years, studies suggest that the actual number of infections is around 10 times greater.

And according to a study published May 2018 by the Centers for Disease Control and Prevention (CDC), those case numbers may increase over time. Over a 13-year period that began in 2004, cases of illness transmitted by ticks, mosquitoes and fleas have more than tripled, the CDC found.

Lyme disease causes a host of uncomfortable symptoms, ranging from headache and neurological problems, heart problems and eye inflammation in earlier stages, and progressing to joint pain and arthritis in later stages. While it can be treated successfully with appropriate antibiotics, the timeframe for kids’ symptom resolution has been unclear.

A new study by researchers at Children’s National Health System shows that symptoms improve just days or weeks after starting antibiotic therapy for the vast majority of patients, with people whose symptoms had been present a briefer time improving the fastest.

“These findings offer a reassuring timeline for doctors, patients and their families about when patients with Lyme disease can expect to feel better,” says study Senior Author Roberta L. DeBiasi, M.D., MS, Children’s National’s chief of the Division of Pediatric Infectious Diseases and co-director of the Congenital Zika Virus Program. Dr. DeBiasi was recently appointed to serve on a 52-member Tick-Borne Disease Working Group established in 2018 by the Department of Health and Human Services.

Dr. DeBiasi and colleagues collected data retrospectively from the medical records of 78 patients who had been hospitalized at Children’s National for Lyme disease from 2008 to 2015. Each child, who was younger than 18 years old, had documented symptoms and lab tests conclusive for this disease.

Just under one-half had symptoms consistent with early-stage disease, such as:

  • A severe headache
  • Meningitis (inflammation of the membranes covering the brain)
  • Cranial nerve palsy (a nerve dysfunction that affects eye movement and can cause double vision)
  • Multiple erythema migrans rashes (the bulls-eye-shaped rash that’s a hallmark of Lyme disease) and
  • Pseudotumor cerebri (increased pressure inside the skull).

Just over one-half had symptoms consistent with late-stage disease, which mostly consisted of arthritis affecting the knees, along with the hips and elbows in some cases.

In the hospital, each patient was started on an antibiotic that can effectively treat Lyme, including doxycycline, cefotaxime or ceftriaxone, which they continued at home for the prescribed length of the course. The researchers then tracked how quickly the patients’ symptoms resolved.

They report online July 30, 2018, in the Journal of the Pediatric Infectious Diseases Society, that the time to symptom resolution for early stages of disease did not depend on the duration of symptoms prior to starting antibiotics. However, for later stages of disease, patients with longer duration of symptoms prior to starting treatment took longer for their symptoms to resolve.

For patients with early-stage disease, the most common symptom was headache; the median time to symptom resolution was just three days, no matter how long the headache had persisted before treatment started. However, for patients with late-stage Lyme disease, the median time to resolution was 18 days. However, the time depended largely on how long symptoms had persisted before patients began taking antibiotics. For example, patients who had experienced arthritis for less than one week had a shorter time to resolution than those who had arthritis for more than two weeks.

This finding is important, Dr. DeBiasi says, because it suggests that diagnosing Lyme disease earlier – and prescribing the appropriate therapy as soon as possible – can hasten recovery. The vast majority of patients in the study, she adds, eventually experienced full resolution of their symptoms, which should be comforting to families worried about whether their child will ever feel well again.

“We all want what patients and their families want: to feel better as quickly as possible,” Dr. DeBiasi says. “This study gives us valuable information about how soon that will happen given the duration of pediatric patients’ symptoms.”

Dr. DeBiasi and Children’s Psychologist Maureen Monaghan, Ph.D., are leading another Lyme study in collaboration with the National Institutes of Health/National Institute of Allergy and Infectious Diseases to evaluate symptom resolution, quality of life and neurocognitive outcomes in a larger group of pediatric patients with Lyme disease.

In addition to Dr. DeBiasi and Monaghan, Children’s co-authors include Lead Author Mattia E. Chason; Biostatistician Jichuan Wang, Ph.D.; and Yao Cheng.

Staphylococcus aureus

Understanding antibiotic resistance in patients with cystic fibrosis

Staphylococcus aureus

Patients with cystic fibrosis who carried antibiotic-resistant bacteria, such as Staphylococcus aureus, in their lungs had significantly lower microbial diversity and more aggressive disease, according to a small study published in Heliyon.

A defective gene causes thick, sticky mucus to build up in the lungs of patients with cystic fibrosis (CF). There, it traps bacteria, causing patients to develop frequent lung infections that progressively damage these vital organs and impair patients’ ability to breathe.

Most patients with this progressive genetic disorder die by the fourth decade of life. A key to helping patients live even that long – a vast improvement from an average lifespan of 10 years  just decades ago – is judicious use of antibiotics, explains Andrea Hahn, M.D., a pediatric infectious diseases specialist at Children’s National Health System.

But antibiotics are a double-edged sword, Dr. Hahn adds: Although they’re necessary to eradicate lung infections, repeated use of these drugs can lead to antibiotic resistance, making it tougher to treat future infections. Also, antibiotic use can kill the nonpathogenic bacteria living in the lungs as well. That decreases the diversity of the microbial community that resides in the lungs, a factor associated with disease progression. But how antibiotic resistance impacts the relationship between lung bacterial diversity and CF patients’ pulmonary function has been unknown.

Dr. Hahn and colleagues investigated this question in a small study that was published online Sept. 17, 2018, in Heliyon. Their findings suggest that the presence of multidrug resistant bacteria in the airways of patients with CF is associated with decreased microbial diversity and decreased pulmonary function.

In the study, the researchers recruited six patients with CF from Children’s National during well-child visits. During those appointments, the research team collected respiratory secretions from these volunteers. They collected more samples at subsequent visits, including:

  • When patients were admitted to the hospital for pulmonary exacerbations (periods when infections inflamed their airways, making it difficult to breathe);
  • Just after intravenous antibiotic courses to treat these infections; and
  • Thirty days after patients completed antibiotic therapy, when their lungs’ bacterial flora had some time to bounce back.

Over the 18-month study period, these patients made multiple visits for exacerbations and antibiotic treatments, leading to samples from 19 patient encounters overall.

The scientists then analyzed each sample in two different ways. They used some to grow cultures in petri dishes, the classic method that labs use to figure out which bacterial species are present and to determine which antibiotics are effective in tamping them down. They used another part of the sample to run genetic analyses that searched for antibiotic resistance genes. Both methods were necessary to gather a complete inventory of which antibiotic-resistant bacteria were present, Dr. Hahn explains.

“Laboratory cultures are designed to grow certain types of bacteria that we know are problematic, but they don’t show everything,” she says. “By genetically sequencing these samples, we can see everything that’s there.”

Their results revealed a host of bacterial species present in these patients’ airways, including methicillin-resistant Staphylococcus aureus, a notoriously hard-to-treat microbe. Patients who carried this or other antibiotic-resistant bacteria had significantly lower microbial diversity in their samples and more aggressive disease. Their samples also were more likely to contain bacteria of the genus Alcaligenes, whose role in CF is not yet known.

Although heavy antibiotic use probably contributed to both the antibiotic resistance and lowered microbial diversity, Dr. Hahn says, the answer isn’t to reduce use of these drugs: They’re necessary to help patients with CF recover after each bout with pulmonary exacerbations. Rather, she says, using methods beyond a simple lab culture can help doctors target infectious bacteria more selectively, perhaps avoiding collateral damage.

“We can’t stop using antibiotics,” she says, “but we can learn to use them better.”

In addition to Dr. Hahn, Children’s co-authors include Aszia Burrell; Hani Fanous; Hollis Chaney, M.D.; Iman Sami Zakhari, M.D.; Geovanny F. Perez, M.D.; Anastassios C. Koumbourlis, M.D., MPH; and Robert J. Freishtat, M.D., MPH; and Senior Author, Keith A. Crandall, of The George Washington University.

Financial support for the research described in this post was provided by the National Institutes of Health National Center for Advancing Translational Sciences under award number UL1TR000075 and the National Heart, Lung and Blood Institute under award number K12HL119994.

Staphylococcus

How our bladder’s microbiota affect health

Staphylococcus

The presence of bacteria such as Staphylococcus in the urine is linked to the incidence and severity of urge urinary incontinence as well as treatment success.

About half of the cells in our bodies aren’t really “ours” at all. They’re the microbiota: The vast array of microorganisms that live in our gut, skin, oral cavity and other places. Decades ago, researchers thought that these organisms simply happened to colonize these areas, playing only a tangential role in health, for example, helping to break down food in the intestines or causing cavities. More recent work has revealed the incredibly complex role they play in diseases ranging from diabetes and schizophrenia.

The bladder is no exception. Just a single decade ago, the bladder was thought to be a sterile environment. But that view has shifted radically, with more sensitive cultivation methods and precise 16S rRNA gene-sequencing techniques revealing a significant bladder microbiome that could have an enormous impact on pediatric urologic diseases. These findings have opened brand new fields of research aimed at clarifying the role that the bladder’s microbiome plays in common urological diseases that affect children, according to a review article published online Feb. 22, 2018, by Current Urology Reports.

“There is a growing appreciation for the role of diverse bacteria in contributing to improved health as well as triggering disease processes or exacerbating illness,” says Michael H. Hsieh, M.D., Ph.D., director of the Clinic for Adolescent and Adult Pediatric Onset Urology (CAPITUL) at Children’s National Health System and study senior author. “Already, we know that probiotics and dietary modifications have the potential to play powerful roles in preventing urinary diseases that commonly occur among pediatric patients,” Dr. Hsieh says. This underscores the importance of conducting even more studies to improve our understanding and to identify new therapies for health conditions that resist current treatment options.”

The review conducted by Dr. Hsieh and co-authors highlights the effects of the microbiome on a number of urologic diseases that affect children, including:

  • Urinary tract infection A number of studies point to the association between decreased microbial diversity and the incidence of what is commonly called urinary tract infection (UTI) or “dysbiosis.” This relationship suggests that using probiotics to replace or supplement antibiotics could favorably alter the urinary microbiome. Future research will focus on the pathophysiological role of the microbiome to determine whether it can be manipulated to prevent or treat UTIs.
  • Urge urinary incontinence While data vary by study, the presence of bacteria in the urine, especially certain bacterial species – such as Gardnerella, Staphylococcus, Streptococcus, Actinomyces, Aerococcus, Corynebacterium and Oligella – are linked to the incidence and severity of urge urinary incontinence (UUI) as well as treatment success. Most studies find an association between greater genitourinary biodiversity and reduced incidence and lessened severity of UUI as well as improved treatment response. Future research will focus on further clarifying this relationship.
  • Urolithiasis Calcium oxalate stones, the most common type of kidney stone, have a microbiome that differs from the urinary microbiome leading researchers to question whether the stone’s own bacterial makeup could help to predict recurrence of future kidney stones. What’s more, Oxalobacter formigenes, a gram-negative bacterium, lowers oxalate levels in the blood and are associated with a 70 percent reduction in the risk of kidney stones forming. In an experimental model, fecal transplants with the full microbiome represented had a pronounced and persistent effect on oxalate production. Patients who receive some antibiotics often have reduced rates of formigenes colonization. However, the bacteria are resistant to amoxicillin, augmentin, ceftriaxone and vancomycin, which could point to preferential use of these antibiotics to stave off disease and ward off kidney stone formation.

Additional authors include Daniel Gerber, study lead author, The Georgetown University School of Medicine and Health Sciences; and Catherine Forster, M.D., study co-author, Children’s National.

physician looking at little girl's ear

Residents: Frontline defenders against antibiotic resistance?

physician looking at little girl's ear

A recent survey assessed whether residents knew which antibiotics were most appropriate for treating five common pediatric infections, including acute otitis media (ear infection).


Antibiotic resistance continues to grow around the world, with sometimes disastrous results. Some strains of bacteria no longer respond to any currently available antibiotic, making death by infections that were once easily treatable a renewed reality.

Avoiding this fate is possible, research suggests, if antibiotic prescribers do five essential things correctly: Give the right patient the right medication at the right dose through the right route at the right time. Medical residents – doctors who have finished medical school but are still receiving training at clinics and hospitals by working under more experienced physicians – are key to this strategy since they often are part of the frontline care team that selects and initiates antibiotic therapies. However, it has been unclear whether their prescribing patterns match these five “rights,” says Geovanny F. Perez, M.D., a pulmonologist at Children’s National Health System.

“Residents often decide which antibiotics to start a patient on, so they could become the first line of defense against antibiotic resistance,” Dr. Perez says. “They also could be an important target for education efforts if their prescribing patterns aren’t aligned with current guidelines.”

To determine whether residents are prescribing in ways that best avoid antibiotic resistance, Dr. Perez and colleagues sent an email survey to all 189 residents at two large children’s hospitals: Children’s National, a tertiary care center that serves patients throughout the greater Metropolitan Washington area at its main campus and network of primary care clinics; and Nicklaus Children’s Hospital, the largest freestanding pediatric hospital in South Florida.

The survey was divided into two parts. The first aimed to assess the knowledge of these residents about which antibiotics are most appropriate to treat five common pediatric infections: Acute otitis media (ear infection), group A streptococcal pharyngitis (strep throat), sinusitis (sinus infection), pneumonia and urinary tract infections.

The second part of the survey was meant to ascertain how residents acquired their antibiotic knowledge and prescribing behaviors. It asked about their awareness of antibiograms – a profile of which medications are effective against different local bacterial strains that is updated periodically at most hospitals – whether residents ever prescribed antibiotics for viral infections and the major influences on their prescribing decisions.

About one-half of the residents returned their surveys. Their answers suggested that most of them followed prescribing guidelines for the recommended drugs to treat otitis media, streptococcal pharyngitis and urinary tract infections. However, there were significant variations from guidelines for treating sinusitis and pneumonia, with many residents choosing antibiotics that were against current recommendations.

Additionally, only 3 percent of respondents indicated that they frequently used antibiograms, an important tool in selecting the most effective antibiotics. About one-half indicated that they sometimes used antibiograms, and one-quarter said that they never used an antibiogram. An additional 17 percent disclosed that they did not know what an antibiogram was. Even among those that knew about this important resource, about one-half said that they didn’t know where to access antibiograms specific to their hospitals.

Three-quarters of respondents indicated that they had prescribed antibiotics to patients who they considered to have a viral infection, rather than a bacterial one – a scenario in which antibiotics have no effect. In a follow-up question assessing the reasons for these decisions, 63 percent answered that they were following instructions from an attending physician or senior resident. More experienced physicians also played a more general role in shaping residents’ antibiotic knowledge: About 54 percent of residents said that their general pediatric inpatient attending physician – who oversees their training efforts – was their most influential source of knowledge in this area.

The findings, published in the September 2017 issue of Hospital Pediatrics, provide eye-opening insights into how residents prescribe antibiotics and their motivations for these choices, says Dr. Perez – particularly how the training they receive from mentors steers decisions many residents must make multiple times a day. He adds that antibiotic stewardship programs, which provide instruction to health care providers about current prescribing guidelines and practices, should focus on both residents and their resident charges for maximum impact.

“Ideally, we should be matching the guidelines 100 percent or at least close to it,” Dr. Perez says. “We think this goal is definitely attainable with the right training for both residents and their mentors alike.”

White children more likely to receive unnecessary antibiotics in ED

Although antibiotics can turn the tide for a variety of illnesses, they are ineffective against those caused by viruses. Despite this well-known fact, doctors often prescribe antibiotics for viral illnesses.

Infections now considered relatively easy to treat, including some forms of diarrhea and pneumonia, were the leading cause of death throughout the developed world until the 20th century. Then, scientists developed what eventually turned into a miracle cure: Antibiotics that could kill or thwart the growth of a broad array of bacterial species.

Although antibiotics can turn the tide for a variety of illnesses, they are ineffective against those caused by viruses. Despite this well-known fact, doctors often prescribe antibiotics for viral illnesses. Taking these drugs unnecessarily can fuel antibiotic resistance, giving rise to bacteria that don’t respond to the drugs that kept them in check in the past.

A new multicenter study shows how prevalent this scenario can be in hospitals’ Emergency Departments. This research, led by Monika K. Goyal, M.D., M.S.C.E., director of research in the Division of Emergency Medicine at Children’s National Health System, shows that non-Latino white children seeking treatment for viral infections in the Emergency Department (ED) are about twice as likely to receive an antibiotic unnecessarily compared with non-Latino black children or Latino children.

These findings, published online Sept. 5, 2017 in Pediatrics, echo similar racial and ethnic differences in treating acute respiratory tract infections in the primary care setting.

“It is encouraging that just 2.6 percent of children treated in pediatric EDs across the nation received antibiotics for viral acute respiratory tract infections since antibiotics are ineffective in treating viral infections,” Dr. Goyal says. “However, it is troubling to see such persistent racial and ethnic differences in how medications are prescribed, in this case in the ED. In addition to providing the best evidence-based care, we also strive to provide equitable care to all patients.”

Acute respiratory tract infections are among the most common reasons children are rushed to the ED for treatment, Dr. Goyal and co-authors write. Overprescribing antibiotics is also rampant for this viral ailment, with antibiotics erroneously prescribed for 13 percent to 75 percent of pediatric patients.

In the retrospective cohort study, the research team pored over deidentified electronic health data for the 2013 calendar year from seven geographically diverse pediatric EDs, capturing 39,445 encounters for these infections that met the study’s inclusion criteria. The patients’ mean age was 3.3 years old. Some 4.3 percent of non-Latino white patients received oral, intravenous or intramuscular antibiotics in the ED or upon discharge, compared with 2.6 percent of Latino patients and 1.9 percent of non-Latino black patients.

“A number of studies have demonstrated disparities with regards to how children of different ethnicities and races are treated in our nation’s pediatric EDs, including frequency of computed tomography scans for minor head trauma, laboratory and radiology tests and pain management. Unfortunately, today’s results provide further evidence of racial and ethnic differences in providing health care in the ED setting,” Dr. Goyal says. “Although, in this case, minority children received evidence-based care, more study is needed to explain why differences in care exist at all.”

At a time of growing antibiotic resistance, the study authors underscored the imperative to decrease excess antibiotic use in kids. Since the 1940s, the nation has relied on antibiotics to contend with diseases such as strep throat. Yet, according to the Centers for Disease Control and Prevention, at least 2 million people in the United States are infected with antibiotic-resistant bacteria each year.

According to the study authors, future research should explore the reasons that underlie racial and ethnic differences in antibiotic prescribing, including ED clinicians eager to appease anxious parents as well as implicit clinical bias. Dr. Goyal recently received a National Institutes of Health grant to further study racial and ethnic differences in how children seeking treatment at hospital EDs are managed.

“It may come down to factors as simple as providers or parents believing that ‘more is better,’ despite the clear public health risks of prescribing children antibiotics unnecessarily,” Dr. Goyal adds. “In this case, an intervention that educates parents and providers about appropriate antibiotic use could help the pediatric patients we care for today as well as in the future.”

Deer Tick

Treating Lyme disease: When do symptoms resolve in children?

Deer Tick

Some experts are predicting a rise in the number of ticks this year. That potential boom could lead to another boom – in Lyme disease, a bacterial illness transmitted specifically by deer ticks.

For many Americans, the warmer weather of summer means more time spent outside: More gardening and yard work, more hikes in the woods, more backyard barbecues. But for this year in particular, some experts predict warmer weather will lead to more ticks.

That potential boom in ticks could lead to another boom – in Lyme disease, a bacterial illness transmitted specifically by deer ticks. When ticks attach for at least 36 hours – what studies have shown is typically the lower bound needed to transmit Lyme-causing bacteria—many patients develop a bullseye-like rash at the site of the bite within seven to 10 days. If they’re not treated quickly, within weeks patients can develop symptoms such as headaches, heart arrhythmias, rashes and facial paralysis. Within months, Lyme can lead to arthritis, most commonly of the knee.

The standard treatment for Lyme disease is a course of antibiotics, such as oral doxycycline if the patient is older than 8 years old or amoxicillin if the child is younger than 8 – typically two weeks for early symptoms and longer for late symptoms. While the data showing when symptoms clear has been well established for adults, says Mattia Chason, M.D., a third-year resident at Children’s National Health System, little was known about how quickly symptoms typically resolve in children. That paucity of data can leave physicians and their families unsure about whether a child might need a repeat dose of antibiotics – or a different kind—or whether lingering symptoms might have a different cause.

To answer this question, he and colleagues – including Dr. Chason’s mentor, Roberta L. DeBiasi, M.D., M.S., chief of Children’s Division of Pediatric Infectious Diseases – looked at data in the electronic medical records of 79 children who were admitted to Children’s main hospital with a laboratory-confirmed diagnosis of Lyme disease from June 2008 to May 2015. The research team was particularly interested in children who had a headache – a strong marker of the early disseminated form of the disease – or pain and swelling of the knee, a strong marker of the late form of the disease.

Mattia Chason

Mattia Chason, M.D., and colleagues in infectious disease examined how quickly Lyme disease symptoms typically resolve in children, a research question that has received little prior study.

They found that after children with the early form of Lyme disease started treatment, their Lyme-associated headaches resolved rapidly – most within one to three days­ – no matter how long headaches were present before they came to the hospital for treatment.

However, for those with knee pain and swelling, the majority took between two to four weeks to resolve. The longer symptoms had been in place before treatment started, Dr. Chason says, the longer they tended to take to disappear.

The team also looked at a phenomenon called post-treatment Lyme disease syndrome, characterized by a constellation of symptoms, such as fatigue, generalized musculoskeletal pain and cognitive slowing, that can occur six months after an initial diagnosis of Lyme. Only two children out of the 79 met the criteria for this diagnosis, suggesting that it’s exceedingly rare in the pediatric population.

Taken as a whole, Dr. Chason says the findings provide a guide to doctors and family members alike on when to expect relief from Lyme symptoms. “Patients who come in with early symptoms tend to resolve rather quickly,” he says. “But for those with later symptoms, resolution can take quite some time. Those patients should see their doctors if there’s any suspicion of Lyme to get treatment sooner rather than later.”

Children’s infectious disease experts routinely advise parents about how to protect their children from Lyme disease. Their tips:

  • Help kids avoid exposure by either wearing long sleeves and pants – a tough sell in warm weather – or using repellents with 20 percent to 30 percent DEET. These repellents can be used on babies as young as 2 months old, Dr. Chason says, and are safe for most individuals.
  • Check for ticks anytime a child has spent time outside. The best way to perform them, Dr. Chason says, is to check the child each night. Before bath or bedtime, remove the child’s clothes and check every part of his or her body, including their hair, armpits, buttock region and the creases of the knee.
  • Remove ticks gently with tweezers to try to get as much of the arachnid out as possible.
  • Know what deer ticks look like. If you are unsure how to identify this species, save the tick or take a photo for your pediatrician to view.
  • If a tick has been attached for at least 36 hours, consult your child’s pediatrician for advice on whether the child will need prophylactic antibiotics.