Leprosy antibiotic is safe treatment for M. abscessus infections, CHOC infectious disease team finds

An oral antibiotic used to treat leprosy is safe and well-tolerated in the treatment of children with challenging-to-treat mycobacterium abscessus infections, the CHOC Children’s infectious disease team has found.

In their study, clofazimine was given to 27 patients during an outbreak of odontogenic mycobacterial infections as part of a multidrug regimen. Though clofazimine performed well in test-tube experiments against M. abscessus, reports in children were previously limited.

This group of patients represents the highest number of children to receive clofazimine outside of leprosy treatment settings.

The study findings were published in the July 2019 Journal of the Pediatric Infectious Disease Society. Its authors are CHOC infectious disease specialists Dr. Felice Adler-Shohet; Dr. Jasjit Singh; Dr. Delma Nieves; Dr. Negar Ashouri; and Dr. Antonio Arrieta; as well as Cathy Flores, a CHOC clinical research nurse coordinator, and Tuan Tran, an infectious disease pharmacist at CHOC.

The patients who received the antibiotic were among a large group of children who underwent pulpotomy procedures at a dental practice with a contaminated water system.

CHOC’s team added clofazimine to its original first-line medication regimen after receiving special use approval from the Food and Drug Administration.

An additional benefit of use of clofazimine was the ability to stop use of an intravenous antibiotic given thrice daily that prompted many side effects, the team found.

Learn how to refer a patient to CHOC Children’s infectious disease specialists.

CHOC Becomes SCID Referral Center

CHOC Children’s is pleased to have recently become a referral center for severe combined immune deficiency (SCID), filling a regional gap that once required Orange County infants to go outside the county for care.

Led by Drs. David Buchbinder, Wan-yin Chan, Diane Nugent and Jasjit Singh, the immunodeficiency program is a multidisciplinary effort crossing multiple specialties at CHOC including allergy and immunology, hematology and infectious disease

Though they appear healthy at birth, infants with this primary immunodeficiency disease lack T lymphocytes, one of the white blood cells that help fight infections. 

Babies with SCID cannot fight even the most innocuous infections and often die. The condition is considered by the medical community as a pediatric emergency.

“Prior to development of SCID newborn screening, the diagnosis would be delayed,” Dr. Chan says. “Often times these patients would not get sick until after 6 months of age. No one would know they were affected until the antibodies from their mother would wane. They end up with life threatening infections with serious complications often resulting in death.”

However, studies show that early bone marrow or stem cell transplants can improve outcomes significantly, Dr. Chan says.

Survival rates increase to 94 percent if administered to an affected infant by age 3 ½ months. However, if transplants occur after that age, survival rates increase to only 70 percent, underscoring the importance of early detection and intervention. 

To that end, California became one of the first states to add SCID to its list of recommended newborn screenings in 2010. In the years since, all states have followed suit. 

Under CHOC’s program, immunodeficiency team physicians review each case of Orange County babies who test positive in newborn screenings for SCID and ask parents to immediately seek a confirmatory blood test for the infant, Dr. Chan says.

If the additional tests confirm the diagnosis, patients are urgently admitted to CHOC for workup and treatment, Dr. Chan says.

Since CHOC’s center was formed in August, more than 20 patients have been flagged in the surrounding communities and each individual case has been reviewed by the immunodeficiency team in collaboration with local pediatricians.

Those urgent blood tests confirmed the presence of SCID or a SCID-like disorder in more than 25 percent of cases thus far. 

CHOC Children’s leaders observe International Women’s Day

As the world celebrates International Women’s Day, we turned to CHOC Children’s female physicians and nursing leaders for insight and words of encouragement to other women pursuing healthcare careers.

Melanie Patterson, vice president, patient care services, and chief nursing officerWhen beginning your career in medicine, don’t focus on one trophy. The fields of medicine and nursing have so many opportunities within them; be courageous and try new things. The most important aspect of leadership and of career success is to be kind. Remember to form your own opinion — go into every relationship with your eyes open and stop looking through others’ eyes; they don’t always have 20/20 vision.

Dr. Mary Zupanc, pediatric neurologist and epileptologist & co-medical director of the CHOC Children’s Neuroscience Institute

When I went to medical school, women were not encouraged, and it was hard. There were a lot of things that happened that made it very difficult, but medicine is truly one of the most gratifying professions you will ever have. Every patient is different. I believe that if you really and truly listen, a patient and their family will give you the diagnosis you’re searching for. Everyone’s story is so fascinating, and that makes our work like being a detective. Sometimes I feel like Sherlock Holmes searching for answers. Then once you do find an answer, you need to work with the family to make sure the treatment works for their lifestyle, culture and religion. That makes the work challenging, fun and meaningful.

The best piece of advice that I’ve ever received is to never apologize for excellence. Anyone would want their doctor to strive for excellence – and that goes for any profession.

Amy Waunch, nurse practitioner and trauma program managerNever underestimate your capabilities. Do not shy away from opportunities and always take on new challenges. Believe in yourself but don’t be afraid to ask for help. You may not have all of the answers all of the time, but you do have the ability to learn and grow.

Spot growth opportunities when they present themselves because they are the key learning opportunities. You will know because they make you uncomfortable and your initial impulse will be that you are not ready.

Dr. Azam Eghbal, medical director, radiologySince I was 7 years old, I wanted to be a doctor and becoming one has been the best decision of my life. As a female immigrant, I was told that I could never get to medical school, which, of course, motivated and challenged me even more to do so. The best advice I’ve gotten is don’t be discouraged about all your falls and obstacles. Think how you can succeed to get where you want to be.

Dr. Amber Leis, pediatric plastic surgeonMy advice for women pursuing a career in medicine is to trust yourself! Early on in your career, it’s easy to be overcome by feeling like you are not up to the task ahead of you. Your unique qualities will become your greatest strengths, so just keep chasing your passion.

I have great faith that if I stay true to my core principles, the right path will open in front of me. I try not to set specific goals for the future and instead I give my best to where I am. It keeps me focused on what I am doing now, and not distracted by trying to maneuver into some future place.

The best piece of career advice I’ve ever gotten has been, “You get to choose what kind of person you will be.”

Dr. Jasjit Singh, medical director, infection prevention & controlMy advice for women pursuing a career in medicine is to follow your passion! There are few other careers that offer the personal satisfaction and the intellectual rigor that medicine does. Find a good mentor early in your career. Later, make sure your practice partners have abilities that you respect, and the talent to make your shared time together meaningful.

I learned early on that delegation and time management are important, particularly if you want to balance a medical career and family. You can’t always do it all, and prioritization is tantamount to success in all the different spheres of your life.

One of the best pieces of advice that I got was from a mentor during fellowship, who told me, “It’s not enough to just be a good clinician.” He showed me the importance of asking good research questions and pursuing new knowledge. He also encouraged my love of teaching upcoming generations of pediatricians!

Dr. Katherine Williamson, pediatricianI love being a pediatrician. I help take care of kids every day and partner with their parents to help keep them healthy. To me, being successful is loving what you do, because then working hard and being motivated to do well doesn’t feel like work – it’s fulfilling a passion.

When asked to give advice, I always say these three things: be yourself, don’t rush, and follow your heart every step of the way. Be yourself, always. No matter how busy or loud life gets, never lose sight of you who you are and what you want to do.  Don’t be in a rush. Enjoy the journey because that is where you learn who you truly are. Lastly, follow your heart in every decision you make. When I look back on what got me to where I am in my career, I realize that it was not one or two big decisions that were the deciding factor, but instead it was a million little decisions along the way. And with each of those decisions I followed my heart and my passion.

Protect Infants from Next Wave of Pertussis

The California Immunization Coalition, along with Dr. Jasjit Singh, director, infection prevention and epidemiology at CHOC Children’s, recommend the following pertussis guidelines for pediatricians and their patients.

As pertussis increases to peak levels every 3- 5 years, California is due for its next epidemic by 2019. Young infants remain at highest risk of hospitalization and death from pertussis. Since 2010, at least 2,800 California infants younger than four months of age have contracted pertussis. Most of these infants have been hospitalized, and at least 18 have died.

Please consider the following measures to protect infants against pertussis:

Prevention

  • Prenatal Interview – Promote Prenatal Immunization! Remind parents and prenatal providers to give prenatal Tdap vaccine to women between 27 and 36 weeks of gestation of each pregnancy, regardless of vaccination history. Encourage vaccination of household and caregivers.
  • Administer the first dose of DTaP vaccine to infants promptly at 6-8 weeks of age. A dose as early as 6 weeks will help protect infants sooner if their mothers did not receive Tdap during pregnancy. Complete the DTaP series without delay.
  • Maternal immunization is associated with infant survival. Receipt of Tdap by mothers between weeks 27 and 36 of pregnancy and receipt of DTaP by infants prior to illness greatly reduce the risk of death from pertussis.

Presentation

Pertussis should be considered in any infant without a documented fever who presents with coryza, cough (especially paroxysmal), apnea, gagging, or post-tussive emesis.

Suspect pertussis in adolescents and adults with prolonged cough, and test and treat promptly to prevent transmission to infants.

Testing

Obtain nasopharyngeal swabs for pertussis PCR testing to confirm the diagnosis. Additional guidance is at www.cdc.gov/pertussis/clinical/diagnostic-testing/specimen-collection.html.

  • In infants, check white blood cell counts with differential – a leukemoid reaction is associated with life-threatening pertussis. A WBC count greater than 10,000 cells/mm3 with ˃50% lymphocytes should be repeated 24 hours later; increasing lymphocytosis should prompt additional monitoring and treatment. A WBC of >20,000 cells/mm3 with >50% lymphocytosis should be considered as a very strong indication that the infant has pertussis.

Treatment

Azithromycin (10mg/kg/day in a single dose for five days) for infants less than 6 months of age.

Empiric treatment is appropriate while awaiting the results of PCR testing.

Additional clinical guidance and access to consultation can be found at eziz.org/assets/docs/Pertussis-YoungInfants2011.pdf.

Further information, California case counts, and clinical guidance for pertussis can be found here.

 

Nasal Flu Vaccine Not Recommended This Season – What Patients and Families Should Know

An advisory committee of the Centers for Disease Control and Prevention (CDC) recently recommended that the nasal spray influenza vaccine not be used this upcoming flu season. In this Q&A, Dr. Jasjit Singh, medical director of infection prevention and control at CHOC Children’s, offers an explanation for your patients and their families.

Q: What does this mean for influenza vaccine recommendations for the upcoming flu season?

A: All individuals over the age of 6 months are recommended to get the influenza vaccine, and that will continue to be the case.  However, for this season at least, the nasal flu vaccine is not an option. Therefore, parents will need to plan for their children to get the flu shot this upcoming season.

Jasjit Singh, M.D.
Jasjit Singh, M.D.

Q: How does the standard flu shot differ from the nasal spray version in terms of composition and effectiveness?

A: Both the flu shot and the nasal spray contain the anticipated predominant circulating strains of influenza every year, but the nasal spray strains are made of weakened live virus while the flu shot is made of inactivated viral components. The CDC reviewed data from this past season that suggested that the nasal spray did not perform as well as it had in the past.

Q: Besides ensuring their children get a flu shot, what else can parents do to help prevent the flu?

A: In addition to ensuring their child is vaccinated against the flu every year, there are many things parents and other caregivers can do to help prevent the flu. Use proper hand-washing techniques, use respiratory etiquette, and stay home from work or school if you are sick with the flu, to prevent spreading it to others.

Q: What do you anticipate will be parents’ reactions to this recommendation? Is there anything else you’d like them to know? Is there anything else you’d like to share with parents about the importance of vaccinations?

A:  Vaccinations are one of the most effective public health measures that have been developed and they save thousands of lives each year. Influenza vaccinations are important because young children can get quite sick from the flu, and some even require hospitalization. Every year there are pediatric deaths in the U.S. due to influenza, about half of which occur in normal healthy children. Children can pass influenza on to the elderly or other fragile members of our community. It’s important for adults to get the flu shot too, particularly those who are caring for young children. Even though the nasal spray is not an option for vaccinating this particular season, it is still important to have your child vaccinated for this year.