The Pediatric Infectious Disease Journal  •  Volume 33, Number 6, June 2014

for severe mastitis and breast abscess. The infant was started on clindamycin and gentamicin. She became febrile to 100.5°F and was transferred to our institution for further evaluation and management. On examination, the child was afebrile and nontoxic appearing. She was tachypneic but comfortable with no signs of respiratory distress. A 4 cm × 2 cm firm, nonmobile mass overlying the right lateral 9th and 10th ribs extending to the back was noted. The mass appeared to be tender to palpation but had no associated erythema or crepitus. Notably, auscultation of the lungs revealed decreased breath sounds over the right middle and lower lobes. Laboratory data at the time of transfer revealed a white blood cell count of 27,310/μL with 39% segmented neutrophils and 9% bands. Platelets were elevated at 770,000/μL. Chest radiograph demonstrated a right lower lobe chest mass with associated medial right 10th rib destruction. A noncontrast chest computed tomography showed a large loculated fluid density in the right hemithorax abutting and inseparable from the pleura, with adjacent osteolytic changes in the posterior right 10th rib and soft tissue thickening of the posterior chest wall. The neonate was admitted for further management and started on empiric antimicrobial therapy with clindamycin, gentamicin and ampicillin. Gentamicin was discontinued in the first 12 hours of admission in favor of cefotaxime. A contrast computed tomography of the chest mass was performed in consideration of potential surgical intervention. This study demonstrated a large, peripherally enhancing fluid collection centered within the right hemithorax consistent with empyema necessitatis. Extension and abscess formation in the posterolateral right chest wall was seen accompanied by osseous involvement of the posterolateral right 9th, 10th and 11th ribs. The patient underwent fluoroscopy-guided percutaneous drainage with pigtail catheter placement, resulting in the removal of 20 mL of purulent fluid. Gram stain of the fluid demonstrated many white blood cells and many Gram-positive cocci in clusters, and cultures grew MRSA. At that time, it was relayed to the medical team that the patient’s mother had undergone incision and drainage of a breast abscess at the outlying hospital with cultures also demonstrating MRSA. Ampicillin and cefotaxime were discontinued, and clindamycin was continued pending susceptibility testing. Culture results confirmed clindamycin-susceptible MRSA. The authors have no funding or conflicts of interest to disclose. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3306-0668 DOI: 10.1097/INF.0000000000000275

© 2014 Lippincott Williams & Wilkins

The infant remained stable in the postoperative period. A repeat chest radiograph on the day of catheter removal revealed considerable improvement in aeration of the right lung. After receiving a total of 4 weeks of intravenous clindamycin, the patient was discharged home on oral clindamycin to complete an additional 4 weeks of therapy. DNA fragment analysis via pulsed-field gel electrophoresis was performed on both the mother’s and the patient’s isolates. The strain was confirmed as USA300, and the isolates from mother and infant were identical by this analysis. Telephone follow up with the family after treatment completion revealed that the patient was growing well and thriving, without any untoward side effects from prolonged antimicrobial therapy. Despite the relatively widespread incidence of invasive infection secondary to CA-MRSA, there are only 3 reported cases of CA-MRSA associated empyema necessitatis documented in the pediatric literature and none involving neonates. None of these prior cases identified breast-feeding or maternal breast abscess as potential routes of acquisition. The diagnosis of empyema necessitatis requires tomographic imaging to visualize the pathognomonic changes of a pleural effusion connected to the chest wall mass.1 Treatment of this condition requires a combination of antimicrobial therapy targeted at the most likely causative agent(s) in conjunction with prompt surgical drainage.2 The optimal duration of antibiotic therapy for empyema necessitatis and associated osteomyelitis in a patient who has undergone surgical drainage is not established. We recommended a total of 8 weeks therapy given the age of the patient and the invasive nature of the infection, including contiguous osteomyelitis.

Julia Rosebush, DO Ryan Summers, MD Joseph Snitzer, MD Paul Spearman, MD

Department of Pediatrics Emory University School of Medicine

Robert Jerris, PhD

Children’s Healthcare of Atlanta

Sarah Satola, PhD

Department of Medicine and Infectious Diseases Emory University School of Medicine Atlanta, GA REFERENCES 1. Mizell KN, Patterson KV, Carter JE. Empyema necessitatis due to methicillin-resistant Staphylococcus aureus: case report and review of the literature. J Clin Microbiol. 2008;46:3534–3536. 2. Kono SA, Nauser TD. Contemporary empyema necessitatis. Am J Med. 2007;120:303–305.

Letters

The Impact of an Infectious Diseases Consultation on Antimicrobial Prescribing To the Editors: he article published in the April issue by Gwee et al1 describes the activities of an infectious diseases (ID) consult service in children. Their study did not aim to compare patients who received a consult with those who did not. Using national Australian data, we have compared patients who received a consult with those who did not, to provide additional insight to the value of ID consultation in improving antimicrobial use. In conjunction with the international Antimicrobial Resistance and Prescribing in European Children study,2 8 Australian pediatric hospitals participated in a ­ single-day, hospital-wide point prevalence survey of antimicrobials. Deidentified data were collected about all antimicrobial prescriptions, including the appropriateness of the antimicrobial prescription using a standardized method of describing inappropriate prescribing (decision, choice and application) and whether there had been a concurrent ID consult. Of 1373 patients, 631 (46%) were receiving 1174 antimicrobials. Of this group, 153 (27%) patients had had an ID consult involving 255 (22%) prescriptions. There were 919 (78%) prescriptions not subject to ID consultation and 3 (0.4%) were unknown. Of the 255 antimicrobial prescriptions where an ID consult had occurred, 99 (39%) were from high-intensity units, with consults accounting for 52/235 (22%) of antimicrobial prescriptions in hematology/oncology, 23/78 (28%) in pediatric intensive care unit and 26/222 (12%) in neonates. Gwee et al1 reported lower proportions of ID consults in these units, likely because that study included patients not receiving antimicrobials. A comparison of antimicrobial prescriptions was made between patients who did and did not have an ID consult using a χ2 test (Table 1). Prescriptions guided by ID consultation were significantly more likely than those with no consult to be for treatment of community- or hospital-acquired infection. ID consultation was less likely to be associated with medical and surgical prophylaxis, which is often based on protocols. Targeted treatment for proven infection was significantly more likely to have been guided

T

The authors have no funding or conflicts of interest to disclose. Copyright © 2014 by Lippincott Williams & Wilkins ISSN: 0891-3668/14/3306-0669 DOI: 10.1097/INF.0000000000000285

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The Pediatric Infectious Disease Journal  •  Volume 33, Number 6, June 2014

Letters

by an ID consult, and consultation was less likely for use of empiric therapy, reflecting that 7 of the 8 hospitals had guidelines for empiric antibiotics for common infections.3 For specific antibacterial agents, there was no universal association between spectrum of antibiotic activity and involvement of an ID consult. Antimicrobials least likely to have involved ID consultation were those incorporated in protocols for prophylaxis (eg, first-generation cephalosporins) or empiric treatment (eg, aminoglycosides). Antimicrobials most likely to have involved ID consultation were those restricted by antimicrobial stewardship programs (eg, carbapenems). Although some broader spectrum antibiotics were associated with ID consultation, a limitation of our data is

the inability to determine confounders, for example, patient complexity. Antimicrobials subject to ID consultation were more likely to have a reason documented for their use. Inappropriate prescribing was significantly more common where there was no ID consult, most frequently in relation to decision making concerning the need for antimicrobials at all. Inappropriate choice of agents and their application (dose, frequency, route) were also more common when there was no ID consult, although numbers were low, perhaps reflecting the impact of guidelines. In an era when antimicrobial stewardship is of critical importance, our data provide important evidence for the value of an ID consult in ensuring targeted and appropriate use of antibiotics.

TABLE 1.  Comparison of Antimicrobial Prescriptions With and Without an ID Consult With ID Consult  

Total antibiotic prescriptions Indication  Community-acquired infection  Hospital-acquired infection*  Medical prophylaxis  Surgical prophylaxis  Unknown Type (excluding prophylaxis)  Empiric treatment  Targeted treatment Antimicrobial  Antibacterial  Narrow spectrum penicillin   β-lactam/β-lactamase inhibitor  1st generation cephalosporin  3rd or 4th generation cephalosporin  Carbapenem  Aminoglycoside  Trimethoprim/sulfamethoxazole  Glycopeptide  Fluoroquinolone  Macrolide  Lincosamide  Antifungal (excluding oral nystatin)  Azole  Amphotericin  Echinocandin  Antiviral  Aciclovir  Ganciclovir  Foscarnet Reason documented in notes Appropriateness (may be >1 type)  Inappropriate (total)  Decision  Treatment  Prophylaxis  Choice  “Too broad”†  “Too narrow”‡  Application  Insufficient information

Number of Prescriptions (%)

Without ID consult Number of Prescriptions (%)

255/1174 (22)

919/1174 (78)

152/255 (60) 76/255 (30) 25/255 (10) 1/255 (0.4) 1/255 (0.4)

397/919 (43) 98/919 (11) 266/919 (29) 165/919 (18) 9/919 (1)

The impact of an infectious diseases consultation on antimicrobial prescribing.

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