In this retrospective review, we were able to identify aspects of the clinical presentation and medication history that may be helpful in differentiating between candidemia and CoNS bacteremia. Those key features may be used by clinicians to initiate empiric amphotericin B therapy in premature neonates at risk for nosocomial infections. Prolonged use of third-generation cephalosporins was strongly associated with candidemia. There was no statistically significant difference in the morbidity and mortality between patients infected with C parapsilosis and those infected with C albicans. Observed delays in removal of the central venous catheter may have contributed to finding a mortality rate from C parapsilosis that was higher than was previously reported.

Patient age, use of local anesthetic, and trainee stylet techniques were associated with LP success rates. This offers an additional rationale for pain control. Predictors identified in this study should be considered in the training of physicians, to maximize their success with this important procedure.

Bacteremic infants experienced fewer infection-related complications when the central catheter was removed promptly. One positive blood culture for S aureus or a Gram-negative rod warrants central line removal in a neonate. Clinicians who are faced with a neonate who has 1 positive culture for CoNS may attempt medical management without central catheter removal, but documentation of subsequent negative blood cultures is crucial. Once a neonate has 3 positive blood cultures for CoNS, the central catheter should be removed.central line, neonate, bacteremia, bacteria, umbilical catheter, Broviac, percutaneous.

f Standard genotypic antiretroviral resistance testing, performed by bulk sequencing, does not readily detect variants that comprise <20% of the circulating HIV-1 RNA population. Nevertheless, it is valuable in selecting an antiretroviral regimen after antiretroviral failure. In patients with poor adherence, resistant variants may not reach this threshold. Therefore, deep sequencing would be potentially valuable for detecting minority resistant variants. We compared bulk sequencing and deep sequencing to detect HIV-1 drug resistance at the time of a second-line protease inhibitor (PI)-based antiretroviral regimen failure. Eligibility criteria were virologic failure (HIV-1 RNA load of >500 copies/ml) of a first-line nonnucleoside reverse transcriptase inhibitor-based regimen, with at least the M184V mutation (lamivudine resistance), and second-line failure of a lopinavir/ritonavir (LPV/r)-based regimen. An amplicon-sequencing approach on the Roche 454 system was used. Six patients with viral loads of >90,000 copies/ml and one patient with a viral load of 520 copies/ml were included. Mutations not detectable by bulk sequencing during first-and second-line failure were detected by deep sequencing during second-line failure. Low-frequency variants (>0.5% of the sequence population) harboring major protease inhibitor resistance mutations were found in 5 of 7 patients despite poor adherence to the LPV/r-based regimen. In patients with intermittent adherence to a boosted PI regimen, deep sequencing may detect minority PI-resistant variants, which likely represent early events in resistance selection. In patients with poor or intermittent adherence, there may be low evolutionary impetus for such variants to reach fixation, explaining the low prevalence of PI resistance. Standard HIV drug resistance genotypic testing often involves a PCR amplifying the HIV-1 pol coding region, followed by sequencing by electrophoresis of the total sample of circulating HIV RNA species (26); hence, this method is referred to as bulk sequencing. This process has clinical value in the detection of antiretroviral resistance and allows the selection of a new antiretroviral regimen in patients who have experienced failure of their current antiretroviral therapy regimen. However, an important limitation of bulk sequencing is that it is able to reliably detect only viral variants that comprise at least 20% of the circulating viral population; otherwise, the sequence readout may represent only the nucleotide sequence of the predominant variant (13, 17). Nevertheless, if these minor variants harbor resistance-associated mutations, they are likely clinically relevant. For example, in mothers who were exposed to nevirapine (NVP) as part of prevention of mother-to-child transmission (PMTCT), the detection of a minor variant population with resistance mutations such as K103N and Y181C increased the likelihood of future NVP regimen failure (16). In clinical settings where one is interested in the identification of mutations only at a limited number of ...

Bone and joint infections in neonates differ significantly from what is seen in older children, adolescents, and adults. They are more common in preterm neonates but occasionally are seen in term babies. A high index of suspicion, coupled with careful daily physical examination, is important for early identification and treatment. Multiple foci should be sought. Underlying bone or joint involvement should be suspected in patients who have cutaneous abscesses. Surgical debridement or drainage, as required, and long-term appropriate antibiotic therapy are the pillars of therapy. Long-term outcome must be monitored closely, even in babies whose disease is rapidly identified and appropriately treated.