926 | www.pidj.

com The Pediatric Infectious Disease Journal Volume 32, Number 8, August 2013
unrelated bone marrow transplantation from
a suitably matched donor.
Osteomyelitis occurs in 13% of
CGD patients
2
; in childhood, most occur
in the long bones, with only 14% in the
hands or feet.
3
Osteomyelitis in infancy
particularly when caused by S. marcen-
scens should raise the suspicion of the
presence of CGD as an underlying condi-
tion. We believe that this is the rst case of
osteomyelitis in a CGD patient reported in
the neonatal period.
REFERENCES
1. Friend JC, Hilligoss DM, Marquesen M, et al.
Skin ulcers and disseminated abscesses are
characteristic of Serratia marcescens infection
in older patients with chronic granulomatous
disease. J Allergy Clin Immunol. 2009;124:
164166.
2. van den Berg JM, van Koppen E, Ahlin A, et al.
Chronic granulomatous disease: the European
experience. PLoS One. 2009;4:e5234.
3. Chad WM, Shahid B, Joseph AB, et al. Bahna
Serratia marcescens osteomyelitis in an infant.
Allergy Asthma Proc. 2006;27:544548.
Management of Pediatric
Contacts of Multidrug
Resistant Tuberculosis in
the United Kingdom
To the Editors:
C
hildren exposed to drug-susceptible
tuberculosis are less likely to progress
to active disease if receiving prophylactic
treatment, a practice now recommended
by most international guidelines.
1,2

Appropriate prophylactic therapy cov-
ering multidrug-resistant tuberculosis
(MDR-TB) was shown to reduce the risk
of progression to MDR-TB disease 5-fold
in children who were household contacts
of adults with pulmonary MDR-TB.
3

No unied guidance currently exists
for management of MDR-TBexposed
children.
2,4
A retrospective audit of manage-
ment of MDR-TBexposed children was
conducted as part of a wider survey of
management of pediatric MDR-TB in
England.
5
Data were included if the con-
tact had more than 8 hours of exposure to
a household or close social contact with
culture-conrmed pulmonary MDR-TB
between January 1, 2006, and Decem-
ber 31, 2010. Demographic, diagnostic
and management details were collected
through questionnaires sent to the lead
TB pediatrician at each center. Returned
information was collated, and descriptive
analyses were carried out using Excel ver-
sion 972003 workbook.
There were 23 children in 6 centers
in close contact with culture-proven pulmo-
nary MDR-TB. Eight were uninfected, did
not receive chemoprophylaxis and to date
none has developed disease.
Twelve children were identied as
latently infected. Eight children (66.6%)
received treatment for presumed latent
MDR-TB. In all cases 2 drugs were used for
a median of 6 months (range 612 months).
Treatment regimens were selected accord-
ing to the contacts in vitro susceptibility
testing. Two children currently remain in
follow-up for 2 years. The other 10 children
were all well at the time of discharge with no
evidence of TB disease.
Three children had suspected but
not culture-conrmed MDR-TB disease,
all of whom had a known parental contact
LETTERS TO THE EDITOR
To the Editors:
Serratia marcescens infection
of bone and soft tissue is a presentation
of chronic granulomatous disease
(CGD) in infancy.
1
We report a case of a
neonate diagnosed with X-CGD who
developed a phalanx osteomyelitis due to
S. marcenscens.
A 25-day-old male was admitted
to our unit with a 2-day history of tender-
ness and swelling of the ring nger of the
left hand. Topic therapy was administered
without results. There was swelling between
the third and fourth ngers of the left hand
limiting movement of the metacarpophalan-
geal joint. C reactive protein was 9.83 mg/
dL, and the leukocyte count was 20,810
cell/mm
3
with 13,260 cell/mm
3
neutrophils.
A radiograph showed osteomyelitis that
affected the proximal phalanx of the ring
nger; alternating areas of osteoscleroris
and bone rarefaction were remarkable with
a initial exuberant process of periosteal
apposition (see Fig., Supplemental Digital
Content 1, http://links.lww.com/INF/B536).
The head of the phalanx was fractured. Cul-
ture from the nger abscess grew S. marcen-
scens. Intravenous antibiotic therapy with
meropenem, amikacin and ciprooxacin
was given for 5 weeks. The family history
was remarkable for the mother being a car-
rier of X-CGD. The brother was similarly
affected. Molecular investigations led to the
diagnosis of X-linked CGD in the infant.
Marked clinical improvement was noted
during the hospitalization, and he was dis-
charged on prophylactic trimethoprim and
itraconazole; oral ciprooxacin was pre-
scribed for an additional 2 months. Twelve
months after the admission, the swelling
had subsided and the bone had returned to
its normal contour, although bone expan-
sion was still detectable. The patient had
no functional sequelae. He is currently in
good clinical condition, receiving standard
prophylaxis management and awaiting an
Copyright 2013 Lippincott Williams & Wilkins
ISSN: 0891-3668/13/3208-0926
DOI: 10.1097/INF.0b013e31828f682a
The Pediatric Infectious Disease Journal
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8
Copyright 2013 Lippincott Williams & Wilkins
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10.1097/INF.0b013e31828f682a
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Divya J
Pediatr Infect Dis J
Lippincott Williams & Wilkins
Hagerstown, MD
XXX
Serratia marcescens
Osteomyelitis in a
Newborn With Chronic
Granulomatous Disease
Irene Salfa, MD
Nicoletta Cantarutti, MD
Giulia Angelino, MD
Unit of Immunology and Infectious Disease
University-Hospital Pediatric Department
Bambino Ges Children Hospital
IRCCS
Gigliola Di Matteo, PhD
Valentina Capo, BSc
Giada Farinelli, PhD
Department of Public Health and
Cellular Biology
University of Rome Tor Vergata
The authors have no funding or conicts of interest
to disclose.
Supplemental digital content is available for this arti-
cle. Direct URL citations appear in the printed
text and are provided in the HTML and PDF
versions of this article on the journals website
(www.pidj.com).
Caterina Cancrini, MD, PhD
Unit of Immunology and Infectious Disease
University-Hospital Pediatric Department
Bambino Ges Children Hospital
IRCCS
Rome, Italy
Alessandro Aiuti, MD, PhD
Unit of Immunology and Infectious
Disease University
Hospital Pediatric Department University
of Rome Tor Vergata
Childrens Hospital Bambino Ges San
Raffaele Telethon Institute for
Gene Therapy
San Raffaele Scientic Institute
Milan, Italy
Paolo Palma, MD, PhD
Andrea Finocchi, MD, PhD
Unit of Immunology and Infectious Disease
University-Hospital Pediatric Department
Bambino Ges Children Hospital
IRCCS
Rome, Italy
NIHR Senior Fellowship to B.K. (MRC, Imperial
College, UK). The authors have no other funding
or conicts of interest to disclose.
Copyright 2013 Lippincott Williams & Wilkins
ISSN: 0891-3668/13/3208-0926
DOI: 10.1097/INF.0b013e31829157e9
The Pediatric Infectious Disease Journal Volume 32, Number 8, August 2013 Letters to the Editor
2013 Lippincott Williams & Wilkins www.pidj.com | 927
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Divya J
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The Pediatric Infectious Disease Journal
Matching Michigan in
Neonatal Intensive Care
Units: A Plea for Uniform
Data Presentation
To the Editors:
W
e thank Montgomery-Taylor and col-
leagues
1
for reporting their experi-
ence of introducing Matching Michigan
(MM) to their neonatal intensive care unit.
MM was made a priority within the UK
National Health Service; reporting both
infection and denominator data was recom-
mended as the rst step toward benchmark-
ing and improving practices.
2
In a recent study
3
from 2 UK cent-
ers over a 14-month period predating MM
introduction, our denite catheter-related
sepsis (CRS) rate was 6.8 per 1000 cath-
eter days, somewhat higher than the 4.5 per
1000 catheter days reported by Montgom-
ery-Taylor et al using a similar case deni-
tion. Our gures are not directly compara-
ble because we only analyzed percutaneous
central venous catheters (PCVCs). Inclu-
sion of umbilical catheters probably lowers
overall CRS rates by catheter days because
umbilical lines are placed more frequently
than PCVCs, but are removed sooner and
therefore less liable to colonization/infec-
tion. We suggest that future reporting of
neonatal CRS rates should include subdi-
visions by catheter type to facilitate valid
comparisons between centers.
The Pediatric Infectious Disease Journal
32
8
0891-3668
INF
2013
August
00
00
2013
Divya J
Pediatr Infect Dis J
Lippincott Williams & Wilkins
Hagerstown, MD
The authors have no funding or conicts of interest
to disclose.
The Pediatric Infectious Disease Journal
32
8
0891-3668
INF
Letters to the Editor
Letters to the Editor
2013
August
929
930
2013
Divya
Pediatr Infect Dis J
Lippincott Williams & Wilkins
Hagerstown, MD
with MDR-TB. All children had sputum
samples sent for cultures, but no organ-
ism was isolated. The median number of
drugs used for treatment was 4 (35), and
the median planned length of therapy was
18 months (range 1224). One of the 3
children received an injectable agent. The
resistance pattern of the index case did
not obviously account for the regimen
choice in the children. All children were
still being followed at the time of writ-
ing, and none are known to be receiving
directly observed treatment.
Although we have a small dataset,
our audit is the first to review the man-
agement of pediatric contacts with infec-
tious MDR-TB in England and is the
largest dataset from Western Europe and
North America published to date. Clini-
cal practice showed considerable vari-
ability, and children were less likely to
receive prophylactic therapy if there was
resistance to several drugs in the index
case. Our small dataset cannot provide
sufficient evidence for or against treat-
ment for latent TB in MDR-exposed chil-
dren, but illustrates that many clinicians
chose to treat. It will be important to
examine the age-related risk of progres-
sion to active disease in larger groups
of patients and balance these data with
the likelihood of adherence, which might
be compromised by treatment regimens
sometimes more difficult to administer
or prone to side-effects.
Bhanu Williams, MRCPCH
North West London Hospitals NHS Trust
Harrow, United Kingdom
Shiva Ramroop, MRCPCH
Great Ormond Street Hospital
Pooja Shah, MB BS
Imperial NHS Trust
Laura Anderson, PhD
Health Protection Agency
Sreena Das, MRCPCH
Anna Riddell, MRCPCH
Susan Liebeschuetz, MRCPCH
Barts Health NHS Trust
London, United Kingdom
Jolanta Bernatoniene, MRCPCH
Bristol Royal Hospital for Children
Bristol, United Kingdom
Delane Shingadia, FRCPCH
Great Ormond Street Hospital
Beate Kampmann, PhD
Imperial College
London, United Kingdom
MRC Unit
The Gambia
REFERENCES
1. Beyers N, Gie RP, Schaaf HS, et al. A prospec-
tive evaluation of children under the age of ve
years living in the same household as adults
with recently diagnosed pulmonary tuberculo-
sis. Int J Tuberc Lung Dis. 1997;1:3843.
2. World Health Organization 2006. Guidelines
for national tuberculosis programmes on the
management of tuberculosis on children.
Available at: http://www.who.int/tb/challenges/
children/en/. Accessed February 4, 2013.
3. Schaaf HS, Gie RP, Kennedy M, et al. Evaluation
of young children in contact with adult multi-
drug resistant pulmonary tuberculosis: a 30
month follow up. Pediatrics. 2002;109:765771.
4. van der Werf MJ, Langendam MW, Sandgren
A, et al. Lack of evidence to support policy
development for management of contacts of
MDR-TB patients: two systematic reviews. Int
J Tuberc Lung Dis. 2012;16:288296.
5. Williams B, Ramroop S, Shah P, et al. Multi-drug
resistant tuberculosis in UK children: presenta-
tion, management and outcome. Eur R J. 2013.
Copyright 2013 by Lippincott Williams & Wilkins
ISSN: 0891-3668/13/3208-0927
DOI: 10.1097/INF.0b013e318292f57f
The authors concluded that their
MM interventions had reduced all coag-
ulase-negative staphylococcal (CoNS)
infections and blood culture (BC) contami-
nations, and implied a reduction of cathe-
ter-related bloodstream infection.
1
Due to a
lack of comparable pre-MM data, it is not
possible to say that this overall reduction
represents a signicant reduction in de-
nite CRS with MM. Fewer CoNS-positive
BCs may simply reect better hand hygiene
techniques reducing contaminant cultures
rather than a true reduction in denite CRS.
Some reduction in infection rates may also
have occurred coincidentally due to pre-
ceding and concurrent national improve-
ment efforts.
4
The authors did not include raw
data for total numbers of catheters inserted,
catheter days, neonates admitted, or popu-
lation demographics during their 18-month
study period. Nor were data included for
catheter-suspected blood stream infec-
tion (catheter present but negative BC
in the presence of antibiotics plus signs
of sepsis), even though such cases were
dened for monthly collection via the
National Patient Safety Agency MM form.
2

In our prospective study, 24 of 47 (51%)
PCVCs removed from clinically septic
babies had an accompanying negative BC.
3

Provision of full denominator data is essen-
tial for meaningful comparisons within and
between neonatal centers.
The authors also excluded rst day
CoNS-positive blood cultures, stating that
CoNS do not cause early onset sepsis.
1

However, CoNS are a rare but recognized
cause of early-onset sepsis in neonates.
5
The authors found that non-CoNS
sepsis were virtually all unrelated to the
presence of a central catheter.
1
Further
analysis of our own dataset
3
shows that 2
of 15 (13%) denite CRS cases were non-
CoNS: these comprised 2 (40%) of 5 non-
CoNS septicemias present at line removal
(n = 1 Enterococci, n = 1 Enterobacter clo-
acae), and a non-CoNS organism was cul-
tured from almost 10% (6/61) of PCVCs
which had 1 culture-positive segment.
MM has shown a signicant impact
in reducing infection rates in UK adult and
pediatric intensive care units.
4
As cath-
eter care bundles are increasingly used in
NICUs, we consider it vital that all collect
a complete and consistent dataset, ideally
via established, dedicated neonatal data
systems (such as the BadgerNet Platform
[CleverMed Ltd, UK] and the Neonatal
Data Analysis Unit [http://www.impe-
rial.ac.uk/ndau], or the Vermont-Oxford
Networks program). Careful reporting of
baseline denominator data will allow more
meaningful epochal comparisons within