Children NHS Foundation Trust Research Articles

Demographic, clinical and laboratory differences between paediatric acute COVID-19 and PIMS-TS-results from a single centre study in the UK.

Paediatric symptomatic SARS-CoV-2 infections associate with two presentations, acute COVID-19 and paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS). Phenotypic comparisons, and reports on predictive markers for disease courses are sparse and preliminary. A chart review of COVID-19 and PIMS-TS patients (≤19 years) admitted to Alder Hey Children's NHS Foundation Trust, a tertiary centre in the North-West of England, was performed (02/2020-09/2022). A total of 161 symptomatic COVID-19 and 50 PIMS-TS patients were included. Peaks in admissions of patients with PIMS-TS occurred approximately 4 weeks after those for acute COVID-19. The incidence of in-patients with PIMS-TS reduced over time, and there were no admissions after February 2022. When compared to acute COVID-19, PIMS-TS patients were older (median: 10.3 years vs. 2.03 years; p < 0.001). There were no differences in gender distribution, but minority ethnicities were over-represented among PIMS-TS patients. Regional ethnic distribution was reflected among acute COVID-19 patients (66% vs. 84.5% White Caucasian, p = 0.01). Pre-existing comorbidities were more common among acute COVID-19 patients (54.7% vs. 8%, p < 0.001). PIMS-TS patients more commonly presented with abdominal symptoms (92% vs. 50.3%), neurological symptoms (28% vs. 10.6%) and skin rashes (72% vs. 16.8%), (p ≤ 0.01) when compared with acute COVID-19, where respiratory symptoms were more common (51.6% vs. 32%, p = 0.016). PIMS-TS more frequently required intensive care admission (64% vs. 16.8%), and inotropic support (64% vs. 9.3%) (all p < 0.05). More deaths occurred among acute COVID-19 patients [0 vs. 7 (4.4%)], with 5/7 (71%) in the context of pre-existing comorbidities. When compared to acute COVID-19, PIMS-TS patients exhibited more lymphopenia and thrombocytopenia, a more pronounced acute phase reaction, and more hyponatraemia (p < 0.05). Partial least square discriminant analysis of routine laboratory parameters allowed (incomplete) separation of patients at diagnosis, and variable importance projection (VIP) scoring revealed elevated CRP and low platelets as the most discriminatory parameters. Admissions for PIMS-TS reduced with increasing seroconversion rates in the region. Young age and pre-existing comorbidities associate with hospital admission for acute COVID-19. While PIMS-TS may present more acutely with increased need for intensive care, acute COVID-19 had an increased risk of mortality in this cohort.

Psychological/social factors associated with transfer readiness in young people with juvenile idiopathic arthritis

The aim of this study is to investigate the relationships between psychological/social factors and transfer readiness from paediatric to adult rheumatology services in pre- and post-transfer young people (YP) with juvenile idiopathic arthritis (JIA). Participants completed questionnaires measuring a broad range of psychological/social factors (generalised anxiety, pain-specific anxiety, pain-related thoughts, depression, prosocial behaviours, problem behaviours, arthritis-related quality of life (QoL), social support, family functioning) and transfer readiness (transfer-related knowledge and skills, health-related self-efficacy). JIA disease activity was measured on the same day as the questionnaires. This study received all relevant ethical and regulatory approvals, and informed consent was received from or on behalf of all participants. In total, 40 pre-transfer YP with JIA aged 10-16 years (M = 13.54 years, 26 females) and their parents/guardians participated at Sheffield Children's NHS Foundation Trust, and 40 post-transfer YP with JIA aged 16-24 years (M = 20.16 years, 26 females) participated at Sheffield Teaching Hospitals NHS Foundation Trust. For both pre- and post-transfer YP, greater transfer readiness was associated with lower generalised anxiety levels, lower pain-specific anxiety levels, fewer pain-related thoughts, lower depression levels, fewer problem behaviours, better arthritis-related QoL, better social support, and better family functioning. Greater transfer readiness was also associated with less JIA disease activity for post-transfer YP only. A broad range of psychological/social factors were associated with transfer readiness in pre- and post-transfer YP with JIA. This highlights the importance of assessing and addressing YP's psychological/social well-being during their transition to adult services. Key Points • A wide range of psychological and social factors may be associated with how ready young people with juvenile idiopathic arthritis feel to move from paediatric to adult rheumatology services. • Transition outcomes may be improved by comprehensively assessing and addressing young people's psychological and social well-being.

Neutrophil function is impaired in paediatric patients with malignancy and may be a useful clinical marker.

Patients treated with cytotoxic chemotherapy are at risk of neutropenia, neutropenic fever and neutropenic sepsis. We hypothesised that pre-existing neutrophil function dysfunction may increase susceptibility to neutropenic fever in paediatric patients receiving cytotoxic chemotherapy. Prospective cohort study recruited patients at Alder Hey Children's NHS Foundation Trust, United Kingdom. We measured neutrophil phagocytic function using a validated flow cytometric whole blood phagocytosis assay in paediatric patients (n = 16) with oncological disease before and after chemotherapy in a prospective cohort study. We recruited healthy children as a control comparator (n = 10). We found significantly decreased phagocytic function in oncology patients compared to healthy participants. In five patients who developed neutropenic fever, we observed increased pre-dose neutrophil respiratory burst. With further validation, measurement of neutrophil function could potentially be used to personalise appropriate prophylactic antimicrobial administration for patients receiving cytotoxic chemotherapy.

Integrating e‐collections following the merger of two specialist hospital libraries: a case study

BackgroundBirmingham Women’s and Children’s NHS Foundation Trust was formed in February 2017 following an acquisition. The Library and Knowledge Services (LKS) merged while operating across two hospital sites. A priority for the merged Library and Knowledge Service was to integrate e‐collections. A literature review identified six papers reporting health libraries that had merged and integrated e‐collections.ObjectivesA priority for the merged Library and Knowledge Service was to integrate e‐collections.MethodsTo ensure equitable and cost‐effective access to an extended collection, an audit of pre‐existing e‐collections was conducted. Electronic licence agreements enabling cross‐site access were negotiated. A new OpenAthens ID was created.ResultsThe integration of e‐collections enabled Trust staff access to a greater number of e‐journals and additional e‐content, and an overall cost‐saving was achieved.DiscussionThis case study supports existing literature stating that integrating collections increases the number of e‐journals. It further identifies cost‐difference in acquiring cross‐site access to e‐journals compared to databases providing full‐text e‐journals and additional e‐content.ConclusionIntegrating e‐collections enables equity of access and value. A national co‐ordinated approach to procurement of e‐collections will further support equity and best value throughout NHS LKS.

Repeat paediatric dental general anaesthesia at Sheffield Children's NHS Foundation Trust: a service evaluation.

Introduction The use of general anaesthesia in paediatric dentistry should be appropriate and justified. During the treatment of children, a clinician should have foresight into the future dental requirements of the patient and whether a future general anaesthetic will be required in quick succession. Efforts should be made when possible to avoid this.Aims This service evaluation was performed to gather information regarding repeat dental general anaesthetics within Sheffield Children's Hospital NHS Foundation Trust.Methods All children's records who had experienced a repeat dental general anaesthetic between 1 January 2015 and 31 December 2018 were analysed. Those who had experienced a repeat dental general anaesthetic within two years were investigated.Results Overall, 0.63% of children had a repeat dental general anaesthetic within a two-year period. These repeat dental general anaesthetics were mainly justified due to new dental caries. 43.9% had modifying factors, such as a complex medical history, that could have impacted the need for a second dental general anaesthetic.Conclusion The repeat rate in Sheffield Children's Hospital NHS Foundation Trust is low. We believe this is a result of specialist treatment planning and appropriate use of both 'extraction only' and 'restorative and extraction' GA lists.

Rapid sperm capture: high-throughput flagellar waveform analysis.

STUDY QUESTIONCan flagellar analyses be scaled up to provide automated tracking of motile sperm, and does knowledge of the flagellar waveform provide new insight not provided by routine head tracking?SUMMARY ANSWERHigh-throughput flagellar waveform tracking and analysis enable measurement of experimentally intractable quantities such as energy dissipation, disturbance of the surrounding medium and viscous stresses, which are not possible by tracking the sperm head alone.WHAT IS KNOWN ALREADYThe clinical gold standard for sperm motility analysis comprises a manual analysis by a trained professional, with existing automated sperm diagnostics [computer-aided sperm analysis (CASA)] relying on tracking the sperm head and extrapolating measures. It is not currently possible with either of these approaches to track the sperm flagellar waveform for large numbers of cells in order to unlock the potential wealth of information enclosed within.STUDY DESIGN, SIZE, DURATIONThe software tool in this manuscript has been developed to enable high-throughput, repeatable, accurate and verifiable analysis of the sperm flagellar beat.PARTICIPANTS/MATERIALS, SETTING, METHODSUsing the software tool [Flagellar Analysis and Sperm Tracking (FAST)] described in this manuscript, we have analysed 176 experimental microscopy videos and have tracked the head and flagellum of 205 progressive cells in diluted semen (DSM), 119 progressive cells in a high-viscosity medium (HVM) and 42 stuck cells in a low-viscosity medium. Unscreened donors were recruited at Birmingham Women’s and Children’s NHS Foundation Trust after giving informed consent.MAIN RESULTS AND THE ROLE OF CHANCEWe describe fully automated tracking and analysis of flagellar movement for large cell numbers. The analysis is demonstrated on freely motile cells in low- and high-viscosity fluids and validated on published data of tethered cells undergoing pharmacological hyperactivation. Direct analysis of the flagellar beat reveals that the CASA measure ‘beat cross frequency’ does not measure beat frequency; attempting to fit a straight line between the two measures gives n}{}{mathrm{R}}^2 values of 0.042 and 0.00054 for cells in DSM and HVM, respectively. A new measurement, track centroid speed, is validated as an accurate differentiator of progressive motility. Coupled with fluid mechanics codes, waveform data enable extraction of experimentally intractable quantities such as energy dissipation, disturbance of the surrounding medium and viscous stresses. We provide a powerful and accessible research tool, enabling connection of the mechanical activity of the sperm to its motility and effect on its environment.LARGE SCALE DATAThe FAST software package and all documentation can be downloaded from www.flagellarCapture.com.LIMITATIONS, REASONS FOR CAUTIONThe FAST software package has only been tested for use with negative phase contrast microscopy. Other imaging modalities, with bright cells on a dark background, have not been tested but may work. FAST is not designed to analyse raw semen; it is specifically for precise analysis of flagellar kinematics, as that is the promising area for computer use. Flagellar capture will always require that cells are at a dilution where their paths do not frequently cross.WIDER IMPLICATIONS OF THE FINDINGSCombining tracked flagella with mathematical modelling has the potential to reveal new mechanistic insight. By providing the capability as a free-to-use software package, we hope that this ability to accurately quantify the flagellar waveform in large populations of motile cells will enable an abundant array of diagnostic, toxicological and therapeutic possibilities, as well as creating new opportunities for assessing and treating male subfertility.STUDY FUNDING/COMPETING INTEREST(S)M.T.G., G.C., J.C.K-B. and D.J.S. gratefully acknowledge funding from the Engineering and Physical Sciences Research Council, Healthcare Technologies Challenge Award (Rapid Sperm Capture EP/N021096/1). J.C.K-B. is funded by a National Institute of Health Research (NIHR) and Health Education England, Senior Clinical Lectureship Grant: The role of the human sperm in healthy live birth (NIHRDH-HCS SCL-2014-05-001). This article presents independent research funded in part by the NIHR and Health Education England. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The data for experimental set (2) were funded through a Wellcome Trust-University of Birmingham Value in People Fellowship Bridging Award (E.H.O.).The authors declare no competing interests.

Introducing outpatient parenteral antimicrobial therapy in a children's hospital.

Outpatient parenteral antimicrobial therapy (OPAT) offers an alternative to inpatient care for delivering intravenous antibiotics in patients' homes or in a day care clinic setting. It was first introduced in North America in the 1970s and has evolved over the years, starting with the adult population and now moving to the paediatric population ( Chapman 2013 ). OPAT has the potential to offer excellent, patient-centred, high-quality care to treat a wide variety of infectious conditions in patients who are medically stable and do not need hospitalisation. For children and young people OPAT has the potential for families to resume their normal lives: returning to work, school and home. Paediatric OPAT (P-OPAT) is being implemented across the UK, with five centres now established. This article reports on the implementation of P-OPAT at Sheffield Children's NHS Foundation Trust (Sheffield Children's) in June 2016, highlighting the challenges and successes.

Best position and depth of anaesthesia for laryngeal mask airway removal in children: A randomised controlled trial.

There is a wide variation in clinical practice amongst clinicians in the process of removal of the laryngeal mask airway (LMA) in children. Some of the airway complications during recovery are associated with the position of the child as well as the depth of anaesthesia and are potentially avoidable. We wished to determine whether removal of the LMA in the lateral position reduces the incidence of airway complications, either in a deep plane of anaesthesia or awake. A randomised trial. A tertiary children's hospital. The study population comprised 216 American Society of Anesthesiologists (ASA) 1 to 2 patients aged 1 to 16 years scheduled for elective surgery under general anaesthesia using an LMA. Exclusion criteria were children less than 1 year old, ASA 3 or above, presence of congenital heart disease or gastro-oesophageal reflux, anticipated difficult airway and patients undergoing airway or dental surgery. We randomly allocated 212 children into one of four groups for LMA removal, deeply anaesthetised or awake in either the lateral or supine position. Various airway complications were recorded after removal of the LMA. The primary outcome measure was the number of patients experiencing one or more complication in each group. We also devised a novel 'Clinical Importance' score on the basis of the clinical relevance of airway complications. There were significant differences among groups (P = 0.001); the fewest complications occurred when the LMA was removed in a deep plane of anaesthesia in the lateral position. There was a significant difference among groups in the 'Clinical Importance' scores (P < 0.001); the greatest risk occurred when the LMA was removed in deeply anaesthetised supine patients. The results of the present study suggest that lateral positioning of children for removal of the LMA provides the safest conditions if the LMA is to be removed at a deep plane of anaesthesia. Sheffield Children's NHS Foundation Trust Study number CA08014.

In case you missed it: thePrenatal Diagnosissection editors bring you the most significant advances of 2013

Mother Infant Research Institute at Tufts Medical Center, Boston, Massachusetts, USA Department of Obstetrics and Gynecology, University Hospitals Leuven, Leuven, Belgium Paw Print Genetics, Genetic Veterinary Sciences, Inc., Spokane Washington, USA Department of Human Genetics, Radboud University Medical Centre, Nijmegen, the Netherlands UCL Institute of Child Health, Great Ormond Street Hospital for Children NHS Foundation Trust and University College Hospital NHS Foundation Trust, London, UK Inova Alexandria Hospital, Alexandria, Virginia, USA *Correspondence to: Diana W. Bianchi. E-mail: dbianchi@tuftsmedicalcenter.org

Polysomnographic sleep parameters in an aging population

Polysomnographic sleep parameters in an aging population

Nutrition education: the way to reduce childhood obesity?

Nutrition education: the way to reduce childhood obesity?

Letter in response to Chitale et al.: determining the utility of the 60‐minute cortisol measurement in the short synacthen test

Clinical EndocrinologyVolume 80, Issue 6 p. 925-925 Letter to the Editor Letter in response to Chitale et al.: determining the utility of the 60-minute cortisol measurement in the short synacthen test C. J. Elder, C. J. Elder [email protected] Academic Unit of Child Health, University of Sheffield, Sheffield, UKSearch for more papers by this authorL. M. Somerset, L. M. Somerset School of Medicine, University of Sheffield, Sheffield, UKSearch for more papers by this authorV. Ram, V. Ram School of Medicine, University of Sheffield, Sheffield, UKSearch for more papers by this authorN. P. Wright, N. P. Wright Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UKSearch for more papers by this authorJ. K. Wales, J. K. Wales Academic Unit of Child Health, University of Sheffield, Sheffield, UKSearch for more papers by this authorP. J. Dimitri, P. J. Dimitri Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UKSearch for more papers by this author C. J. Elder, C. J. Elder [email protected] Academic Unit of Child Health, University of Sheffield, Sheffield, UKSearch for more papers by this authorL. M. Somerset, L. M. Somerset School of Medicine, University of Sheffield, Sheffield, UKSearch for more papers by this authorV. Ram, V. Ram School of Medicine, University of Sheffield, Sheffield, UKSearch for more papers by this authorN. P. Wright, N. P. Wright Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UKSearch for more papers by this authorJ. K. Wales, J. K. Wales Academic Unit of Child Health, University of Sheffield, Sheffield, UKSearch for more papers by this authorP. J. Dimitri, P. J. Dimitri Sheffield Children's NHS Foundation Trust, Western Bank, Sheffield, UKSearch for more papers by this author First published: 11 July 2013 https://doi.org/10.1111/cen.12285Citations: 1Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume80, Issue6June 2014Pages 925-925 RelatedInformation

Emergence of carbapenem-resistant Enterobacteriaceae in a UK paediatric hospital

Carbapenem-resistant Enterobacteriaceae are an emerging global infection threat. However, there are few data describing their clinical importance in children. This retrospective study reviewed the prevalence and resistance mechanisms of carbapenem-resistant Enterobacteriaceae grown from clinical and surveillance samples in a large tertiary referral children's hospital in the UK. Carbapenem-resistant Enterobacteriaceae were sought in specimens submitted for diagnostic and surveillance purposes at Alder Hey Children's NHS Foundation Trust, Liverpool, between September 2011 and August 2012. Mechanisms of resistance were identified using phenotypic and/or molecular methods. Variable number tandem repeat profiling was used to type carbapenemase-producing strains. During the 12-month study period, carbapenem-resistant Enterobacteriaceae were recovered from 24 patients. Five isolates were from clinical diagnostic specimens whereas 19 of 421 patients had positive rectal surveillance swabs (4.5%). Of the 24 isolates, seven (all Klebsiella spp.) harboured carbapenemases: three had blaKPC and four blaNDM, whereas 17 had resistance due to combinations of AmpC or extended-spectrum β-lactamase activity plus impermeability. Carbapenem-resistant Enterobacteriaceae and, in particular, those with carbapenemases, are an emerging infection problem in a major paediatric hospital in the UK. Active surveillance is required to monitor and control their spread.

An audit of intravenous meropenem in inpatients at Alder Hey Children's NHS Foundation Trust

ObjectivesTo determine the indications for which meropenem was being used and to assess whether these indications adhered to Trust guidelines and national recommendations. This was prompted by the emergence and...

Child Protection and Mental Health

Child Protection and Mental Health

Ethnic differences in burn mechanism and severity in a UK paediatric population

BackgroundBurns in children are a major public health problem with long-lasting physical and psychological sequelae. Previous studies have identified that children from ethnic minorities have higher rates of burns. ObjectiveThe purpose of this study was to analyse the differences in paediatric burn mechanism and severity within different ethnic groups. MethodsDemographic and burn data from all paediatric patients presenting with burn at the Burns Service, Alder Hey Children's NHS Foundation Trust, Liverpool, UK were collected over a 5 year period. Results766 paediatric patients (age range: 7 days to 16 years old, mean: 4.5 years) were included in the study. Ethnic minority children had higher total body surface area of burn (p<0.001) and length of stay (p<0.001) compared with non-ethnic minority children. Chinese children had most burns from hot food (60%), whereas non-ethnic minority children had most burns from hot beverages (35.8%). Ethnic minority children were more deprived compared with non-ethnic minority children (Index of Multiple Deprivation 48.7 vs. 40.9; p=0.02). ConclusionThese results show that there are significant differences in the patterns of burns in ethnic minority groups. This data should guide targeted public health prevention and educational strategies.

Preexpanded Muscle-Sparing Latissimus Dorsi Free Flap in Complex Lower Limb Trauma: The Orthoplastic Approach

Sir: Reconstruction of large defects of the knee may require free flaps with a large surface area of pliable skin along with a long pedicle. Flaps that have been described to cover such defects include free latissimus dorsi and free expanded latissimus dorsi flaps; however, these can be too bulky and may leave large defects on the back. We present the case of a 15-year-old boy who was involved in a road traffic collision 4 years previously, in which he sustained a degloving injury to the posterior knee complicated by an open femoral fracture. Initial treatment involved stabilization of the fracture, bony cover with local tissue, and split skin graft for reconstruction of the skin defect. Subsequently, there was growth arrest caused by significant injury to the growth plate, compounded by severe soft-tissue contracture resulting in a fixed flexion deformity of the left knee (Fig. 1).Fig. 1.: Preoperative flexion contracture and tissue expander in situ (digitally acquired leg length images).According to the joint British Association of Plastic, Reconstructive, and Aesthetic Surgery and the British Orthopaedic Association guidelines, the patient was assessed by the multidisciplinary lower limb trauma and reconstruction team. It was immediately apparent that tissue coverage of the deformity would require a sizable skin paddle of approximately 36 × 20 cm. Given the patient's clinical needs and the lack of a suitable immediate donor site, the decision was made to expand a large fasciocutaneous skin flap on the patient's back. During the first stage, a customized three-chambered tissue expander was placed in the subfascial plane in the back, and a Doppler device was used to identify and therefore avoid the perforator to the left latissimus dorsi. Over a 3-month period, expansion of 2440 ml was achieved, creating a sizable soft-tissue paddle. At definitive surgery, the flexion deformity was corrected with femoral valgus and derotational osteotomy, along with application of a rail fixator for femoral lengthening by distraction. The area of split skin graft covering the popliteal fossa was excised. This allowed correction of a significant component of the flexion deformity. This large-sized soft-tissue defect (36 × 20 cm) was covered with the preexpanded muscle-sparing latissimus dorsi free flap, incorporating much of the expanded skin but still leaving enough to allow primary closure of the secondary defect. Three months postoperatively, the patient had good range of movement at the knee, with no flap or donor-site complications (Fig. 2).Fig. 2.: Postoperative flap and femoral distractor (left), and the donor site (right).Complex and large soft-tissue defects of the knee require coverage with a large flap. Both free latissimus dorsi and expanded latissimus dorsi flaps have been described to cover such defects.1,2 The muscle-sparing latissimus dorsi flap has been described mainly in breast reconstruction.3–5 The advantages of this flap are reduced seroma rates and lack of functional morbidity, without cosmetic sequelae.4,5 To our knowledge, this is the first report of this flap being used for this purpose. We believe that preexpanded muscle-sparing latissimus dorsi free flap reconstruction has a role in large, complex, lower limb trauma cases. It provides large amounts of skin with minimum donor-site morbidity and shows the versatility of the muscle-sparing latissimus dorsi flap beyond the realms of breast reconstruction. DISCLOSURE No funding was received to support this work. The authors have no commercial associations or financial interest to declare. Nathan T. J. Hamnett, M.R.C.S. Anuj Mishra, M.R.C.S. Selvadurai Nayagam, M.Ch.(Orth.), F.R.C.S.(Plast.) Ken Graham, F.R.C.S.(Plast.) Christian Duncan, F.R.C.S.(Plast.) Department of Plastic Surgery Alder Hey Children's NHS Foundation Trust Liverpool, England

Brain Abscesses Due to Citrobacter koseri in a Pair of Twins

To the Editors: Intracranial abscesses are uncommon in the newborn and have not been reported in a pair of twins. We describe Citrobacter meningitis complicated by multiple brain abscesses. These dizygotic twins were born by normal delivery, following induced labor at 37 weeks gestation. The babies were healthy at birth, weighing 2.18 kg and 2.30 kg. Perinatally, there were no prolonged ruptures of membranes, maternal fever, or illness. The twins were bottle-fed on formula and discharged home on day five. Twin 1 presented with a temperature of 37.8°C and a history of jerky movements on day 21 of life. Cerebrospinal fluid (CSF) analysis from lumbar puncture showed elevated white cell count of 5250 × 106/L (90% polymorphs, 10% lymphocytes). No organism was seen on Gram stain but culture yielded scanty growth of Citrobacter koseri. No organism was isolated from blood cultures. Twin 2 was asymptomatic but also had CSF obtained which showed 30 × 106/L white blood cells. No organism was isolated from the CSF or blood. Both babies were empirically treated with intravenous cefotaxime. Despite in vitro susceptibility of the organism to cefotaxime, both babies developed brain abscesses, evident on brain imaging at the end of the first week of treatment (Fig., Supplemental Digital Content 1, https://links.lww.com/INF/A260 and Fig., Supplemental Digital Content 2, https://links.lww.com/INF/A261). Intravenous meropenem was added in the second week but the abscesses continued to increase in size. On day 22 of antibiotic treatment the abscesses were drained by stereotactic needle aspiration; pus from the frontal abscesses in twin 2 grew Citrobacter koseri. Both babies remained clinically well throughout their hospitalization. Echocardiograms did not show cardiac abnormality to account for possible cerebral embolizsation. Four weeks of intravenous meropenem was completed and the babies were discharged home on further 3 months therapy for oral ciprofloxacin. At 4 months of age both babies were neurologically normal with resolution of cerebral abscesses on CT scans but persistence of a porencephalic cyst in twin 1 (Fig., Supplemental Digital Content 1, https://links.lww.com/INF/A260 and Fig., Supplemental Digital Content 2, https://links.lww.com/INF/A261). Citrobacter species are anaerobic Gram negative rods found infrequently as normal inhabitants of the intestinal tract of human and animals.1Citrobacter accounts for up to 4% of neonatal meningitis cases,2Citrobacter koseri (formerly Citrobacter diversus) being the most common species implicated.3 Newborns can acquire colonization at the time of passage through the birth canal of a colonized mother.4Citrobacter infection almost always results in meningitis but the mechanism for the neurotropism of this organism is not fully understood. Meningitis leads to intracerebral abscesses in 75% of cases.3 Case-fatality rate for Citrobacter meningitis of 30% has been observed, with at least 50% of surviving infants having neurologic sequelae.3 As our case demonstrates, bacteria can be cultured from abscesses despite systemic antibiotics, and also despite good concentration of antibiotics within the cavity.5 Neurosurgical management is therefore advocated: goals of abscess aspiration include removal of the mass effect, and reduction of the bacterial load thereby improving the local environment for systemic antibiotics to have their effect. This case report also highlights the increased risk of infection in the asymptomatic twin of an affected infant. Onajite Etuwewe, MB ChB, MRCPCH Department of Paediatric Infectious Diseases and Immunology Richa Kulshrestha, MB BS, MRCPCH Department of Neurology Meharpal Sangra, FRCS Department of Neurosurgery Andrew Riordan, MD, DTM&H, MRCP(UK), FRCPCH Department of Paediatric Infectious Diseases and Immunology Alder Hey Children's NHS Foundation Trust Liverpool, United Kingdom