PURPOSE OF REVIEW
HIV screening in pregnancy, universal suppressive antiretroviral therapy (ART) and breastfeeding avoidance can almost completely prevent vertical transmission of HIV. Breastfeeding is associated with an additional risk of transmission, although this risk is extremely low with suppressive maternal ART. This minimal risk must be balanced with the benefits of breastfeeding for women living with HIV (WLHIV) and their infants. Guidance in high-income countries has evolved, moving towards supported breast feeding for women on suppressive ART.


RECENT FINDINGS
Breastmilk transmission accounts for an increasing proportion of new infant infections globally. The majority of transmission data comes from studies including women not on suppressive ART. Breastmilk transmissions in the context of undetectable viral load have rarely occurred, although risk factors remain unclear. Outcome data on supported breastfeeding are accumulating, providing evidence for guidelines and informing infant feeding decisions. Long-acting ART for maternal preexposure prophylaxis or treatment, and infant postnatal prophylaxis are promising future options.


SUMMARY
Breastfeeding on suppressive ART has a very low risk of vertical transmission and can have multiple benefits for WLHIV and their infants. However, caution is advised with relaxation of breastfeeding guidance so as not to jeopardise the global goal of elimination of vertical transmission by 2030.

Infant feeding: emerging concepts to prevent HIV transmission.

Fitz-Hugh–Curtis syndrome

Salmonella is a rare causative pathogen of osteomyelitis and is commonly detected in patients with sickle cell disease. We described 2 consecutive cases of nontyphoidal Salmonella osteomyelitis identified in immunocompetent children. It is evident that even children without apparent risk factors for immune dysfunctions can be affected, so maintaining clinical suspicion is crucial for early diagnosis and prompt treatment. 

Nontyphoidal salmonella osteomyelitis in immunocompetent children: report of two cases and literature review

An Unexpected Case of Fitz-Hugh-Curtis Syndrome in a 4-Year-old Child Without a Sexually Transmitted Infection.

To the Editors: Less than 1% of pediatric Salmonella infections present with osteomyelitis often associated to hemoglobinopathies, yet extraordinary in immunocompetent children.1,2 Despite relevant antibiotic therapy, treatment is often prolonged and duration is without international consensus. We report a case of Salmonella osteomyelitis (SOM) in an immunocompetent 10-month-old girl. A previously healthy 10-month-old girl was admitted to the pediatric ward due to persistent fever and being unable to crawl. Physical examination revealed fever (38.1°C), erythema, swelling, pain, and dysfunction of the left shoulder joint. Three weeks prior the family had been on vacation in Bali, Indonesia. They reported no event of trauma. On admission blood samples revealed increased leucocytes (17.2 billion/L), C-reactive protein (CRP) (79 mg/L) and erythrocyte sedimentation rate (55 mm/h), ultrasounds and radiograph of the shoulder joints were normal and stool, throat and urinary samples were culture-negative. Culturation of blood and joint fluid revealed Salmonella enterica serotype enteritidis type ST11 susceptible to ampicillin, piperacillin/tazobactam, ceftriaxone, meropenem, azithromycin, gentamicin, trimethoprim/sulfamethoxazole and ciprofloxacin. Magnetic resonance imaging showed fluid accumulation in the anterior shoulder region. Three weeks after admission, radiograph of the shoulder region showed a periosteal reaction along the entire humerus. The 10-month-old girl was diagnosed with Salmonella bacteremia, septic arthritis of the shoulder and humerus osteomyelitis. She was successfully treated with 4 weeks of intravenous (IV) ceftriaxone (2 weeks with oral ciprofloxacin due to CRP increase despite relevant intravenous therapy) following 5 weeks of oral ciprofloxacin. The patient fully recovered. No international consensus about the duration of antibiotic (AB) therapy in pediatric SOM has been established. In the literature, the duration of treatment ranges from 3 weeks to 6 months.3 Previously, Pääkkönen and Peltola4 proposed a minimum of 20 days of IV AB and Saavedra-Lozano et al3 suggested a minimum of 3–4 weeks of AB therapy (total duration). Both agree that the duration of AB therapy should be individually tailored in complex cases in the presence of children younger than 3 months, significant bone destruction, sepsis, shock, immunodeficiency, resistant or unusual agents like Salmonella species.3,4 In those cases, Saavedra-Lozano et al recommend a minimal duration of AB for 4–6 weeks with at least 3 weeks of IV therapy for children aged <3 months and 1–2 weeks for children >3 months before switching to oral therapy.3 Similarly, Wen et al recommend 4–6 weeks of antibiotics with a minimum of 3 weeks of parenteral therapy when treating SOM5 (Table 1). TABLE 1. - Recommended Duration of Antibiotic Therapy of Salmonella osteomyelitis in Immunocompetent Children Reference Total AB Duration IV AB Duration Oral AB Duration Peltola and Pääkkönen 4 Min. 4–6 weeks NA NA Saavedra-Lozano et al* 3 Min. 4–6 weeks 3 wks (age < 3 mo)1–2 wks (age > 3 mo) 3 wks (to mo) Wen et al 5 4–6 wks Min. 3 wks 1–3 wks This study 9 wks 2 wks monotherapy2 wks with oral AB 2 wks with IV AB5 wks monotherapy IV indicates intravenous. Min., minimum; NA, not available.*European Society of Paediatric Infectious Diseases Guidelines. SOM is extremely uncommon in immunocompetent children making conventional case-control studies difficult to facilitate. To the best of our knowledge, less than 80 cases of SOM have been reported in previously healthy children. In this case, we successfully treated an immunocompetent 10-month-old girl for a total duration of 9 weeks of AB therapy comprising 4 weeks of IV therapy and 7 weeks of oral therapy. The duration of AB therapy in this case may be used as inspiration in future cases taking the clinical and paraclinical status into account. The authors obtained written consent for publication from the parents before submission. The authors confirm that the Journal’s position on issues involved in ethical publication has been assessed carefully and affirm that this report is consistent with those guidelines. 

Recommended Duration of Antibiotic Treatment for Immunocompetent Children With Salmonella osteomyelitis.

Infant postnatal prophylaxis following maternal viraemia during breastfeeding.

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An Unexpected Case of Fitz-Hugh-Curtis Syndrome in a 4-Year-old Child Without a Sexually Transmitted Infection.

Recommended Duration of Antibiotic Treatment for Immunocompetent Children With Salmonella osteomyelitis.

Infant postnatal prophylaxis following maternal viraemia during breastfeeding.