Showing papers in "Pediatric Infectious Disease Journal in 1995"

Mycoplasma pneumoniae and Chlamydia pneumoniae in pediatric community-acquired pneumonia: comparative efficacy and safety of clarithromycin vs. erythromycin ethylsuccinate.

Abstract: We evaluated 260 previously healthy children ages 3 through 12 years who had clinical signs and symptoms of pneumonia, radiographically confirmed. Patients were randomized 1:1 to a 10-day course of either clarithromycin suspension 15 mg/kg/day divided twice a day or erythromycin suspension 40 mg/kg/

Penicillin-resistant Streptococcus pneumoniae in acute otitis media: risk factors, susceptibility patterns and antimicrobial management.

Abstract: From January, 1992, to January, 1994, penicillin-resistant (minimal inhibition concentration (MIC) > 0.06 μg/ml) Streptococcus pneumoniae (PRSP) isolates accounted for 48 (17%) of 283 isolates from acute otitis media (AOM) or recurrent AOM in 246 ambulatory patients in rural Kentucky. By broth micro

Potential interventions for the prevention of childhood pneumonia: geographic and temporal differences in serotype and serogroup distribution of sterile site pneumococcal isolates from children--implications for vaccine strategies.

Abstract: Streptococcus pneumoniae is a leading cause of fatal bacterial pneumonia in young children. Pneumococcal polysaccharide vaccines have not been promoted for use in young children because many constituent serotypes are not immunogenic in children < 2 years old. Conjugating pneumococcal polysaccharide epitopes to a protein carrier would likely increase vaccine immunogenicity in children. We reviewed published and unpublished pneumococcal serotype and serogroup data from 16 countries on 6 continents to determine geographic and temporal differences in serotype and serogroup distribution of sterile site pneumococcal isolates among children and to estimate coverage of proposed and potential pneumococcal conjugate vaccine formulas. The most common pneumococcal serotypes or groups from developed countries were, in descending order, 14, 6, 19, 18, 9, 23, 7, 4, 1 and 15. In developing countries the order was 6, 14, 8, 5, 1, 19, 9, 23, 18, 15 and 7. Development of customized heptavalent vaccine formulas, one for use in all developed countries and one for use in all developing countries, would not provide substantially better coverage against invasive pneumococcal disease than two currently proposed heptavalent formulas. An optimal nanovalent vaccine for global use would include serotypes 1, 5, 6B, 7F, 9V, 14, 18C, 19F and 23F. Geographic and temporal variation in pneumococcal serotypes demonstrates the need for a species-wide pneumococcal vaccine.

Comparison of the response to antimicrobial therapy of penicillin-resistant and penicillin-susceptible pneumococcal disease.

Abstract: The continued spread of penicillin-resistant pneumococci raises therapeutic concerns. Optimal therapy for resistant infections is unknown and it is not clear whether the efficacy of penicillin or equally active beta-lactam agents is compromised in non-meningeal-resistant infections. A prospective nonintervention study was undertaken to compare the clinical response in penicillin-resistant vs. penicillin-susceptible bacteremic pneumococcal infections, excluding meningitis. Of 108 children enrolled, 35 (32%) had penicillin-resistant (one highly resistant) isolates. Seventy-eight children had pneumonia, 21 had occult bacteremia (sepsis) and 9 had peritonitis. Children with resistant infections were more likely to have underlying disorders, especially human immunodeficiency virus infection, and to have received antimicrobial therapy in the previous month. After 48 hours of therapy 64% of penicillin-susceptible infections showed improvement vs. 60% of penicillin-resistant infections (odds ratio, 1.2; 95% confidence intervals, 0.5 to 3.0). In children with pneumonia treated with ampicillin or an equivalent beta-lactam agent, 93% with penicillin-susceptible infections had improved by Day 7 of therapy compared with 88% with resistant infections (odds ratio, 1.9; 95% confidence interval 0.3 to 15.9). The durations of respiratory distress, fever and oxygen requirement were similar in penicillin-susceptible and -resistant infections. These results suggest that intermediate penicillin resistance is of little significance in pneumococcal pneumonia or sepsis and that standard beta-lactam therapy is still highly effective. Further studies of highly penicillin-resistant infections are necessary.

Lactobacillus GG promotes recovery from acute nonbloody diarrhea in Pakistan.

Abstract: A prospective, placebo-controlled, triple blind clinical trial was carried out in Pakistan to determine the effect of Lactobacillus GG on the course of acute diarrhea in hospitalized children. Forty children (mean age, 13 months) were enrolled and after rehydration received either oral Lactobacillus GG (n = 21) or placebo (n = 19) twice daily for 2 days, in addition to the usual diet. The clinical course of diarrhea was followed during the treatment period. Features on admission into the study groups were similar and were characterized by severe diarrhea, malnutrition and inappropriate management before presentation. Response was evident on Day 2 when the frequency of both vomiting and diarrhea was less in the Lactobacillus group. In those who had presented with acute nonbloody diarrhea (n = 32), the percentage of children with persistent watery diarrhea at 48 hours was significantly less in the Lactobacillus group: 31% vs. 75% (P < 0.01). No significant difference was observed by 48 hours in those presenting with bloody diarrhea. The relevance of this finding to the management of diarrhea in the tropics is discussed.

High prevalence of multidrug-resistant Streptococcus pneumoniae among children in a rural Kentucky community

Abstract: In 1992 drug-resistant Streptococcus pneumoniae was cultured with increasing frequency from aspirates of middle ear fluid from children with acute otitis media in a rural Kentucky community. To determine the prevalence of carriage of drug-resistant S. pneumoniae in the community, we obtained nasopharyngeal swabs from 158 (70%) of 227 children attending a child daycare center and from 82 children attending the county health center. S. pneumoniae was isolated from 126 children. Among 123 isolates tested 65 (53%) were penicillin-resistant, including 41 (33%) strains that were highly resistant; 61 (50%) were multidrug-resistant. Serotypes 19F, 6B, 23F and 6A comprised 89% of the penicillin-resistant isolates. Detection of a variety of serotypes and drug resistance patterns among nasopharyngeal isolates of S. pneumoniae suggests that multidrug-resistant pneumococcal strains are endemic in this community. Surveillance for drug-resistant pneumococci with the use of respiratory secretions obtained by nasopharyngeal swab may provide useful information on the prevalence of drug-resistant strains causing invasive disease and otitis media. Such information could be used to guide empiric therapy of pneumococcal infections.

Perinatal transmission and manifestation of hepatitis C virus infection in a high risk population.

Abstract: We studied the perinatal transmission of hepatitis C virus (HCV) in 70 high risk mother/infant pairs. Seventy-six percent of the mothers (53 of 70) were coinfected with human immunodeficiency virus (HIV) and 79% (55 of 70) had a history of drug addiction. During the follow-up HCV RNA was detected in

Mechanism of electrical enhancement of efficacy of antibiotics in killing biofilm bacteria

Abstract: The bioelectric effect, in which electric fields are used to enhance the efficacy of biocides and antibiotics in killing biofilm bacteria, has been shown to reduce the very high concentrations of these antibacterial agents needed to kill biofilm bacteria to levels very close to those needed to kill planktonic (floating) bacteria of the same species. In this report, we show that biofilm bacteria are readily killed by an antibiotic on all areas of the active electrodes and on the surfaces of conductive elements that lie within the electric field but do not themselves function as electrodes. Considerations of electrode geometry indicate that very low (< 100 microA/cm2) current densities may be effective in this electrical enhancement of antibiotic efficacy against biofilm bacteria, and flow experiments indicate that this bioelectric effect does not appear to depend entirely on the possible local electrochemical generation of antibacterial molecules or ions. These data are expected to facilitate the use of the bioelectric effect in the prevention and treatment of device-related bacterial infections that are caused by bacteria that grow in biofilms and thereby frustrate antibiotic chemotherapy.

Accuracy of leukocyte indices and C-reactive protein for diagnosis of neonatal sepsis: a critical review

Abstract: To evaluate the value of C-reactive protein and leukocyte indices in the workup of patients suspected of having infection in a neonatal intensive care setting, a literature search was conducted in all languages using MEDLINE (1966 to May, 1994), EMBASE (1988 to May, 1994), bibliographic lists of primary and review articles and personal files. Citations identified as potentially relevant were reviewed by two independent investigators; only studies meeting preset criteria for population, diagnostic test and data presentation were included. Two observers independently assessed studies using explicit methodologic criteria. All data from the articles were extracted by one observer, whereas the second reviewer checked these data for accuracy. Four of the selected studies dealt with leukocyte count and ratios. The chi square test for homogeneity of proportions revealed significant heterogeneity across studies (P = 0.014 for the ratios; P < 0.001 for white blood cell count), suggesting that test properties varied widely across studies. Fifteen of the selected studies evaluated C-reactive protein; of these six were qualitative using a latex agglutination method. Among these studies the chi square test for homogeneity of proportions was highly significant (P < 0.01), reflecting the great heterogeneity across studies. Among the nine studies that evaluated five different quantitative methods heterogeneity was again present (P < 0.001). Because of the striking heterogeneity among the studies evaluated, pooling to give a summary point estimate of the sensitivity and specificity of the various studies was not possible and the results are reported as ranges.(ABSTRACT TRUNCATED AT 250 WORDS)

Group A streptococcal necrotizing fasciitis complicating primary varicella: a series of fourteen patients.

Abstract: We retrospectively reviewed the clinical course of group A Streptococcus necrotizing fasciitis complicating primary varicella in children admitted to Children's Hospital and Medical Center, Seattle, WA, during a 18-month period. The potential benefit of various therapeutic interventions was examined. Fourteen children ages 6 months to 10 years were treated for group A Streptococcus necrotizing fasciitis as a complication of primary varicella. Eight patients experienced a delay in initial diagnosis as a result of nonspecific, early clinical findings of necrotizing fasciitis. Each patient underwent surgical exploration with fasciotomies and debridement. Initial antibiotic therapy was broad spectrum and included clindamycin. Hyperbaric oxygen therapy for as many as 6 treatments was used as adjunctively therapy in 12 patients, with subjective benefit in 6 patients. All 14 patients were discharged home with good function and no long term sequelae. This potentially fatal bacterial infection of the deep fascial layers requires early recognition by primary care physicians and an intensive, multidisciplinary therapeutic approach, including thorough surgical debridement and appropriate antibiotic therapy.

Comparison of 10% povidone-iodine and 0.5% chlorhexidine gluconate for the prevention of peripheral intravenous catheter colonization in neonates: a prospective trial

Abstract: The purpose of the study was to compare the efficacy of 10% povidone-iodine with that of 0.5% chlorhexidine gluconate in 70% isopropyl alcohol for the prevention of peripheral intravenous catheter colonization in neonates. This was a multicenter, nonrandomized prospective study in a tertiary neonatal intensive care setting in which povidone-iodine and chlorhexidine gluconate were each used as antiseptic skin preparations over sequential 6-month periods. During the first 6 months of the study when povidone-iodine was in use 9.3% (38 of 408) of catheters were colonized. During the second 6 months of the study when chlorhexidine gluconate was in use, catheter colonization occurred in 4.7% (20 of 418, P = 0.01). Catheter-related bacteremia occurred during only 0.2% (2 of 826) of all catheterizations. Heavy skin colonization before catheter insertion (relative risk, 3.6; 95% confidence interval, 1.9, 7.0), catheterization > or = 72 hours (relative risk. 2.0; 95% confidence interval, 1.01, 3.8) and gestational age < or = 32 weeks (relative risk, 1.8; 95% confidence interval, 1.02, 3.3) increased colonization risk. Ampicillin infusion (relative risk, 0.4; 95% confidence interval, 0.2, 0.7) and 0.5% chlorhexidine gluconate cutaneous antisepsis (relative risk, 0.4; 95% confidence interval, 0.2, 0.8) were factors associated with decreased colonization risk. We conclude that 0.5% chlorhexidine gluconate in 70% isopropyl alcohol appears to be more efficacious than 10% povidone-iodine for the prevention of peripheral intravenous catheter colonization in neonates.

Respiratory tuberculosis in childhood: the diagnostic value of clinical features and special investigations.

Abstract: During a 16-month period children presenting to a pediatric outpatient facility from an area with a high tuberculosis incidence (> 400/100,000) and suspected of having respiratory tuberculosis (TB) were evaluated for close contact with adult pulmonary tuberculosis, weight loss, symptom duration, respiratory signs, lymphadenopathy and hepatosplenomegaly and by chest radiography and tuberculin testing (Mantoux or tine). Probable tuberculosis was diagnosed in 258 children and was confirmed in 109 (42%) patients with a mean age of 31 months by culture of Mycobacterium tuberculosis from gastric aspirate or another source. Eleven children with confirmed TB had a normal chest radiograph. After review of special investigations, clinical course and follow-up of the remaining 149 children, 86 children (58%) with a mean age of 32.4 months were considered to have probable TB and 63 (42%) with a mean age of 27 months not to have TB. Significantly fewer children in the "not TB" group than in the confirmed and probable TB groups had a close adult pulmonary tuberculosis contact (13 (21%) and 95 (49%), respectively; P 2 weeks, the presence of bronchial breathing, wheeze, hepatomegaly or splenomegaly or peripheral lymphadenopathy. Final diagnoses in the "not TB" group included bacterial or viral pneumonia or bronchopneumonia in 37, asthma often accompanied by segmental collapse in 9 and cavitating pneumonia in 3 children.(ABSTRACT TRUNCATED AT 250 WORDS)

Respiratory carriage of Kingella kingae among healthy children.

Abstract: The role of Kingella kingae as an invasive pathogen of young children is being increasingly recognized, but the niche of the organism in the respiratory tract and its prevalence in the normal flora of children remain unknown. To investigate these two aspects throat and nasopharyngeal cultures were obtained every 2 weeks from two cohorts of children, ages 6 to 42 months on enrollment, attending a day-care center in southern Israel. To determine the age-related prevalence of K. kingae, throat cultures were obtained from children ages 6 months to 14 years hospitalized for elective surgery who had not received antibiotics during the previous 30 days and from healthy infants younger than 6 months attending a well-baby-care clinic for routine vaccinations. During an 11-month follow-up 109 of 624 (27.5%) throat cultures but none of the nasopharyngeal cultures obtained from 48 day-care center attendees grew K. kingae. The monthly prevalence of K. kingae ranged from 6.1 to 34.6% with December and April peaks. Overall 35 of 48 (72.9%) children had at least one positive culture for the organism. Among the 27 children who had > or = 2 positive cultures, continuous and intermittent patterns of carriage were observed. None of the colonized children experienced an invasive K. kingae infection. The prevalence of pharyngeal carriage among surgical patients was 8.0%, and the organism was not isolated from any of the infants younger than 6 months attending the well-baby-care clinic.

Erythrocyte sedimentation rate, white blood cell count and serum C-reactive protein in assessing etiologic diagnosis of acute lower respiratory infections in children.

Abstract: The clinical signs, symptoms and host responses (erythrocyte sedimentation rate, white blood cell count and C-reactive protein) were studied to distinguish bacterial from viral acute lower respiratory infection (ALRI) in 121 children hospitalized for ALRI. Etiologic diagnosis was based on blood culture, antibody assays and antigen detection. Children with bacterial involvement only were older than those with viral involvement alone (mean, 5.1 vs. 2.5 years), and their duration of respiratory symptoms had lasted longer (mean, 4.6 vs. 3.3 days). Children with unknown etiology had a shorter duration of fever before hospitalization than those with etiology identified with the methods used (mean, 1.6 vs. 2.9 days). The host response ranged widely within etiologic groups. The mean erythrocyte sedimentation rate did not differ significantly between the bacterial and viral ALRI (38 vs. 28 mm/hour); neither did white blood cell count (13.2 vs. 13.6 x 10(9)/liter) or C-reactive protein (68 vs. 49 mg/liter). No combination of clinical signs and host responses or any cutoff values could be shown to differentiate reliably bacterial from viral ALRI.

Serologic status and measles attack rates among vaccinated and unvaccinated children in rural Senegal.

Abstract: During a measles vaccine trial in a rural area of Senegal, antibody status was examined within 10 days of exposure for 228 previously vaccinated and 313 unvaccinated children more than 12 months old who were exposed to measles at home. Thirty-six percent of the children developed clinical measles, the clinical diagnosis being confirmed for 135 of the 137 children from whom 2 blood samples were collected. Vaccine efficacy was 90% (95% confidence interval, 83 to 94%). The hemagglutinin-inhibiting antibodies (HI) or plaque neutralizing antibodies (PN) assays were equally efficient in predicting susceptibility and protection against measles. Vaccinated children who had no detectable HI or PN antibodies at exposure had significant protection against measles compared with seronegative unvaccinated children (HI vaccine efficacy, 49% (95% confidence interval, 21 to 68%); PN vaccine efficacy, 43% (95% confidence interval, 12 to 62%)). The attack rate was high for children with a titer of 40 to 125 mIU) 67% (4 of 6) of those with a positive hemagglutinin-inhibiting antibody test and 36% (13 of 36) of those with a positive PN test developed measles. Attack rates among children with HI or PN titers above 125 mIU were 2% (6 of 295) and 3% (7 of 258), respectively. Because titers of < or = 120 mIU have been found to offer little protection in another study, this antibody level may be the best screening value for assessing susceptibility and protection against measles. However, it should be noted that many seronegative vaccinated children are protected against measles infection.

Persistent acute otitis media: I. Causative pathogens.

Abstract: In this prospective study tympanocentesis was performed to determine the pathogens isolated from middle ear fluid of 200 ears in 137 children with acute otitis media (AOM) which had not responded after one or two empiric antimicrobial treatment courses (termed persistent AOM). For comparison tympanocentesis from 154 ears in 111 children with AOM not previously treated are described. Patients were enrolled from October, 1989, until September, 1992. In the persistent AOM group amoxicillin and trimethoprim/sulfamethoxazole were the most frequently used antimicrobials before tympanocentesis. Middle ear aspirates produced no pathogenic bacterial growth in 49% of persistent AOM patients, Streptococcus pneumoniae in 24%, Haemophilus influenzae in 7%, Branhamella catarrhalis in 7%, Streptococcus pyogenes in 6%, Staphylococcus aureus in 5% and two pathogens in 3%. Two (18%) of 11 S. pneumoniae isolates tested were penicillin-resistant; 1 was intermediate and 1 was highly resistant. Ten (83%) of 12 H. influenzae and all of 11 B. catarrhalis AOM isolates produced beta-lactamase. In comparison previously untreated AOM patients produced no bacterial growth from tympanocentesis in 30%, S. pneumoniae in 36% (8% penicillin-resistant), H. influenaze in 13% (44% beta-lactamase-producing) and B. catarrhalis in 11% (85% beta-lactamase producing). AOM which is persistent after initial empiric antimicrobial therapy may be caused by middle ear inflammation after bacteria are killed or involve penicillin-resistant S. pneumoniae, beta-lactamase-producing H. influenzae or B. catarrhalis more commonly than occurs in AOM which has not been recently treated.

Epidemiology and prevention of meningococcal disease

Abstract: Epidemiology and prevention of meningococcal disease FRANCIS RIEDO;BRIAN PLIKAYTIS;CLAIRE BROOME; The Pediatric Infectious Disease Journal

Colonization with penicillin-resistant Streptococcus pneumoniae in a child-care center

Abstract: We obtained nasopharyngeal cultures for Streptococcus pneumoniae from 54 children ages 2 to 24 months attending an Omaha child-care center (CCC) in April 1994. Thirty-two (59%) of the 54 children were colonized with S. pneumoniae belonging to serotypes 23, 19, 6 and 11. Seventeen (53%) of the pneumococcal isolates were highly resistant to penicillin (minimal inhibitory concentration > or = 2.0 micrograms/ml; HR-SP) and 7 (22%) were intermediately resistant to penicillin (0.12 < or = minimal inhibitory concentration < or = 1.0 microgram/ml; IR-SP). Within each pneumococcal capsular serotype, there were 1 to 3 DNA subtypes based on pulsed field gel electrophoresis analysis. A single pulsed field gel electrophoresis strain predominated in most CCC rooms, suggesting horizontal transmission among cohorted children. Nasopharyngeal cultures obtained 4 months later revealed similar S. pneumoniae colonization rates (28 of 52, 54%); however, only 2 (7%) of 28 isolates were HR-SP and 11 (39%) were IR-SP. Colonization with resistant pneumococci persisted after 4 months in 4 (12%) of 34 children cultured on both occasions. Antibiotic use by attendees had decreased notably between the two sampling periods, suggesting that selective pressure within the CCC might contribute to seasonal variation in colonization rates with HR-SP and IR-SP. We conclude that multiple genetic clones of penicillin-resistant pneumococci can occur simultaneously in a single CCC, especially during periods of heavy antibiotic selection pressure. However, individual clones of penicillin-resistant S. pneumoniae may be spread from child to child, suggesting that colonization with penicillin-resistant S. pneumoniae should now be considered a CCC-associated phenomenon.

Emergence of resistant Streptococcus pneumoniae: a problem in pediatrics.

Abstract: Penicillin resistance among strains of Streptococcus pneumoniae has emerged as an important worldwide problem. Beta-lactam-resistant pneumococci also can be resistant to erythromycin, trimethoprim/sulfamethoxazole and tetracycline and are uniformly susceptible to vancomycin and imipenem. Crowded conditions (e.g. daycare centers, hospitals, military barracks and prisons) and prior beta-lactam antibiotic therapy are the principal predisposing factors to colonization and disease. To date the two conditions caused by penicillin- and cephalosporin-resistant pneumococci that have been especially difficult to treat are acute otitis media and meningitis. Concentrations of beta-lactams in cerebrospinal fluid and middle ear fluid are usually inadequate to achieve prompt eradication of some intermediately resistant and most highly resistant pneumococcal strains. Use of unconventional therapeutic agents such as ceftriaxone or clindamycin for acute otitis media and vancomycin or rifampin for meningitis may be necessary. Control of this global problem will require innovative methods to reduce the selective pressure that results from widespread antibiotic use and to develop effective pneumococcal vaccines that are immunogenic in young infants.

Epithelial antibiotics induced at sites of inflammation

Abstract: The role of antimicrobial peptides in epithelial defense is not fully understood. An epithelial beta-defensin, lingual antimicrobial peptide (LAP), was isolated from bovine tongue and the corresponding complementary DNA cloned. LAP showed a broad spectrum of antibacterial and antifungal activities. LAP messenger RNA abundance was markedly increased in the epithelium surrounding naturally occurring tongue lesions. This increase coincided with the cellular hallmarks of acute and chronic inflammation in the underlying lamina propria, supporting a role for epithelial antimicrobial peptides as integral components of the inflammatory response.

Viral etiology and epidemiology of acute lower respiratory tract infections in Korean children.

Abstract: Viral etiologic agents of acute lower respiratory tract infections were studied from November, 1990, through April, 1994, in Korean children From 712 children who visited or were admitted to Seoul National University Children's Hospital because of acute lower respiratory tract infections, 804 nasal

Beneficial effects of dexamethasone in children with pneumococcal meningitis

Abstract: Fifty-six children older than 2 years with meningitis caused by Streptococcus pneumoniae were enrolled in a prospective, double blind, placebo-controlled trial to evaluate the efficacy of dexamethasone therapy in addition to antimicrobial therapy. Twenty-nine of 56 received dexamethasone (0.6 mg/kg/day iv, divided into 4 daily doses for 4 days) and the remaining 27 received placebo. At the beginning of therapy the clinical and laboratory characteristics of the patients in the treatment groups were comparable, except for the Glasgow coma score (P = 0.004), which was lower in the dexamethasone group. Patients were examined daily during hospitalization and 6 weeks after discharge from the hospital. Hearing was assessed 6 weeks after discharge by means of pure tone audiometry. Two patients in the dexamethasone group and one patient in the placebo group died. There were no differences between the two groups with regard to the duration of fever, the incidence of secondary fever and electrolyte imbalance, seizure activities occurring during hospitalization and rash. Although the differences were statistically insignificant, moderate or severe unilateral or bilateral sensorineural hearing loss at 6 weeks and the overall neurologic sequelae, including hearing loss, at 1 year were higher in the placebo group, at 23% vs. 7.4% (P = 0.11) and 26.9% vs. 7.4% (P = 0.062), respectively. At 3 months after discharge, because of the improvement in hearing loss in one dexamethasone-treated patient the incidence of hearing impairment was significantly less than that in the placebo group, at 3.7% vs. 23%, respectively (P = 0.044). No improvement in hearing loss was observed after 3 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Cerebrospinal fluid shunt infections in children

Abstract: We reviewed cerebrospinal fluid (CSF) shunt infections treated in the Royal Children's Hospital, Melbourne from 1981 to 1991. Forty-one episodes of CSF shunt infection were found after 900 shunt operations, an infection rate of 4.5%. Clinical symptoms were nonspecific in 31.7% of episodes, and in 17.1% of episodes the initial CSF sample was normal on microscopy and biochemistry, although a pathogen was isolated on culture. Most episodes occurred within 4 months of the last operation on the shunt, the exception being infections caused by Haemophilus influenzae. Four patients died during treatment, but none could be attributed to infection alone. Treatment of suspected CSF shunt infection should not be withheld because of lack of firm clinical diagnosis or normal CSF microscopy, and episodes occurring more than 4 months after the last operation on the CSF shunt should receive antibiotic cover for H. influenzae.

A population-based serologic survey of immunity to tetanus in the united states

Abstract: BACKGROUND Vaccination rates are frequently considered a surrogate measure of protection. To provide more accurate estimates, serum levels of antibody against tetanus were measured as part of the third National Health and Nutrition Examination Survey (NHANES III), which studied a representative sample of the civilian, noninstitutionalized population of the United States. METHODS We measured tetanus antitoxin using a solid-phase enzyme immunoassay in serum samples from 10,618 persons six years of age and older who were examined during phase 1 of NHANES III in 1988 to 1991. RESULTS Overall, 69.7 percent of Americans six years of age and older had protective levels of tetanus antibodies (> 0.15 IU per milliliter). The rate decreased from 87.7 percent among those 6 to 11 years of age to 27.8 percent among those 70 years of age or older. Among children 6 to 16 years of age, 82.2 percent had protective levels of tetanus antibodies, with little variation according to race or ethnicity. More men than women were immune (79.0 percent vs. 62.4 percent). Mexican Americans had a significantly lower rate of immunity (57.9 percent, P < 0.05) than either non-Hispanic whites (72.7 percent) or non-Hispanic blacks (68.1 percent). Those with a history of military service, higher levels of education, or incomes above the poverty level were more likely to have protective antibody levels. Although the prevalence of immunity declined rapidly starting at the age of 40 years, most of the 107 cases of tetanus (with 20 deaths) reported in 1989 and 1990 occurred in persons 60 years of age or older. CONCLUSIONS Despite the fact that effective vaccines against tetanus have been available since the 1940s, many Americans do not have immunity to tetanus, and the rates are lowest among the elderly. There is an excellent correlation between vaccination rates (96 percent) and immunity (96 percent) among six-year-olds. However, antibody levels decline over time, and one fifth of older children (10 to 16 years of age) do not have protective antibody levels.

Neonatal Candida parapsilosis outbreak with a high case fatality rate.

Abstract: A Candida parapsilosis outbreak of 58 cases in a neonatal intensive care unit lasted for 55 months Patients infected by or colonized with C parapsilosis were mainly very low birth weight infants (birth weight < 1500 g) Their mean birth weight was 817 g and their mean gestational age was 28 weeks Statistical analysis including logistic regression confirmed that prematurity was the main risk factor The analysis also suggested that C parapsilosis infection (or colonization) was associated with a poor prognosis In infants with gestational age < 29 weeks the risk for death in C parapsilosis-infected patients was 16-fold greater than in those with no C parapsilosis infection The case fatality rate of C parapsilosis patients was higher than that of the controls (9 of 23 vs 1 of 40; P < 00001) The outbreak was most likely a result of cross-infection because C parapsilosis could be isolated only from the patients and from the hands of four nurses immediately after they had cared for a colonized patient Cessation of the outbreak was temporally associated with long term parenteral fluconazole (6 mg/kg/day) prophylaxis

Serial serum C-reactive protein to monitor recovery from acute hematogenous osteomyelitis in children.

Abstract: Serial C-reactive protein (CRP) and erythrocyte sedimentation rate determinations were compared with clinical course and outcome at 1 to 2 months in 63 children with acute hematogenous osteomyelitis. High CRP values (163 \pm 108 mg/liter) on admission began to descend after the second day of treatme

Anti-capsular polysaccharide antibody concentrations in saliva after immunization with Haemophilus influenzae type b conjugate vaccines.

Abstract: IgG and IgA antibodies to Haemophilus influenzae type b (Hib) capsular polysaccharide (PS) were measured in saliva of 7- to 19-month-old children after vaccination with 2 or 3 doses of Hib conjugate vaccine. Both the concentration and the prevalence of these antibodies were higher after 3 than after 2 doses of vaccine. The presence and concentration of IgG Hib PS antibodies in saliva correlated with their concentration in serum. Fifty-four percent (20 of 37) of the children with serum IgG concentrations higher than 30 micrograms/ml had detectable salivary IgG, whereas the 21 children with a low serum IgG concentration (< 3 micrograms/ml) had no IgG in saliva. The IgA anti-Hib PS in saliva was mainly secretory and was found in saliva of 29% (19 of 65) of the children who had no detectable serum IgA anti-Hib PS. The results suggest that the IgG anti-Hib PS in saliva was derived from serum, whereas the IgA antibodies were locally produced. The Hib PS antibodies on mucosa are suggested to be responsible for the reduction of Hib carriage observed among children vaccinated with Haemophilus type b conjugates.

Fluid restriction does not improve the outcome of acute meningitis

Abstract: The objective of this prospective study was to examine the effect of fluid restriction on body water and the outcome of children with acute meningitis. Fifty consecutively hospitalized children with acute meningitis, divided into two groups (A, without hyponatremia ; and B, with hyponatremia), were randomly assigned to receive either normal maintenance (M) or restricted (R subgroup) (65 to 70% of M subgroup) fluids during the first 48 hours. Total body water, extracellular water (ECW), serum and urinary sodium and plasma and urinary osmolality were measured at admission and after 48 hours. In both groups children receiving restricted fluids showed a significant decrease in the mean total body water and ECW whereas body water remained unchanged in those on maintenance fluids. Children having an ECW reduction of 10 ml/kg or more in 48 hours had a significantly lower intact survival (10 of 28, 36%) than those with <10 ml/kg or no reduction of ECW (15 of 22, 64%) (P < 0.05). The mortality was also higher in the former (7 of 28, 25%) than in the latter (2 of 22, 9%). On multiple stepwise regression analysis, ECW volume at admission (partial r 2 0.20), ECW loss in 48 hours (partial r 2 0.13) and plasma osmolality at admission (partial r 2 0.22) were significantly related to outcome. We conclude that fluid restriction does not improve the outcome of acute meningitis. Indeed a decrease in ECW volume at 48 hours increases the likelihood of adverse outcome.