Showing papers in "Pediatric Infectious Disease Journal in 1997"

Clinical applications of C-reactive protein in pediatrics.

Abstract: The body of literature concerning studies of the applications of CRP measurement in the pediatric population continues to grow. Based on current data serial CRP measurements appear to be most useful for monitoring patient response to therapy after the primary diagnosis of invasive infectious or inflammatory diseases, for monitoring patients after major surgical procedures and those with serious burns. Monitoring CRP over time may be used to assess for recrudescent disease, a secondary process or ineffective therapy. In addition CRP appears to be suited to most applications for which the ESR is used but offers many advantages. At present there are no objective outcome-based clinical trial data to justify using CRP values alone, whether elevated or normal, as a basis for management decisions regarding instituting or withholding antimicrobial therapy, or its early discontinuance for patients suspected of having neonatal sepsis, meningitis, bacteremia or pneumonia, regardless of immune status. In addition, because of significant inconsistencies among studies for which CRP has been applied to differential diagnosis of bacterial vs. viral diseases, including meningitis, acute otitis media and lower respiratory tract infection, we cannot recommend it for this purpose. Data do not support a role for CRP in differential diagnosis of acute appendicitis or for localizing urinary tract infections.

Bacteriotherapy with Lactobacillus reuteri in rotavirus gastroenteritis.

Abstract: Background.Certain lactic acid bacteria may accelerate recovery from acute diarrhea. Lactobacillus reuteri is a commonly occurring Lactobacillus species with therapeutic potential in diarrhea.Design.Prospective, randomized, placebo-controlled trial in two hospitals.Methods.Children between 6 and 36

The expanding spectrum of Bartonella infections : II. Cat scratch disease.

Abstract: Recent advancements and developments in molecular biotechnology have allowed more precise reclassification of many microorganisms. With the use of these new taxonomy tools, several organisms previously thought to belong to other genera have been recently described as bartonellae. Of the 11 organisms now described as Bartonella spp., only four have been shown to be pathogenic for humans. Table 1 lists the four Bartonella human pathogens along with the their known epidemiology and the scope and range of disease associated with each. All are now considered to be bacteria and can be grown on blood-enriched agar although primary isolation in some may best be achieved in cell tissue culture. B. bacilliformis infection is limited to certain geographic regions in South America where the only human reservoir and the sandfly vector(s) that spreads the disease reside together. Specific antibiotic treatment is dramatically effective in treating the highly fatal, acute intraerythrocytic hemolytic form of the disease, but their effectiveness in treating the vascular proliferative forms (verruga peruana) or the chronic asymptomatic, bacteremic, carrier state of the disease has not been effective. This disease should remain confined to its present endemic geographic areas in South American unless asymptomatic bacteremic persons from these areas migrate to areas where sandflies and humans exist that are capable of establishing this infection in new endemic areas. B. quintana and B. henselae cause a wide range of clinical diseases in humans, the type and extent of which varies significantly with the immune status of the host. In immunocompetent hosts the pathologic response is granulomatous, suppurative, extracellular and intracellular, generally self-limited and usually unresponsive to antibiotic treatment, even to those drugs to which the organism is shown to be sensitive in vitro. In contrast, in immunocompromised hosts the pathologic response is vasculoproliferative, organisms may be seen intracellularly but they are often seen in abundance in extracellular clumps and infection is usually progressive and fatal unless treated. In these patients clinical response to treatment with drugs that are effective in vitro against these organisms has usually been dramatic. Of these agents those that penetrate cells and are found in high concentrations intracellularly, such as erythromycin, clarithromycin, azithromycin, rifampin, doxycycline and gentamicin, appear to be most effective. These agents not only appear to provide the most dramatic treatment response in patients with BA, BP and PRFB and other manifestations of B. henselae (and B. quintana as well) in immunocompromised persons, they appear to be the most promising agents for treatment of persons with both typical and atypical CSD. Further studies will be necessary to more clearly elucidated the mechanisms responsible for the diverse clinical presentations of infection with these organisms in human hosts relative to their immune status. In addition clarification of the epidemiology of B. elizabethae infections in humans may be helpful in understanding the nature of infection with Bartonella organisms.

Urinary tract infections in young febrile children

Abstract: UTI is a common and important clinical problem in infants and young children, with a prevalence of 5.3% among febrile infants seen in our Emergency Department. White females with rectal temperature > or = 39 degrees C are at particularly high risk (prevalence, 17%). Several studies have highlighted the limitations of the standard urinalysis for identifying UTI in infants and young children and have recommended performance of both urinalysis and urine culture. Alternative methods such as dipstick urinalysis, although attractive because of ease of performance, are inadequate as a screen for UTI. Hemocytometer WBC counts of an uncentrifuged urine specimen can be performed in an office or hospital-based laboratory with minimal training. Performance of Gram-stained smears, however, is most appropriate for the hospital-based laboratory. In the hospital setting where both tests can readily be performed, the positive predictive value of the combination of pyuria and bacteriuria (85%) allows prompt institution of antimicrobial therapy before culture results are available, whereas the lower positive predictive value of the single finding of either pyuria or bacteriuria (40%) justifies delaying treatment decisions until culture results are available. In the office setting where hemocytometer counts can easily be performed, culturing only specimens with pyuria and those of children presumptively treated with antimicrobials will result in the identification of almost all patients with true UTI, sparing large health care expenditures. Although the urine culture is traditionally regarded as the gold standard of UTI, positive urine cultures may occur secondary to contamination or in cases of ABU, leading to a false diagnosis of UTI. In contrast we found pyuria to be a reliable marker to discriminate infection from colonization of the urinary tract. The sustained absence of an inflammatory response, on repeat UA within 24 h, constitutes strong evidence that infection is absent. Management of ABU is controversial; many experts recommend withholding antibiotics because eradication of low virulence organisms may be followed by colonization with more virulent species that cause pyelonephritis. Preliminary results of our ongoing treatment trial suggest that management of young febrile children with UTI as outpatients receiving oral cefixime is as efficacious as inpatient management with intravenous cefotaxime. Results of renal ultrasound and DMSA scan at the time of infection have not modified management in any patient. Accordingly selective rather than routine performance of ultrasound is recommended. A voiding cystourethrogram at 1 month and a DMSA scan 6 months later have been valuable in identifying patients with vesicoureteral reflux and renal scarring, respectively. Among patients initially identified as having acute pyelonephritis, the incidence of renal scarring at 6 months has been substantially more frequent (approximately 40%) than we had expected. However, the long term implications of small scars identified with renal scintigraphy remain to be determined.

Influenza virus infections in infants.

Abstract: Background.Universal immunization of children with live attenuated cold recombinant vaccine has been proposed. The renewed recommendation for maternal immunization with influenza vaccine should increase the amount of antibody transmitted to the infant and postpone the need for active immunization. T

Patient density, nurse-to-patient ratio and nosocomial infection risk in a pediatric cardiac intensive care unit

Abstract: Background.An investigation of a Serratia marcescens outbreak in a pediatric cardiac intensive care unit (CICU) suggested that under-staffing or overcrowding might have been underlying risk factors.Objective.To assess the effect of fluctuations in CICU nurse staffing levels and patient census on CIC

Reduction of pneumococcal nasopharyngeal carriage in early infancy after immunization with tetravalent pneumococcal vaccines conjugated to either tetanus toxoid or diphtheria toxoid

Abstract: Background.Pneumococcal nasopharyngeal colonization is important for transmission of the organisms. We assessed the ability of two tetravalent conjugate vaccines administered in early infancy to prevent carriage of vaccine-related pneumococci.Methods.A vaccine containing pneumococcal type 6B, 14, 19

Tobacco smoke as a risk factor for meningococcal disease.

Abstract: Background. Since 1992 the US Pacific Northwest has experienced a substantial increase in the incidence of serogroup B meningococcal disease. The current meningococcal polysaccharide vaccine is poorly immunogenic in young children and does not protect against N. meningitidis serogroup B. Defining alternative approaches to the prevention and control of meningococcal disease is of considerable public health importance. Methods. We performed a case-control study comparing 129 patients in Oregon and southwest Washington with 274 age- and area-matched controls. We used conditional logistic regression analysis to determine which exposures remained associated with disease after adjusting for other risk factors and confounders and calculated the proportion of disease attributable to modifiable exposures. Results. After adjustment for all other significant exposures identified, having a mother who smokes was the strongest independent risk factor for invasive meningococcal disease in children <18 years of age [odds ratio (OR), 3.8; 95% confidence interval (CI) 1.6 to 8.9)], with 37% (CI 15 to 65) of all cases in this age group potentially attributable to maternal smoking. Adult patients were more likely than controls to have a chronic underlying illness (OR 10.8, CI 2.7 to 43.3), passive tobacco smoke exposure (OR 2.5, CI 0.9 to 6.9) and to smoke tobacco (OR 2.4, CI 0.9 to 6.6). Dose-response effects were seen for passive smoke exposure and risk of disease in all age groups. Conclusion. Tobacco smoke exposure independently increases the risk of developing meningococcal disease.

Success of a scabies control program in an Australian Aboriginal community

Abstract: Objective.To adapt, implement and evaluate a model of scabies control in an Australian Aboriginal community.Methods.After initially examining the population, we offered all residents treatment with 5% permethrin cream. Visits were made during the ensuing 25 months to rescreen and to treat newcases o

Frequency of low level bacteremia in infants from birth to two months of age

Abstract: The frequency of low level bacteremia (≤10 colony-forming units/ml) in infants from birth to 2 months of age and the optimal volume of blood and number of blood cultures to be collected have not been well-documented. During 1991 guidelines at this hospital for collection of blood for culture from these infants were revised. Blood from each infant with suspected bacteremia was usually inoculated into an Isolator 1.5 Microbial Tube® (1.5 ml of blood) and a bottle of anaerobic broth (0.5 to 3.0 ml of blood). The use of a second Isolator tube and the total blood volume recommended for culture (2 to 6 ml) depended on the weight and total blood volume of each infant. Forty-four bacterial pathogens were recovered from the blood of 40 (2.5%) of 1589 infants. Of 34 infants from whose blood the concentration of pathogens could be determined, 23 (68%) had low level bacteremia. Of 50 isolates of pathogens recovered from Isolator cultures, 32 (64%) were detected in counts of ≤10 colony-forming units/ml. When 2 or 3 blood culture devices were inoculated with a total of 2 to 6 ml of blood from each infant, significantly more cases of bacteremia were detected (34 (3.0%) of 1126 infants had positive blood cultures) than when only one culture device containing ≤1.5 ml of blood was used (2 (0.5%) of 398 infants had positive blood cultures; P = 0.008). However, when 4 or more culture devices were inoculated with a total of >6 ml of blood from each infant (5 (7.7%) of 65 infants had positive blood cultures), the difference in recovery of pathogens compared with the culturing of from 2 to 6 ml of blood per infant was not significant (P = 0.089). Low level bacteremia was common in our infants' patient population. The culturing of up to 6 ml of blood which represented up to 4.5% of an infant's total blood volume was required for detection of the pathogens.

Ciprofloxacin in pediatrics: worldwide clinical experience based on compassionate use--safety report.

Abstract: Background. Quinolone-induced cartilage toxicity has been observed in experimental juvenile animal studies and is species- and dose-specific. Accordingly these findings have led to the contraindication of fluoroquinolones in children. Previous data in 634 adolescents and children treated with compassionate use ciprofloxacin demonstrated low rates of reversible arthralgia and a safety profile similar to that for adult patients. Objective. This report describes the safety findings in 1795 children who received 2030 treatment courses of intravenous or oral ciprofloxacin. Results. The average doses of intravenous and oral ciprofloxacin in the study population were 8 and 25 mg/kg/day, respectively. Treatment-associated events were reported in 10.9% of children receiving oral ciprofloxacin compared with 18.9% among intravenous recipients. Overall arthralgia occurred during 31 ciprofloxacin treatment courses (1.5%) and the majority of events were of mild to moderate severity and resolved without intervention. More than 60% of arthralgia episodes were in children with cystic fibrosis. Conclusion. The adverse event pattern in children receiving ciprofloxacin in this analysis was similar to that observed in adults. Rates of reversible arthralgia were low and unchanged from previously published surveillance data in children.

Causative pathogens, antibiotic resistance and therapeutic considerations in acute otitis media.

Abstract: Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis are the most frequently isolated pathogens in patients with acute otitis media (AOM). Other potential causative pathogens include Streptococcus pyogenes in older children and Chlamydia pneumoniae in younger children. The recent emergence of penicillin-resistant S. pneumoniae and the increasing frequency of beta-lactamase-producing strains of M. catarrhalis and H. influenzae are creating concerns regarding the use of amoxicillin as traditional first line empiric therapy for AOM in younger children. Both the in vitro antibiotic activity against these more resistant causative pathogens and the antibiotic concentrations achieved in middle ear fluid must be considered when selecting antibiotics for treatment of refractory AOM. The newer macrolides, azithromycin and clarithromycin, provide reasonable in vitro coverage against penicillin-resistant S. pneumoniae and beta-lactamase-producing H. influenzae, although azithromycin is more active against the latter. Both drugs also achieve notably higher, sustained concentrations in middle ear fluid than do beta-lactam antibiotics. Thus the newer macrolides represent important new rational alternatives for the management of AOM.

Equivalent efficacy and reduced occurrence of diarrhea from a new formulation of amoxicillin/clavulanate potassium (Augmentin) for treatment of acute otitis media in children.

Abstract: Objective.To compare the safety and efficacy, in treating acute otitis media (AOM) in children, of a new formulation of amoxicillin/clavulanate potassium (Augmentin®) oral suspension providing 45/6.4 mg/kg/day and administered twice daily (bid) for 5 and 10 days, respectively, with the safety and ef

Shortened course of antibiotic therapy for acute otitis media, sinusitis and tonsillopharyngitis

Abstract: There is now increasing pressure to contain health care expenditure by providing patients with more cost-effective treatments. For bacterial infections, it is well-recognized that patients benefit from effective antibiotics, without which they may be at increased risk of morbidity or mortality. Trea

Epidemiology of pertussis.

Abstract: Throughout this century infants and young children have remained most susceptible to pertussis-related morbidity and mortality. In recent years infants younger than 6 months who are not old enough to have received three doses of the diphtheria-tetanus-pertussis vaccine and under-vaccinated preschool children have been at highest risk for pertussis-associated complications. Pertussis infection rates dropped dramatically after the whole cell pertussis vaccine came into widespread use, and an all-time low in reported cases in the United States was reached in 1976. Just as widespread immunization helped control the incidence of pertussis, it has probably been the primary factor in reducing pertussis-related mortality. Despite a stable or increasing vaccination rate in the United States since 1962, pertussis infection rates have been rising since the early 1980s. In 1993 the number of cases of pertussis reported represented an 82% increase over reported cases during the previous year and the highest incidence of pertussis since 1967. In 1993 pertussis became the most commonly reported vaccine-preventable disease among children in the United States younger than 5 years old. Growth of a susceptible adult population appears to be the primary factor contributing to the resurgence of pertussis in the United States; widespread immunization has reduced the potential for individuals to acquire exposure-induced immunity. It has been suggested that the majority of patients now infected with Bordetella pertussis are adults. Several studies have confirmed the importance of pertussis as the cause of persistent cough among teenagers and adults. As the diagnosis of pertussis goes unrecognized in these older patients and treatment is delayed or administered only partially, adolescents and adults have become an important source for transmission of B. pertussis infection to other household members, particularly infants and young children who are not adequately immunized.

Antimicrobial prescribing for acute purulent rhinitis in children: a survey of pediatricians and family practitioners.

Abstract: Background.The tenet that children with acute purulent rhinitis need not be treated with antibiotics unless drainage persists for 7 to 10 days is taught to medical students and residents in primary care specialties but may not be adhered to in actual clinical practice. Because of the global increase

Safety and immunogenicity of tetravalent pneumococcal vaccines containing 6B, 14, 19F and 23F polysaccharides conjugated to either tetanus toxoid or diphtheria toxoid in young infants and their boosterability by native polysaccharide antigens.

Abstract: Background New vaccines against pneumococcal infections in infancy are needed. We assessed in young infants the safety and immunogenicity of two tetravalent vaccines containing pneumococcal 6B, 14, 19F and 23F polysaccharides conjugated to either tetanus toxoid (Pnc-T) or diphtheria toxoid (Pnc-D). Methods Pnc-T or Pnc-D containing 3 microg of polysaccharide of each of the four pneumococcal polysaccharides or placebo were given intramuscularly in a double blinded fashion (25 infants per group) at 2, 4 and 6 months of age. At 12 months of age all 75 children were boosted with a 23-valent nonconjugate polysaccharide pneumococcal vaccine. Serum type-specific anticapsular antibody concentrations were measured at 2, 4, 6, 7, 12 and 13 months of age. Adverse events occurring within 72 h after each injection were recorded. Results Both Pnc-T and Pnc-D were well-tolerated. Pnc-T and Pnc-D had higher antibody concentrations compared with placebo after primary immunity (type 6B, 1.66, 1.40 and 0.60 microg/ml, respectively; type 14, 4.81, 2.65 and 2.22 microg/ml, respectively; type 19F, 2.40, 3.48 and 0.83 microg/ml, respectively; type 23F, 0.96, 0.44 and 0.35 microg/ml, respectively). Proportions of infants with concentrations above 1.0 microg/ml were also higher in the vaccine recipients than in those given placebo. After booster with the nonconjugate polysaccharide vaccine, both geometric antibody concentration and proportion with concentrations > or =1.0 microg/ml were significantly higher among either Pnc-T or Pnc-D recipients than among placebo recipients. Conclusions Both Pnc-T and Pnc-D were well-tolerated, induced serotype-specific anticapsular antibodies and induced immunologic memory.

Pharmacokinetics and pharmacodynamics of newer macrolides.

Abstract: Requirements for the antimicrobial activity of an antibiotic are: (1) binding of the drug to a specific site in the bacteria; (2) occupation of a critical number of binding sites; and (3) persistence at these binding sites for a sufficient time. With concentration-dependent antibiotics the ratio of the peak serum drug concentration to the MIC of a pathogen is the primary determinant of bacterial killing; with concentration-independent antibiotics it is the length of time serum concentration remains above the MIC, rather than the peak level. The pharmacokinetics of the new macrolides azithromycin and clarithromycin differ notably from those of conventional antibiotics in a more rapid and extensive distribution to body tissues. Because of these unique tissue pharmacokinetics, the pharmacodynamic models that apply to other classes of antibiotics may not explain the antimicrobial activity and clinical efficacy of azithromycin and clarithromycin.

Mycobacterial lung disease in cystic fibrosis: a prospective study

Abstract: Background.Patients with cystic fibrosis (CF) may be predisposed to airway infections with unusual organisms, such as mycobacteria. The aim of the study was to determine the incidence and clinical picture of mycobacterial infection in CF children.Methods.At least 2 acid-fast bacillus (AFB) smears an

Clinical, virologic and immunologic responses of children with advanced human immunodeficiency virus type 1 disease treated with protease inhibitors.

Abstract: Objective. To determine the effects of combination antiretroviral therapy including a protease inhibitor (PI combination therapy) in children with advanced HIV-1 disease. Study design. An observational study of HIV-1 plasma RNA, lymphocyte subsets, delayed type hypersensitivity and physical growth after initiation of PI combination therapy. Results. In nine children the median HIV-1 plasma RNA decreased 1.7 log 10 (mean, 1.57; range, 0.7 to 2.2) following PI combination therapy and CD4 cells increased a median of 499 (mean, 528; range, 9 to 1088) cells/μl. A rebound of RNA, associated with the development of resistance to the PI, occurred in three subjects. Three of six children were no longer anergic and all nine achieved normal weight-growth velocities. Ritonavir was well-tolerated, despite its bitter taste; however, four of five children treated with indinavir developed renal complications. Conclusions. PI combination therapy in children with advanced HIV-1 disease was associated with a decrease in HIV-1 RNA, improved immunologic measures and normal or better weight gain. Of concern was the rebound in plasma HIV-1 associated with resistance to the PI observed in one-third of patients. This emphasizes the need for larger studies to define optimal PI containing regimens with long term efficacy in children.

Visualizing geographic and temporal trends in rotavirus activity in the United States, 1991 to 1996

Abstract: Background. Rotavirus is the leading cause of severe pediatric gastroenteritis worldwide. A vaccine may soon be licensed for use in the United States to prevent this disease. To characterize US geographic and temporal trends in rotavirus activity, we made contour maps showing the timing of peak rotavirus activity. Methods. From July, 1991, through June, 1996, 79 laboratories participating in the National Respiratory and Enteric Virus Surveillance System reported on a weekly basis the number of stool specimens that tested positive for rotavirus. The peak weeks in rotavirus detections from each laboratory were mapped using kriging, a modeling technique originally developed for geostatis-tics. Results. During the 5-year period 118 716 fecal specimens were examined, of which 27 616 (23%) were positive for rotavirus. Timing of rotavirus activity varied by geographic location in a characteristic pattern in which peak activity occurred first in the Southwest from October through December and last in the Northeast in April or May. The Northwest exhibited considerable year-to-year variability (range, December to May) in the timing of peak activity, whereas the temporal pattern in the remainder of the contiguous 48 states was relatively constant. Conclusion. Kriging is a useful method for visualizing geographic and temporal trends in rotavirus activity in the United States. This analysis confirmed trends reported in previous years, and it also identified unexpected variability in the timing of peak rotavirus activity in the Northwest. The causes of the seasonal differences in rotavirus activity by region are unknown. Tracking of laboratory detections of rotavirus may provide an effective surveillance tool to assess the impact of a rotavirus vaccination campaign in the United States.

Effect of rapid viral diagnosis on the management of children hospitalized with lower respiratory tract infection

Abstract: Background.Although rapid viral tests are commonly used in children with lower respiratory tract infection, their effect on patient management has not been studied.Objectives.To examine how physicians utilize an enzyme immunoassay for respiratory syncytial virus (RSV EIA) and a centrifugation-enh

Vitamin C intake and susceptibility to pneumonia

Abstract: Feeding guinea pigs a diet deficient in vitamin C increases their susceptibility to infections, which may be caused by the effects of the vitamin on T lymphocytes and phagocytes (1). A few studies suggest that vitamin C intake affects human susceptibility to infections to some as yet unknown extent (1). In particular four trials involving British males showed an average 30% decrease in common cold incidence in groups given vitamin C, suggesting effects in certain population groups (2). Controlled trials have consistently found that large dose vitamin C supplementation alleviates the symptoms of the common cold, but the mechanism of this effect is poorly understood (1-3). Here we assess the relation of vitamin C intake to the incidence of pneumonia by analyzing findings from three controlled trials. The literature on vitamin C and infectious diseases has already been explored thoroughly (1,2) and all controlled trials that reported the number of pneumonia cases in the study groups were selected for this analysis (Table 1). Fisher's exact test was used to calculate the one-tailed mid-P values (4) for each set of data separately. Exact hypothesis test for several 2×2 contingency tables (4) was used to calculate a one-tailed mid-P value for the combined data of two or three studies. Three controlled trials have reported the number of pneumonia cases in a vitamin C group and a control group, each trial finding a considerably lower incidence of pneumonia in the group given vitamin C (Table 1). Glazebrook and Thomson (5) studied schoolboys (15 to 20 years old) in an institution in the UK. No cases of pneumonia occurred in the vitamin C group. Placebo was not used, but because the vitamin was added to the food in the kitchen the placebo effect does not seem relevant. For practical reasons the subjects were not randomly allocated to the study groups, but certain administrative divisions were served vitamin-supplemented food and others remained as controls. A tonsillitis epidemic that affected all divisions uniformly the year before had shown that they could not be considered discrete units (5). Kimbarowski and Mokrow (6) in the former Soviet Union investigated military recruits who had acquired influenza A infection. The number of pneumonia cases was significantly smaller in the vitamin C group. Placebo was not used and the allocation method was not described. Nevertheless the distribution of influenza severity was similar in both study groups. Pitt and Costrini (7), primarily interested in whether vitamin C affects the common cold, carried out a randomized double blind placebo-controlled trial with military recruits in a training camp in the United States. Pneumonia incidence was substantially lower in the vitamin C group. Each of these three trials found a •80% lower incidence of pneumonia in the vitamin C group. It is highly unlikely that the differences reported between the study groups in favor of the vitamin C groups would have occurred purely by chance (P = 0.00002). The study of Pitt and Costrini (7) is the most carefully conducted of the three, but the size of the effect is similar to the others. Thus there is no obvious tendency for the technically superior trial to show a smaller effect. If the Kimbarowski-Mokrow study is excluded from the analysis because it is technically the least satisfactory, there is still a highly significant difference in the pneumonia incidence between the vitamin C and control groups in the remaining two trials (P = 0.0004). The notion that vitamin C intake may effect various infections is an old one (1,5,8,9). In 1917 Hess (10) concluded from his clinical experience with children that one of the important consequences of vitamin C deficiency was a markedly increased susceptibility to infection, pneumonia being a particular danger. In 1939 Sabin (11) reported about 5 cases of pneumonia in 25 rhesus monkeys deficient in

Tuberculosis in the newborn: an emerging disease

Abstract: Background. In spite of the global increase in tuberculosis, which is in part fueled by the HIV pandemic, tuberculosis in the perinatal period is rare, and to date it has not been directly associated with maternal or neonatal HIV infection. Objectives. To detect tuberculosis in newborns from a province with epidemics of both tuberculosis and HIV infection and to analyze the profile of tuberculosis in their mothers. Methods. At King Edward VIII Hospital, in KwaZulu Natal, South Africa, during a 1-year period all neonates at the neonatal unit in whom a differential diagnosis of tuberculosis was considered were investigated. The clinical profiles, short term outcome and relationship to maternal tuberculosis and HIV infection were determined for those neonates in whom the diagnosis of tuberculosis was confirmed. Results. From the investigation of 77 neonates 11 with culture confirmed perinatal tuberculosis were identified. Six of these infants were born to mothers who had HIV and tuberculosis coinfection. Six of the 11 neonates could be classified as congenital tuberculosis. The predominant clinical findings were progressive pneumonia (9 of 11), pyrexia (9 of 11), growth retardation (7 of 11), hepatomegaly (6 of 11), splenomegaly (4 of 11) and meningitis (2 of 11). Seven of their mothers had evidence of current or past tuberculosis or had close contact with a tuberculosis case. One neonate and two mothers died within the first 3 months. Conclusions. This is the first report of perinatal tuberculosis in association with maternal HIV and tuberculosis coinfection.

Prevalence of Candida species in hospital-acquired urinary tract infections in a neonatal intensive care unit.

Abstract: ObjectiveTo determine the prevalence and clinical features of Candida species in hospital-acquired urinary tract infections (UTI) in a neonatal intensive care unitDesignA retrospective study was conducted of hospital-acquired UTI occurring in infants admitted to a neonatal intensive care unit bet

Comparative efficacy of acellular pertussis vaccines: an analysis of recent trials.

Abstract: Diphtheria-tetanus-acellular pertussis vaccines have been licensed in the United States since 1991. Compared with the whole cell pertussis component diphtheria-tetanus-pertussis vaccine, the diphtheria-tetanus-acellular pertussis vaccines were found in reactogenicity and immunogenicity studies to be immunogenic with respect to their specific antigen content and to be associated with less severe and less frequent adverse reactions. A case definition of pertussis was developed by the World Health Organization for use in vaccine efficacy trials, but this definition eliminates some laboratory-confirmed cases from efficacy calculations. Because these cases are more common in vaccinees than in controls, vaccine efficacy appears better than it truly is whereas less effective vaccines seem comparable with their more effective counterparts. In addition observer bias may contribute to the appearance of enhanced efficacy of the less effective vaccines, which tend to prevent typical but not mild disease. When analyzing efficacy based on prevention of laboratory-confirmed pertussis with cough > or = 7 days, single component pertussis toxin (PT) toxoid vaccines were found to be less effective than two-component PT toxoid/filamentous hemagglutinin vaccines, and three- or four-component vaccines containing pertactin in addition to PT toxoid and filamentous hemagglutinin were more effective than either the single-component or two-component vaccines.

Interleukin 6 in neonates with early and late onset infection.

Abstract: OBJECTIVE To assess the utility of determining interleukin 6 (IL-6) concentrations for diagnosing early (< or = 48 h of life) and late onset infection in a neonatal intensive care setting. METHODS We measured serum IL-6 values in five groups of neonates on both postnatal Days 1 and 2 (early sampling): Group 1, patients with clinical and microbiologic evidence of early onset infection; Group 2, patients with negative body fluid cultures but strong evidence of infection (clinical septicemia); Group 3, patients without clinical and microbiologic evidence of infection; Group 4, patients in whom infection could be neither confirmed nor excluded; and Group 5, healthy neonates with a normal postnatal course. We also measured IL-6 values in older neonates who during their hospital stay developed systemic infection (late sampling). Three controls matched for duration of hospital stay and birth date were chosen for each patient. RESULTS On postnatal Day 1 IL-6 values were elevated in all four patient groups compared with those in healthy neonates (P < 0.05 by analysis of variance (ANOVA)). There were no significant differences found among patient groups. On postnatal Day 2 IL-6 concentrations were persistently elevated in Groups 1 and 2 compared with values from those in Group 3, Group 4 and healthy controls (P < 0.01). At this time no significant differences in IL-6 values were found between uninfected symptomatic patients (Group 3), patients with uncertain findings (Group 4) and healthy controls. IL-6 concentrations were significantly higher in patients with late onset infection at presentation than in the patient controls (P < 0.0001) and returned to low values in those who recovered from infection. CONCLUSIONS There are differences in the serum concentrations of IL-6 that can be helpful in detecting early and late onset infection in preterm and term neonates. During the first 48 h of life serial IL-6 determinations are necessary so as not to overdiagnose infection in a neonatal intensive care setting.

Change in nasopharyngeal carriage of Streptococcus pneumoniae resulting from antibiotic therapy for acute otitis media in children

Abstract: Background.Acute otitis media is the leading reason for antibiotic prescriptions in childhood. The increase in antibiotic resistance of Streptococcus pneumoniae is generally attributed to the extensive use of antibiotics and the selective pressure on the bacterial strains of the nasopharyngeal f

Pertussis: current concepts of pathogenesis and prevention.

Abstract: The selection of acellular vaccine antigens relies on current concepts of pertussis pathogenesis. Animal model data provide evidence that certain products of Bordetella pertussis, which include the putative adhesins filamentous hemagglutinin, pertactin and fimbriae, and pertussis toxin could serve as protective antigens and are available in sufficient quantities of purified material to be considered appropriate candidates for vaccine inclusion. In clinical studies vaccines containing three, four or five components were more effective at preventing pertussis than vaccines containing only inactivated pertussis toxin and filamentous hemagglutinin. These data suggest that pertactin may make a contribution to the protection elicited by an acellular product, but information does not allow evaluation of a possible incremental contribution from fimbriae. Serologic studies of patients in the clinical efficacy trials of the acellular pertussis vaccines did not yield a correlation between antibody levels and protection against pertussis, which suggests that relationships or mechanisms involved in the protective activities of these acellular vaccines are not yet understood. Therefore other mechanisms of immunity (i.e. cellular immunity) may be involved in vaccine-elicited immunity. Increasing understanding of the likely mechanisms of pertussis pathogenesis will provide insights into potential therapies for patients infected with B. pertussis. The mechanisms of vaccine-induced immunity remain elusive and determination of whether these products are working as initially predicted will require further study.

Overall cost in the treatment of otitis media.

Abstract: Background Numerous antimicrobial agents are available for treatment of otitis media (OM); however, little is known about the relative cost effectiveness of these drugs. Methods We developed a noninvasive, observational model to assess the total costs (direct and indirect) associated with commonly used antibiotics in the therapy of OM. We also gathered data on recurrence rates, which can significantly affect costs. Results The average total cost of treating an episode of OM in this study was $115.80. Treatment of a recurrent OM episode was significantly more costly than treatment of an initial episode ($124.64 vs. $107.81, P = 0.0001). This study suggests that significant costs are associated with OM treatment and that antibiotic price constitutes only a small portion of this cost. Recurrence rates appeared to vary with various antibiotic treatments. Conclusion We conclude that recurrence is a major determinant of OM treatment costs. Drugs associated with lower rates of recurrence will usually be the most cost-effective treatment options.