Cerebrospinal fluid shunt infections in children.

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.

Randomized, controlled trial comparing once daily and three times daily gentamicin in children with urinary tract infections.

OBJECTIVE: To undertake population pharmacokinetic modeling and to determine the safety and efficacy of once daily (OD) gentamicin dosing in children with severe urinary tract infections (UTI). METHODS: An open, randomized, controlled trial comparing OD with three times daily (TD) gentamicin dosing in hospitalized children ages 1 month to 12 years with UTI. Daily doses (milligrams per kg per day) of gentamicin in both groups were 7.5 (<5 years old), 6.0 (5 to 10 years old) and 4.5 (>10 years old). RESULTS: There were 179 children enrolled (90 OD, 89 TD). Baseline clinical characteristics and pathogens were similar, except that circulatory compromise and renal cortical scintigraphic defects were more common in the OD group. Median gentamicin treatment durations were 3.0 (OD) and 2.7 (TD) days. Mean peak gentamicin concentrations were 17.3 (OD) vs. 6.4 (TD) mg/l; 99% of peak concentrations were >7 mg/l in the OD group whereas 16% of peak concentrations were <5 mg/l in the TD group. Mean trough concentrations were 0.35 (OD) vs. 0.55 (TD) mg/l. In the OD group 4% of trough concentrations were > or = 2 mg/l, whereas in the TD group only 0.7% were > or = 2 mg/l. Age or prior elevated peak concentrations did not predict high trough concentrations. Population pharmacokinetic modeling of the data fitted a one-compartment model with first order elimination. There were no clinical or bacteriologic failures. The two disease-related complications were confined to the OD group. No nephro- or ototoxicity was identified. CONCLUSIONS: With age-appropriate dosing and measurement of serum trough concentrations before the second dose, OD gentamicin is safe and effective for the treatment of UTI requiring parenteral treatment in children aged 1 month to 12 years.

Multiple outbreaks of Norwalk-like virus gastro-enteritis associated with a Mediterranean-style restaurant.

The role of diverse infectious agents, particularly Norwalk-like viruses (NLV), in three successive gastro-enteritis outbreaks in one setting (a restaurant) was evaluated. Methods included standard bacteriological tests, specific tests for Escherichia coli, tests for verocytotoxins, electron microscopy (EM) for viruses and reverse transcription-PCR (RT-PCR) methodology for NLV. No pathogenic bacteria were detected. Verocytotoxin genes, although detected by PCR in the first outbreak, could not be confirmed in the E. coli isolated, so they did not appear to be of significance. NLV was the main agent detected in each of the three outbreaks. DNA sequencing and phylogenetic analysis of the amplified products obtained from the RT-PCR positive specimens indicated that only one NLV strain was involved in each outbreak, but the NLV strains responsible for the three outbreaks were different from each other. PCR technology for detection of NLV proved highly sensitive, but failed to detect one specimen which was positive by EM. The restaurant associated with the outbreaks is a Mediterranean-style restaurant where food from a common platter is typically eaten with fingers. The findings indicate that NLV was introduced by guests or staff and was not due to a long-term reservoir within the setting.

Invasive central nervous system aspergillosis: cure with liposomal amphotericin B, itraconazole, and radical surgery--case report and review of the literature.

Invasive aspergillosis of the central nervous system is a rare but well-described disease. There have been only a few reported survivors, and mortality exceeds 95% in the immunosuppressed host. We present a 2-year-old boy with acute lymphatic leukemia and multiple Aspergillus brain abscesses who was successfully treated with liposomal amphotericin B, itraconazole, and surgical excision of the abscesses. Liposomal amphotericin B is a new preparation that safely allows the attainment of significantly higher tissue levels with less toxicity than standard amphotericin B. The treatment of patients with invasive central nervous system aspergillosis is reviewed.

Inherited pyruvate kinase deficiency and normal haematologic values in Australian Basenji dogs.

We have carried out a survey to determine the prevalence of carriers of pyruvate kinase deficiency haemolytic anaemia in Basenjis in Victoria. Of 186 dogs tested, 20 were found to be carriers for pyruvate kinase deficiency, a prevalence similar to that reported overseas. Of the 20 carriers found, 17 were born in Australia and were traced directly to 1 of the 3 imported carriers. Despite the relatively high frequency of carriers, no mating of 2 carriers has yet been detected and no dogs with haemolytic anaemia have been observed. The inheritance of the pyruvate kinase deficiency has been traced through up to 5 generations of dogs in Australia and is consistent with co-dominance for pyruvate kinase activity and with an autosomal recessive gene for haemolytic anemia.

Association of a parvovirus with an outbreak of foetal death and mummification in pigs.

A parvovirus was isolated during an outbreak of mummifications and abortions in a commercial piggery. Stillborn piglets from which virus was isolated or in which parvovirus antibody was detected had widespread inflammatory lesions. Lesions were also seen in apparently healthy piglets from affected litters.

Poisoning of chickens and ducks by pyrrolizidine alkaloids of Heliotropium europaeum.

The disease produced by feeding chickens and ducks a commercial poultry feed containing heliotrine and lasiocarpine, pyrrolizidine alkaloids of Heliotropium europaeum, is described. Illthrift, ascites and degenerative lesions in the liver were the major findings. Similar lesions occurred in chickens fed a diet containing H. europaeum. The source of the alkaloids in commercial poultry feed was probably the seeds of H. europaeum harvested with wheat.

Is it food poisoning?

Food borne infections and intoxications, typically manifesting as gastroenteritis, are a common community acquired illness in Australia. For infants, immunocompromised people, pregnant women and the elderly, food borne illness can be fatal. Food borne illness can be difficult to distinguish from illness transmitted by other routes, but specific pathogens, clinical syndromes, and epidemiological clues suggest possible 'food poisoning'. Management is usually supportive, but investigations provide information of public health value. Persons with gastroenteritis should be given simple advice to reduce the risk of transmitting infection to others, and educated about how enteric infections may be spread from infected persons and animals, and from food.

Molecular features of astrovirus associated with a gastroenteritis outbreak in an aged-care centre.

The study presented here was conducted in order to gain a better understanding of the role of astroviruses (AsVs) in outbreaks of gastroenteritis among the elderly. This report is the first to provide detailed information on the molecular characteristics of an AsV causing an outbreak in an aged-care centre and is the first to clearly establish that individuals infected in such an outbreak were, in fact, elderly. The outbreak under investigation took place in Victoria, Australia, in October 2005. Twelve individuals (mean age +/- standard deviation [SD] 85.5 +/- 12.3 years) became ill during the outbreak from a total population of 86 susceptible residents. The mean duration (+/-SD) of illness was 2.3 +/- 1.6 days; symptoms included diarrhoea, abdominal pain, nausea and headache. No bacterial pathogens were detected. AsV was identified in five faecal specimens using electron microscopy and reverse transcription-polymerase chain reaction methodologies; no other gastroenteritis virus was detected. Nucleotide sequence analysis indicated the AsV identified could be assigned to the 1d lineage of AsV serotype 1 and that the AsV was not a recombinant form. The findings, taken together with previous work, indicate the AsV serotype most commonly associated with gastroenteritis outbreaks among the elderly is serotype 1 AsV.

Scytalidium hyalinum isolated from the toe nail of an Australian patient.

The isolation of Scytalidium hyalinum from the toe nail of a patient from Melbourne is reported. This is the first record of the isolation of this fungus from a clinical site in Australia. A brief history is given of the occurrence of Scytalidium hyalinum and the related fungus, Hendersonula toruloidea, in tinea pedis and tinea unguium in immigrants to the United Kingdom from tropical countries. Attention is drawn to the possible presence of these dermatophyte-like infections in patients in Australia.

Invasive pneumococcal disease in the population of Victoria.

OBJECTIVES: To estimate morbidity and mortality rates for invasive Streptococcus pneumoniae (pneumococcal) disease in the non-Indigenous population of Victoria. DESIGN AND SETTING: Survey using data from a statewide voluntary laboratory surveillance scheme (1989-1998), statewide hospital discharge database (1995-1998), medical records of notified patients (1994-1995) and serotyping of notified isolates (1994-1998). MAIN OUTCOME MEASURES: Incidence of pneumococcal bacteraemia and pneumonia; predisposing factors; serotypes of isolates. RESULTS: Minimum estimates of annual incidence of invasive disease, based on laboratory surveillance data for 1995-1998, were 59 per 100,000 for children aged < 2 years, 25 per 100,000 for people aged > or = 65 years, and 8 per 100,000 overall. Annual incidence of pneumococcal pneumonia, calculated from hospital discharge data, was 99 per 100,000 for those aged > or = 65 years. Manifestations of invasive pneumococcal disease varied with age, with meningitis more common in infants, and pneumonia most common in older patients. A predisposing factor for pneumococcal infection was present in 48% of patients. Most isolates from infants (83%) belonged to serotypes in the proposed seven-valent infant vaccine, and 91% of isolates from people aged > or = 2 years belonged to serotypes in the current 23-valent adult vaccine. CONCLUSIONS: S. pneumoniae continues to be a major cause of morbidity and mortality in young children and the elderly in Victoria. More widespread use of the currently available pneumococcal vaccine in adults and introduction of an effective vaccine for infants should greatly reduce incidence of the disease.

Pediatric bacteremia due to Staphylococcus warneri: microbiological, epidemiological, and clinical features.

Between 1991 and 1995, an apparent high rate of Staphylococcus warneri bacteremias at the Royal Children's Hospital, Melbourne, Victoria, Australia, raised the possibility of a virulent nosocomial strain. In a retrospective review of 30 S. warneri bacteremias in children, organisms were viable and verified in 22 episodes, 12 representing significant bacteremias. Of these 12 episodes, 2 pairs shared chromosomal DNA pulsed-field gel electrophoresis patterns in unconnected patients, dispelling concerns about a single virulent strain.

Prevalence of enteric pathogens among community based asymptomatic individuals.

BACKGROUND AND AIMS: The objective of this study was to describe the prevalence of pathogenic microorganisms in asymptomatic individuals in a community study in Melbourne, Australia. METHODS: The study population was a subset of 2803 individuals participating in the Water Quality Study; a community based randomized trial. Faecal specimens (1091) were collected over a 3-month period from asymptomatic individuals. Specimens were tested for a range of bacteria including Salmonella, Shigella and Campylobacter species. Rotavirus and adenovirus were detected using a Rota-Adeno latex kit, and protozoa were detected using a permanent stain (modified iron-haemotoxylin). RESULTS: Twenty-eight known pathogens were identified from the 1091 faecal specimens, a total carriage rate of 2.6%. Giardia species were present in 18 specimens (1.6%), Salmonella in four (0.4%), Campylobacter in one (0.1%), Cryptosporidium in four (0.4%) and adenovirus in one (0.1%). Blastocystis hominis was found in 65 specimens. The median age of those without a pathogen was 12.5 years compared with 6.6 years for those with a pathogen (P=0.02). CONCLUSIONS: Except for Giardia, pathogens were rarely found in asymptomatic individuals in the community. The prevalence of pathogens was higher in children than adults.

Bacteraemia in febrile children presenting to a pae3iatric emergency department.

OBJECTIVE: To determine the prevalence of bacteraemia in young febrile children presenting to a paediatric emergency department. DESIGN: Prospective observational case study. SETTING: Emergency Department of the Royal Children's Hospital, Melbourne, between May 1996 and May 1997. PARTICIPANTS: Patients aged 3-36 months presenting to the Emergency Department with temperature > or = 39 degrees C and without specific viral illnesses (varicella, croup or herpes gingivostomatitis). OUTCOME MEASURES: Bacteraemia (defined as presence of pathogenic bacteria in a blood culture), white blood cell count (WCC), McCarthy score, and final diagnosis based on clinical features and investigations. RESULTS: Bacteraemia was identified in 18 of 534 patients (3.4%). Pathogens isolated were Streptococcus pneumoniae (15), Neisseria meningitidis (2) and Klebsiella pneumoniae (1). Increased WCC counts (P < 0.001) and brief duration of fever (P < 0.001) were associated with bacteraemia. Nevertheless, clinical features, including McCarthy scores, and high WCC counts (> or = 20 x 10(9)/L) had < 10% predictive accuracy for bacteraemia. Overall, final diagnoses in the 534 febrile children included non-specific viral infections (25%), upper respiratory tract infections (24%), otitis media (10%), gastroenteritis (9%), pneumonia (7%), and urinary tract infection (5%). CONCLUSIONS: Most urban Australian children aged 3-36 months presenting to a paediatric emergency department with temperature > or = 39 degrees C without a clinical focus have a viral infection. However, 3%-4% have occult bacteraemia. Neither clinical features nor high WCC counts reliably identify these patients. As empiric antibiotics may contribute to increasing antibiotic resistance and have not been shown to prevent the rare complication of meningitis, we believe that close contact and regular review of these patients is preferable to empiric antibiotic therapy.

Prevention of neonatal group B streptococcal sepsis: is routine antenatal screening appropriate.

Four strategies for prevention of early onset neonatal group B streptococcal (GBS) sepsis were considered: A: routine antenatal screening for GBS vaginal carriage at 26-28 weeks' gestation and intrapartum antibiotic prophylaxis for all carriers; B: screening as above and prophylaxis only for carriers with risk factors for sepsis; C: prophylaxis for all women with risk factors; D: as for C plus screening at 37 weeks' gestation and prophylaxis for carriers. The outcomes considered for each option were: the proportion of women given prophylaxis; the risk of anaphylaxis; cases of neonatal GBS sepsis and deaths prevented; costs of screening, prophylaxis and of acute care of remaining cases. Published local and overseas studies of neonatal GBS sepsis, effectiveness of antenatal screening and prophylaxis and estimated costs were evaluated. Any of the proposed strategies can prevent a significant proportion of cases of neonatal GBS sepsis and a strategy for prevention of neonatal group B streptococcal sepsis should be part of routine obstetric practice. Strategy C is simple, effective, inexpensive and avoids unnecessary antibiotic use; it is recommended particularly when antenatal care is provided mainly in community or private practice. Strategy A (using vaginal and rectal swabs for screening) could prevent more cases, but at greater cost which could be justified only if protocols can be properly implemented and monitored.

Non-toxigenic Corynebacterium diphtheriae biovar gravis: evidence for an invasive clone in a south-eastern Australian community.

OBJECTIVE: To determine the prevalence and clonality of non-toxigenic Corynebacterium diphtheriae biovar gravis in a community with two cases of endocarditis caused by this organism. SETTING: A Koorie (Aboriginal) community in Gippsland, eastern Victoria, in 1994. METHODS: Nose and throat swabs were collected from 359 community contacts of the cases and cultured for C. diphtheriae. Strains isolated from the contacts were compared by pulsed-field gel electrophoresis (after digestion with Sma1, Not1 and Sfi1) with those from the invasive cases in the same community, another invasive case in Victoria, a cluster of invasive cases in New South Wales (NSW) (1990-1991), and other stored strains isolated from skin ulcers and sore throats. RESULTS: Non-toxigenic strains of C. diphtheriae biovar gravis were isolated from throat swabs of five of the case contacts. Uniform DNA patterns were found for the two community cases, the other Victorian case, nine of ten isolates from NSW, and the five throat isolates from case contacts. CONCLUSION: An invasive clone of C. diphtheriae biovar gravis appears to have been responsible for the three Victorian cases of endocarditis. It was also present among case contacts and responsible for previous invasive cases in NSW. Prophylactic treatment should be considered for clearly defined contacts in all instances where C. diphtheriae is isolated from a normally sterile site, regardless of the toxigenic nature of the strain.