Heterotrimeric G proteins physically associated with the lipopolysaccharide receptor CD14 modulate both in vivo and in vitro responses to lipopolysaccharide.

Septic shock induced by lipopolysaccharide (LPS) triggering of cytokine production from monocytes/macrophages is a major cause of morbidity and mortality. The major monocyte/macrophage LPS receptor is the glycosylphosphatidylinositol (GPI)-anchored glycoprotein CD14. Here we demonstrate that CD14 coimmunoprecipitates with Gi/Go heterotrimeric G proteins. Furthermore, we demonstrate that heterotrimeric G proteins specifically regulate CD14-mediated, LPS-induced mitogen-activated protein kinase (MAPK) activation and cytokine production in normal human monocytes and cultured cells. We report here that a G protein binding peptide protects rats from LPS-induced mortality, suggesting a functional linkage between a GPI-anchored receptor and the intracellular signaling molecules with which it is physically associated.

Slipped capital femoral epiphysis without hip pain leads to missed diagnosis.

Prompt diagnosis of slipped capital femoral epiphysis (SCFE) is dependent on recognition of variable clinical manifestations. The charts of 116 children and adolescents with SCFE were reviewed to identify characteristics of patients whose diagnosis was initially missed. Missed diagnosis was found in 34 patients (29%). Sixteen of the 34 whose diagnosis was missed had hip pain, while 58 of the 82 whose diagnosis was not missed had hip pain (P = .0157). Of the 34 patients with missed diagnosis, 15 patients had thigh pain. In comparison, of the 82 patients without missed diagnosis, 19 had thigh pain (P = .0241). It is concluded that SCFE is more likely to be missed at the initial visit if hip pain is absent or if thigh pain is present. This review indicates that despite the evidence that patients with SCFE frequently complain of symptoms other than hip pain, the disorder continues to be missed.

Temperature and total white blood cell count as indicators of bacteremia.

This study was designed to quantify more precisely the accuracy of magnitude of rectal temperature and total white blood cell (WBC) count as indicators of bacteremia in children with an obvious focal bacterial infection. A total of 955 children, aged 3 to 36 months, who had rectal temperature greater than or equal to 39.0 degrees C and were seeking care at either of two urban pediatric emergency departments had blood drawn for culture; 885 had blood drawn for WBC count. Twenty-seven had bacteremia. Various combinations of temperature and WBC count were selected to construct receiver-operating-characteristic curves by plotting sensitivity vs false-positive rate (1 - specificity). The receiver-operating-characteristic curve of WBC count provided significantly better diagnostic information than the curve for temperature increments above 39.0 degrees C. Each increment of 0.5 degrees C led to large decrements in sensitivity and false-positive rates. At a WBC count cutoff of 10,000/mm3, the sensitivity was 92% while the false-positive rate was 57%. Using this cutoff point, the clinician could have avoided performing 368 of 955 blood cultures and missed only 2 of 26 children with bacteremia. Receiver-operating-characteristic curves combining WBC count and temperature increments above 39.0 degrees C provided no better diagnostic information than that of WBC count at a temperature cutoff of 39.0 degrees C. It is concluded that increments in temperature above 39.0 degrees C provided additional diagnostic specificity for bacteremia only at the expense of unacceptable decreases in sensitivity. Total WBC count provided better information. A WBC count cutoff of 10,000/mm3 increased specificity with minimal decrease in sensitivity.(ABSTRACT TRUNCATED AT 250 WORDS)

Bacteremia with otitis media.

To investigate the occurrence and outcome of bacteremia associated with otitis media, charts were reviewed from patients who were 3 to 36 months of age, had temperatures greater than or equal to 39 degrees C, and were diagnosed with isolated clinical otitis media. A total of 2982 patients were identified. Blood cultures were obtained from 1666 (56%). Of the 1666 patients, who had blood drawn for cultures, 50 (3.0%) had bacteremia. These included 39 with Streptococcus pneumoniae, 4 with Haemophilus influenzae, 2 with Neisseria meningitidis, 3 with Salmonella species, and 2 with Staphylococcus aureus. The incidence of bacteremia increased at higher temperatures, being 1.9% at temperatures less than or equal to 40 degrees C and 5.0% at temperatures greater than 40 degrees C. Younger children were more likely to have bacteremia; 3.7% less than or equal to 12 months of age, 2.4% 13 to 24 months of age, and 1.9% 25 to 36 months of age had blood culture results that were positive (not significant). Reevaluation of the 50 bacteremic patients showed that 9 patients had continued fever, 3 patients had persistent bacteremia, pneumonia developed in 1 patient, and meningitis developed in 1 patient. It was concluded that (1) 3% of young febrile children with otitis media have bacteremia at the time of evaluation, a rate comparable to that previously reported in children with no focus of infection; (2) the incidence of bacteremia increases at higher temperatures; and (3) most febrile children with otitis media do well. The clinician must therefore weigh the potential benefit of drawing a blood culture to identify children at risk for complications against the inherent cost, inconvenience, and discomfort.

Spectrum and frequency of pediatric illness presenting to a general community hospital emergency department.

Knowledge of the range of pediatric illness presenting to a general emergency department (ED) is needed to optimize the quality of care delivered there. It was hypothesized that the pediatric population treated at a general ED exhibited a broad range of medical complaints, while differing significantly from children seen in a pediatric ED. General ED records from 1 week each season were reviewed, and patient age, chief complaint, diagnosis, time of arrival, season, and disposition were recorded. Data on 874 patients were analyzed and compared with pediatric ED data. General ED patient age affected chief complaint, diagnosis, and admission rate (9.5% less than or equal to 1 year admitted vs 2.6% greater than 1 year, P less than .001). General ED patients were older (7.9 vs 6.0 years, P less than .001) and admitted less frequently (3.8% vs 11%, P less than .001). Admission rates varied by arrival time only at the general ED, where minor trauma was more common (41% vs 22%, P less than .001). It is concluded that a wide range of pediatric illness is treated in a general ED, supporting the decision to have pediatric emergency physicians on staff, and that significant differences exist in the spectrum and frequency of pediatric illness seen in a general ED and pediatric ED.

Group A beta-hemolytic streptococcal bacteremia: historical overview, changing incidence, and recent association with varicella.

OBJECTIVE: To quantitate the increase in invasive group A beta-hemolytic streptococcal (GABHS) infections and to define a possible association between GABHS bacteremia and primary varicella zoster virus (VZV) infections. METHODS: This was a retrospective chart review conducted at Children's Hospital. Participants were patients with documented GABHS bacteremia occurring from January 1977 through December 1993. MEASUREMENTS/MAIN RESULTS: We identified 63 episodes of GABHS bacteremia in 62 patients. From 1977 to 1992, a mean of 3.2 +/- 2 cases occurred per year (range, 0 to 6), increasing by a factor of 3 (10 cases) in 1993. The median age was 4 years (range, 1 day to 20 years; mean, 8 years +/- 3 months); 36 were male; five children were immunocompromised. One child was dead on arrival and one had a cardiac arrest during evaluation in the emergency department. Primary sites of infection (oropharynx, skin, or middle ear) were identified in 40 (75%) of the cases; in addition, 10 cases occurred in patients with primary VZV. From 1977 to 1992, we identified five VZV-associated cases; an average of 7 +/- 11.5% of the patients with GABHS had concurrent VZV infection annually, with no more than one case per year. In 1993, 50% of the 10 new GABHS cases were in children with VZV infection (P = .003, Fisher's exact test). The diagnosis of invasive GABHS infection in patients with VZV was not readily recognized, requiring a median of two (range, one to four) physician visits before admission and the administration of antibiotics. All 10 children were diagnosed on the fourth or fifth day of the exanthem and were febrile (39.6 +/- 1.1 degrees C, range, 38.3 to 40.8 degrees C), with a mean white blood cell count (WBC) of 11,500 +/- 8,400/mm3 (8 of 10 cases had a WBC less than 15,000/mm3). None of the five VZV-associated cases in 1993 had signs of cutaneous bacterial superinfection; among these were two cases of streptococcal toxic shock syndrome (one death), one case of osteomyelitis, and two cases of occult bacteremia. Of the five VZV-associated cases before 1993, one patient was diagnosed with supraglottitis, one with septic arthritis, one with orbital cellulitis, and two solely with impetiginized or cellulitic lesions. CONCLUSIONS: We found that the incidence of invasive GABHS infections has risen dramatically, increasing by a factor of 3 over the past year. In 1993, 50% of new cases of invasive GABHS disease were associated with VZV infection. Invasive GABHS should be considered in children with VZV who manifest fever on or beyond the fourth day of the exanthem. The absence of an elevated WBC and impetiginized or cellulitic lesions should not eliminate this diagnosis from consideration.

Hematuria and clinical findings as indications for intravenous pyelography in pediatric blunt renal trauma.

The essential aids in the evaluation of suspected blunt urinary tract injury are urinalysis and IVP. In 78 consecutive children who had IVPs because of trauma from January 1982 to March 1986, the following were evaluated: (1) the yield of IVP; (2) the correlations between IVP and hematuria, mechanism of injury, and associated clinical findings; and (3) the effect of IVP on patient management. Of the 26 children (33%) with abnormal IVP findings, 13 had congenital urinary tract anomalies only and 13 had urinary tract injuries (eight renal contusions, four renal lacerations with extravasation, and one bladder rupture). The number of RBCs per high-power field correlated with IVP evidence of injury (P less than .05). If only those patients with greater than or equal to 20 RBCs per high-power field had received IVPs, 42% of IVPs would have been avoided and no injuries or surgically correctable anomalies would have been overlooked. Urinary tract injury occurred significantly more often in patients with extremity fractures (P less than .05) and pelvic fractures (P less than .05). Mechanism of injury, admission to the hospital, and flank tenderness or hematoma were not associated with IVP evidence of trauma (P greater than .05), however. In four patients with trauma, results of IVP led to lengthened hospitalization or further diagnostic studies but did not result in surgery. Two patients in whom ureteropelvic junction obstruction was discovered incidentally had delayed corrective surgery.(ABSTRACT TRUNCATED AT 250 WORDS)

Cost-effectiveness of rapid latex agglutination testing and throat culture for streptococcal pharyngitis.

Decision analysis was used to evaluate the cost-effectiveness of four alternative strategies for management of pharyngitis in children ("treat all," "antigen test alone," "culture alone," "antigen test + culture"). In the model, estimates of test sensitivity and specificity, disease prevalence, treatment rates after positive test results, rates of complications for treated and untreated patient-cases, rates of antibiotic-induced complications, treatment effectiveness, and direct dollar costs of diagnosis and therapy were used. Results were expressed in terms of severe penicillin reactions per disease case prevented and dollars per complication prevented. Sensitivity analysis was performed to assess the impact of changes in parameter estimates on model outcomes. With treat all, 90% of streptococcal complications were prevented and there were low short-term direct dollar costs. However, treat all is associated with a high rate of penicillin allergy (70% of which occurs in uninfected children) and is the least cost-effective strategy when the costs of treating complications are included. The marginal cost of antigen test + culture is less than the cost of either one-test strategy. Antigen test + culture is the most cost-effective strategy when the costs of managing the complications of streptococcal infection are considered. Antigen test + culture is the most clinically effective strategy, and its benefits are obtained at a modest marginal cost relative to the one-test strategy.

Occult bacteremia with group B streptococci in an outpatient setting.

OBJECTIVES: We undertook this study to determine the relative frequency of occult bacteremia with group B streptococci (GBS) and to define the clinical features of infants with occult bacteremia attributable to GBS at the time of initial clinical contact. DESIGN: The logs of the microbiology laboratory were reviewed for blood and cerebrospinal fluid isolates of GBS from 1982 to 1996. Records of patients identified with GBS were abstracted. Patients were classified as having occult bacteremia if GBS were isolated from their blood and they seemed nontoxic and had no apparent clinical or laboratory evidence of focal infection. All other patients were diagnosed with sepsis, meningitis, or nonmeningeal foci. RESULTS: We reviewed the medical records of 147 children with GBS and identified 108 outpatients, including 47 (44%) with occult bacteremia, 42 (39%) with meningitis, 11 (10%) with nonmeningeal foci, and 8 (7%) with sepsis. Compared with patients with sepsis or focal infections, those with occult bacteremia were older (61.1 vs 39.1 days) and had slightly, although not significantly, higher white blood cell (WBC) counts (13 280 +/- 6854 vs 10 688 +/- 8574), but similar degrees of fever. Among the 47 patients with occult bacteremia, none died, as compared with 2 of 61 with serious infections, and fewer had neurologic sequelae (0/47 vs 11/61). Patients with occult bacteremia >90 days of age generally had temperatures >39 degreesC (9/11, mean 39.3 degreesC) and WBC counts >15 000/mm3 (7/10, mean 19 070/mm3), both of which differed significantly compared with those who were <90 days of age. Thirty of the 47 patients with occult bacteremia received intravenous antibiotics and recovered. One of 8 patients discharged without antibiotics and none of 8 with antibiotics developed a focal complication; 1 discharged patient was lost to follow-up. CONCLUSIONS: Almost one-half of the children with GBS disease beyond the immediate neonatal period had occult bacteremia. Among 8 untreated patients with bacteremia, 1 developed a focal complication. Although the small proportion of children with GBS occult bacteremia who were >90 days of age usually had the risk factors of temperature >39 degrees C and WBC >15 000/mm3, as seen with occult bacteremia attributable to other organisms, the majority of the patients who were younger did not have a characteristic clinical syndrome. Prevention of sequelae in these young infants will require a low threshold for diagnosis and treatment.

Clinical and cost-effectiveness of outpatient strategies for management of febrile infants.

Young infants with fever are at risk for serious bacterial infection, but no consensus exists on the optimal approach to diagnosis and treatment. Although the traditional recommendation is always to perform all sepsis tests, including lumbar puncture, and administer intravenous (IV) antibiotics until culture results are negative, recent studies suggest administering intramuscular (IM) ceftriaxone with outpatient follow-up or using laboratory and clinical data to exclude low-risk patients from hospitalization, further testing, and antibiotic treatment. A decision analysis model was used to evaluate six strategies for the diagnosis and treatment of infants aged 28 to 90 days with temperature greater than or equal to 38.0 degrees C. Data from the literature, data from a 1991 study of 503 febrile infants, and direct, short-term costs from the Children's Hospital of Philadelphia were used as model inputs. The model was run for a hypothetical cohort of 100,000 febrile infants who did not require admission for focal infection or for other reasons that clearly necessitated admission. The model included six strategies: (1) no intervention; (2) all sepsis tests (lumbar puncture, blood culture, urine culture, white blood cell count, and urinalysis) followed by hospitalization and IV antibiotics for all infants; (3) all sepsis tests followed by IM ceftriaxone and outpatient management for most infants; (4) blood and urine cultures with white blood cell count and urinalysis followed by either lumbar puncture and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants; (5) white blood cell count and urinalysis followed by either lumbar puncture, blood and urine cultures, and IV antibiotics for high-risk infants or outpatient management without antibiotics for low risk infants; and (6) clinical judgment followed by either all sepsis tests and IV antibiotics for high-risk infants or outpatient management without antibiotics for low-risk infants. The two "all sepsis tests" strategies prevented the most cases of death or neurologic impairment, 78% (when IV antibiotics were used) and 76% (when IM ceftriaxone was used) of all potential cases. The most cost-effective strategy was to use all sepsis tests followed by IM ceftriaxone for all patients without meningitis, at an incremental cost of only $3900 per sequela prevented relative to no intervention. Strategies under which only those patients selected as high-risk by laboratory criteria received antibiotic treatment were less effective but incurred lower rates of antibiotic complications. Clinical judgment alone was the least clinically effective and the second least cost-effective strategy.(ABSTRACT TRUNCATED AT 400 WORDS)

Case-control study of hyperpyrexia in children.

To test the association of hyperpyrexia (temperature greater than or equal to 41.1 degrees C) with increased rates of bacteremia and serious bacterial illness in young children, we performed a retrospective case-control study. Seventy-six hyperpyrexic children and an equal number of control cases with temperatures of 39.1-40 degrees C and 40.1-41.0 degrees C were identified. A significantly larger number of diagnostic procedures including blood cultures, urine cultures, chest x-rays and white blood cell counts were performed in the hyperpyrexic children (P less than 0.05). The frequency of serious bacterial infections and bacteremia did not differ among the groups (P greater than 0.05). Hyperpyrexic children need to be evaluated as thoroughly and carefully as any other febrile child but do not merit special consideration.

Effect of antibiotic therapy on the outcome of outpatients with unsuspected bacteremia.

The records of 559 consecutive outpatient children with unsuspected bacteremia (467 Streptococcus pneumoniae) were reviewed. When compared with patients receiving oral or parenteral antibiotics, those patients who received no antibiotics at the initial visit were in follow-up: (1) less likely to be improved (32% vs. 86%, P < 0.01); (2) more likely to be febrile (75% vs. 28%, P < 0.01); (3) more likely to be hospitalized (67% vs. 22%, P < 0.01); (4) more likely to have persistent bacteremia (28% vs. 3%, P < 0.01); and (5) more likely to have new focal infections (13% vs. 5%, P < 0.01). Compared with patients receiving parenteral antibiotics at the initial visit, patients receiving oral antibiotics were in follow-up: (1) less likely to be improved (81% vs. 89%, P < 0.05); and (2) more likely to have persistent bacteremia (5% vs. 0%, P < 0.05). There was no statistical difference between patients receiving parenteral or oral therapy in the development of focal infections, although children with new focal infections receiving oral antibiotics more often had persistent or new positive cultures. No patients receiving parenteral antibiotics at the initial visit had positive blood or spinal fluid cultures at the follow-up visit. Analyses of the subgroups with (1) occult bacteremia with all organisms, (2) unsuspected bacteremia S. pneumoniae and (3) occult bacteremia with S. pneumoniae show results similar to those for the entire group.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical evaluation of a latex agglutination test for streptococcal pharyngitis: performance and impact on treatment rates.

The accuracy and clinical utility of a latex agglutination test were compared with anaerobic throat culture on selective media for detection of Group A streptococcal pharyngitis in an urban pediatric emergency department. Among 255 symptomatic cases prevalence of positive culture was 29% and antigen test sensitivity was 55%. Among 100 asymptomatic controls prevalence of positive culture was 20% and antigen test sensitivity was 20%. Controls with positive cultures and cases with false negative antigen tests had significantly fewer colonies on culture than cases with true positive antigen tests (P less than 0.01). Symptoms and clinical findings were not associated with antigen test result or number of colonies on culture. Eighty percent of patients with positive cultures received treatment when the antigen test was used as an adjunct to culture, compared with a 57% treatment rate among the subgroup in whom follow-up treatment was attempted based on positive culture results alone (P less than 0.05). We conclude that: (1) the antigen test had lower sensitivity in routine clinical use than previously reported; (2) the high rate of false negative tests may result, in part, from a high proportion of specimens with low colony counts; and (3) the availability of the antigen test as an adjunct to culture significantly increased treatment rates.

Computed tomography imaging in children with head trauma: utilization and appropriateness from a quality improvement perspective.

Computed tomography (CT) imaging plays an important role in the acute evaluation and management of children with head trauma. When routine quality improvement (QI) meetings with representatives from the Children's Hospital radiology and emergency departments revealed disagreement regarding the utilization and appropriateness of CT in children presenting with head trauma, an interdepartmental QI team was formed to address this issue. Because formal criteria for obtaining CTs for head trauma were unavailable, internal institutional criteria were developed by consensus after literature review. Contrary to perceptions of some staff members, the majority (95%) of children who received CT met at least one of the established criteria over a one-year study period. There was little relationship between the presence of criteria and abnormal CT results, but decisions whether to admit patients to the hospital or to send them home were influenced by CT results. Follow-up studies suggested that patients who were discharged home with a normal CT or no CT had uniformly good outcomes.

Accuracy of a noninvasive temporal artery thermometer for use in infants.

OBJECTIVES: To assess the accuracy of a new noninvasive temporal artery (TA) thermometer in infants; to compare the accuracy of the TA thermometer with that of a tympanic thermometer, using rectal thermometry as the criterion standard; and to compare the tolerability of the TA thermometer with that of the tympanic and rectal thermometers. DESIGN: Prospective evaluation of the accuracy of TA and tympanic thermometry, using rectal thermometry as the criterion standard. SETTING: Emergency department of an urban pediatric hospital. SUBJECTS: Convenience sample of 304 infants younger than 1 year presenting for care. MAIN OUTCOME MEASURES: Temperatures were measured using TA, tympanic, and rectal thermometers for all infants. Agreement between TA or tympanic and rectal temperatures was assessed. The sensitivity and specificity of TA or tympanic thermometers for detecting rectal fever were determined. Discomfort scores, using a standardized scale, were assessed by trained observers after each temperature measurement was made. RESULTS: Linear regression analysis of the relation between TA and rectal temperatures yielded a model with a slope of 0.79 (vs a slope of 0.68 for tympanic vs rectal temperature; P =.02) and an r of 0.83 (vs r = 0.75 for tympanic vs rectal temperature; P<.001). Among 109 patients with a rectal temperature of 38 degrees C or higher, the TA thermometer had a sensitivity of 0.66 compared with the tympanic thermometer's sensitivity of 0.49 (P<.001). Discomfort scores with TA thermometry were significantly lower than with rectal thermometry (P =.007). CONCLUSIONS: The TA thermometer has limited sensitivity for detecting cases of rectal fever in infants. However, the TA thermometer is more accurate than the tympanic thermometer in infants, and it is better tolerated by infants than rectal thermometry.

The spontaneous passage of esophageal coins in children.

OBJECTIVES: To determine the likelihood of spontaneous passage of esophageal coins to the stomach in children and to determine the effect of initial coin location on spontaneous passage. DESIGN: Retrospective review of medical records and radiographs. SUBJECTS: Consecutive patients 18 years or younger presenting during a 24-month period (October 1995 to September 1997) whose evaluation revealed an esophageal coin. SETTING: The emergency department of a large, urban academic children's hospital. MAIN OUTCOME MEASURES: Independent measures were time between ingestion and radiographs, initial location of the coin, and categorization of case as "simple" (patients without a history of esophageal disease or surgery, with a single esophageal coin lodged less than 24 hours, and with no respiratory compromise on presentation) or "complex." Dependent measures were spontaneous passage of the coin to the stomach and the time to passage. RESULTS: A total of 116 cases were included in the analysis, of which 84 were simple and 32 complex. Among the 84 simple cases, the coin was initially located in the proximal third of the esophagus in 54 (64%), the middle third in 7 (8%), and the distal third in 22 (26%). For the 32 complex cases, the initial location of the coin was the proximal third of the esophagus in 27 (84%) and the middle third in 5 (16%). Subsequent radiographs were obtained in the emergency department in 58 (69%) of the simple cases. Among these cases, spontaneous passage of the coin to the stomach occurred in 16 (28% [95% confidence interval, 21%-41%]). By initial coin location, spontaneous passage in this group occurred in 22% (7/32) of proximal, 33% (2/6) of middle, and 37% (7/19) of distal esophageal coins (P >.05). Subsequent radiographs were obtained in 14 (44%) of the complex cases; no coin had passed spontaneously to the stomach in these patients (0% [95% confidence interval, 0%-20%]). CONCLUSIONS: Children with a single esophageal coin seen within 24 hours of ingestion, who have no history of esophageal disease and no respiratory compromise on presentation, have a 28% chance of spontaneous passage of the coin to the stomach. Coins in the upper as well as the lower esophagus pass spontaneously. Observing these children for 12 to 24 hours prior to invasive procedures will reduce complications and costs.

Antibiotic treatment of children with unsuspected meningococcal disease.

BACKGROUND: Data from an earlier study suggest that patients with unsuspected meningococcal disease (UMD) cannot be differentiated easily from febrile children with viral syndromes on the basis of physical examinations or peripheral blood counts. Some children with meningococcal disease therefore are treated inadvertently as outpatients. OBJECTIVE: To determine whether antibiotic therapy administered at the outpatient visit prevents complications, permanent sequelae, or death in children with UMD. METHODS: We reviewed the medical records of patients younger than 20 years with invasive meningococcal disease at 7 pediatric referral centers from January 1, 1981, through December 31, 1996. Patients were considered to have UMD if they underwent evaluation and discharge as outpatients and if blood and/or cerebrospinal fluid cultures obtained at evaluation yielded Neisseria meningitidis. We compared the frequency of development of complications (meningitis, sepsis, and pericarditis), permanent sequelae (limb amputation, skin grafting, and persistent neurologic disability) or death between patients who did and did not receive antibiotics at the outpatient visits. RESULTS: Of 58 children with UMD, 19 (33%) received antibiotics and 39 (67%) did not. Complications occurred significantly less frequently in the antibiotic-treated group (7/19 [37%] vs 27/39 [69%]; odds ratio [OR], 0.26; 95% confidence interval [CI], 0.08-0.81; P = .03). There was no significant difference in death or permanent sequelae between groups (0/19 vs 3/39 [8%]; OR, 0; 95% CI, 0-2.61; P=.54). There was insufficient power, however, to exclude the possibility of a clinically meaningful difference between the groups with regard to these latter outcomes. CONCLUSIONS: Antibiotic administration to young patients with UMD at the time of the outpatient visit is associated with a reduction in complications from this disease. Although the routine use of antibiotics in febrile outpatients younger than 20 years cannot be advocated, empirical treatment should be considered in the setting of higher probability of meningococcal disease.

Bacteriology of tonsil surface and core in children.

The tonsils of 97 children undergoing tonsillectomy were studied to determine the correlation between surface culture swab and culture of tonsillar core. In many cases, pathogenic organisms were found in the tonsil core, despite the fact that surface cultures revealed only normal respiratory flora. The tonsil core cultures showed a high incidence of Hemophilus influenzae and Staphylococcus aureus, which was rarely reflected on surface culture. The study indicates that pharyngeal swab cultures do not reliably reflect the presence of pathogens in the tonsil core. The value of parameters such as history of recurrent bouts of tonsillitis and presence of erythema or cryptic debris on physical examination for predicting the differential bacteriology of the tonsil is studied. The implications for treatment of children with adenotonsillar hypertrophy are discussed.

The effect of antibiotic therapy on recovery after tonsillectomy in children. A controlled study.

Tonsillectomy continues to be a commonly performed operation in the pediatric age group. The postoperative period is often protracted and characterized by throat and ear pain, intermittent fever, foul odor from the oral cavity, and poor oral intake. Consequently, antibiotics are frequently prescribed in an effort to minimize these symptoms and/or avoid complications such as dehydration or secondary infection of the operative site. However, to our knowledge, no study to date has been performed to demonstrate the efficacy of antibiotic therapy in this setting. At the Children's Hospital of Philadelphia, a prospective, randomized, double-blind study was undertaken in which ampicillin (or placebo) was administered intravenously at the time of surgery and for 12 to 24 hours postoperatively. The children then continued to receive oral amoxicillin therapy (or placebo) for an additional seven days. The patients were then evaluated for the incidence and severity of postoperative symptoms and complications. Intraoperative cultures of the oropharynx and tonsillar tissue, as well as cultures of the tonsillar fossa, were obtained following completion of one week of therapy. Our results indicate that ampicillin sodium/amoxicillin trihydrate therapy is well tolerated and safe in the nonallergic child and is effective in minimizing fever and other troublesome postoperative symptoms, such as pain, lassitude, mouth odor, and poor oral intake after tonsillectomy.

Hemothorax in a child. An unusual cause of chest pain.

The pediatrician should search carefully in a child with chest pain for evidence in the history or physical examination of an organic cause. Hemothorax is one of the pathologic processes that can present with this symptom. The differential diagnosis of hemothorax in children is reviewed.