Dexamethasone treatment for bacterial meningitis in children and adults.

Four hundred twenty-nine patients with bacterial meningitis were assigned on a nonselective alternating basis into one of two therapeutic regimens. Patients in Group I received dexamethasone in addition to standard antibacterial chemotherapy of ampicillin and chloramphenicol whereas those in Group II received antibacterial chemotherapy alone. Dexamethasone was given intramuscularly (8 mg to children younger than 12 years and 12 mg to adults every 12 hours for 3 days). Both treatment groups were comparable with regard to age, sex, duration of symptoms and state of consciousness at the time of hospitalization. A significant reduction in the case fatality rate (P less than 0.01) was observed in patients with pneumococcal meningitis receiving dexamethasone; only 7 of 52 patients died compared with 22 of 54 patients not receiving dexamethasone. A reduction in the overall neurologic sequelae (hearing impairment and paresis) was observed in patients receiving dexamethasone. This reduction was significant only in patients with Streptococcus pneumoniae meningitis; none of the 45 surviving patients receiving steroids had hearing loss whereas 4 of 32 patients not receiving dexamethasone had severe hearing loss (P less than 0.05). No significant difference was observed between the two groups with regard to time for patients to become afebrile or to regain consciousness or in the mean admission and 24- to 36-hour cerebrospinal fluid leukocyte count, glucose or protein content.

Dexamethasone adjunctive treatment for tuberculous meningitis.

During a 5-year period, 280 of 2010 patients admitted to the meningitis ward of a referral hospital in Cairo, Egypt, were clinically diagnosed as having tuberculous meningitis and were treated with either antituberculous chemotherapy and dexamethasone or antituberculous chemotherapy alone. Fatality rates and neurologic sequelae were compared for the 2 treatment groups in the 160 patients who had cerebrospinal fluid cultures positive for Mycobacterium tuberculosis. The overall mortality rate of 51% reflects the delay in receiving appropriate therapy (79% with symptoms for more than 2 weeks) and the severity of illness on admission (56% in coma, 39% drowsy). The fatality rate was significantly lower in the group receiving dexamethasone (43% vs. 59%, P less than 0.05), particularly in the drowsy patients (15% vs. 40% P less than 0.04), and in patients surviving long enough to receive at least 10 days of treatment (14% vs. 33%, P less than 0.02). Development of neurologic complications after initiation of therapy (4 vs. 10) and permanent sequelae (6 vs. 13) were significantly lower in the dexamethasone-treated group (P less than 0.02).

Oxamniquine versus niridazole for treatment of uncomplicated Schistosoma mansoni infection.

One hundred sixteen male patients with uncomplicated Schistosoma mansoni infection were randomized to treatment with oxamniquine (20 mg/kg a day for 3 days) or niridazole (15 mg/kg a day for 8 days) in an in-hospital study. Fifty-four patients were treated with oxamniquine; no serious drug side effects were noted. Twenty-six percent of children 16 years old and younger were cured, while 85% of adults were cured. Egg reduction was 89%. Sixty-two patients were treated with niridazole; four patients (one child and three adults) had serious side effects which necessitated discontinuing the drug. Seventy-one percent of children and 84% of adults were cured. Egg reduction was 84%. Minor clinical side effects occurred during therapy with both drugs (26% with oxamniquine, 48% with niridazole) but cleared after completion of therapy. Niridazole is the more effective drug for the child with uncomplicated Schistosomiasis mansoni, but oxamniquine is advised for the adult with this disease.

Field trial of 1% niclosamide as a topical antipenetrant to Schistosoma mansoni cercariae.

A randomized, double-blind, placebo-controlled field trial of a topical antipenetrant lotion, 1% niclosamide, applied daily to the upper and lower limbs of farmers occupationally exposed to Schistosoma mansoni cercarial-infested water, was conducted in the Nile Delta to assess its safety and efficacy in preventing reinfection. Farmers aged 18-40 years were treated to cure their S. mansoni infections three months prior to the onset of the trial. Subjects were randomly assigned to receive niclosamide or placebo lotion that was self-applied daily for five months. A total of 186 subjects met the inclusion criteria and completed the trial. The exposure to schistosomal-infested water occurred during routine irrigation activities from June to November 1991. Stool specimens were evaluated monthly during and for two months following the lotion application period. The subjects applying the niclosamide lotion were comparable to those applying placebo lotion in age (mean 30 years for both), total water contact (184.5 hr versus 173.8 hr), reported lotion application compliance (88% versus 92%), and reported water contact involving skin exposure other than upper and lower limbs (23% versus 27%). The schistosomal reinfection rate was lower in the niclosamide group (53.3%) compared with the placebo lotion group (71.3%), (P < 0.02). Increased protection might be obtained with total body application for shorter, less intense, water contact exposures.

Treatment of schistosomiasis mansoni with oxamniquine--five years' experience.

During a 5-year period (1975-1980), 171 male patients aged eight to 58 years infected with Schistosoma mansoni have been treated with oxamniquine on an in-hospital basis. The patients comprised three clinical groups--uncomplicated S. mansoni infection, colonic polyposis due to S. mansoni, and hepatic decompensation due to S. mansoni--all with active infection. After treatment all patients were observed for 12 weeks then evaluated for cure. In the uncomplicated group 40 of 73 children (55%) and 39 of 45 adults (87%) were cured. In the polyps group 24 of 29 patients (83%) were cured and in the decompensated group all 24 patients were cured. The only side effect was a febrile reaction occurring in 65 patients (38%) 3-4 days after treatment was started. This 5 years' experience showed that oxamniquine results in a low cure rate in children but is effective in adults with uncomplicated S. mansoni. In patients with colonic polyposis oxamniquine is safe and well tolerated as initial therapy, particularly in the very ill, debilitated patient. Oxamniquine is clearly the drug of choice in patients with decompensated liver disease and active S. mansoni infection.

Meningitis and encephalitis at the Abbassia Fever Hospital, Cairo, Egypt, from 1966 to 1989.

A total of 7,809 patients with meningitis or encephalitis were admitted to the Abbassia Fever Hospital in Cairo, Egypt from November 1, 1966 to April 30, 1989. The etiology was Neisseria meningitidis (mostly group A) in 27.3% of the patients, Mycobacterium tuberculosis in 19.7%, Streptococcus pneumoniae in 7.3%, and Haemophilus influenzae in 4.1%. Almost 27% of the cases had purulent meningitis but without detectable etiology; however, the epidemiologic data suggest that most of these had meningococcal meningitis. Encephalitis was suspected in 12.5% of the patients. Most of the meningococcal, pneumococcal, and Haemophilus cases occurred during the winter months. The number of meningococcal and culture-negative purulent cases per year reached a maximum three times during the 22.5 years of this study. There were more males than females in all etiologic groups, with the ratio for the total patient population being 1.6:1. The average age ranged between 11.7 and 16.5 years for all groups except for Haemophilus patients, who had a mean age of 2.5 years. The mortality rate was almost 55% for tuberculous patients and was approximately 40% for both pneumococcal and Haemophilus patients; it was 8.5% in patients with meningococcal disease.

Diarrhoeal disease: current concepts and future challenges. Diarrhoeal disease--a military perspective.

Diarrhoeal disease has always been a major medical problem during military operations. Lost personnel time has been significant, with over 50% of deployed forces being affected and unable to do their jobs for several days. During 'Operation Desert Shield' in Saudi Arabia in 1990, the US military took extensive precautions to prevent diarrhoeal disease. Surveys from 1% of the 200,000 US military personnel in Saudi Arabia indicated that 97% experienced diarrhoea, 22% sought medical care, and 19% were not able to perform their duties while affected. Medical evaluation of 452 individuals with diarrhoea determined a bacterial aetiology in 50% and a clear relationship with consumption of local fruits and raw vegetables. Prophylactic antibiotic administration was not a reasonable proposal and treatment was effective only when susceptibility patterns of local enteric agents were considered. Research efforts must continue for diagnostic tests to indicate which individuals with diarrhoeal disease would benefit from early antibiotic therapy and for development of vaccines effective against the common agents of diarrhoeal disease.

Levamisole compared to mebendazole in the treatment of Ancylostoma duodenale in Egypt.

Ancylostoma duodenale in 74 patients and Ascaris lumbricoides in 41 were treated with a single 150 mg dose of levamisole, a single 300 mg dose of mebendazole or the standard three-day regimen of 200 mg mebendazole daily. Levamisole cured all of the 25 hookworm patients and all of the seven Ascaris carriers to whom it was given and is recommended as the drug of choice in Egypt.

A placebo-controlled double-blind trial for the treatment of bancroftian filariasis with ivermectin or diethylcarbamazine.

Therapeutic efficacy and clinical side-effects of ivermectin (single dose of 100 micrograms/kg) and diethylcarbamazine (DEC) (3 mg/kg for one day, then 6 mg/kg daily for 12 d) were evaluated for microfilaricidal effect in Bancroftian filariasis. Seventy-one microfilaraemic consenting adult male patients (greater than or equal to 100 microfilariae (mf)/ml) were randomly assigned to receive ivermectin, DEC or placebo and kept in hospital for 15 d. Those receiving placebo were treated with ivermectin on day 9. Ivermectin (19 'double-blinded' and 22 'unblinded' patients) caused an abrupt reduction in mf count to 1.5% of the pre-treatment level 12 h after drug administration and to 0.06% on day 14, with recrudescence to 1.8% after one month and to 9.2% after 3 months. DEC (30 patients) caused a gradual drop in mf count to 1.1% of the pre-treatment level on day 14, which increased to 2.4% after one and 3 months. The total scores of side-effects were 77 (1%), 305 (2.1%) and 311.5 (3.0%) for placebo, ivermectin and DEC respectively; the differences between DEC or ivermectin and placebo were statistically significant. Ivermectin produced lower side-reaction scores than DEC and the differences were highly significant at the 95% confidence level. Side-effects were mainly headache and body aches in the ivermectin patients, which appeared as early as 4 h after drug administration, resolved within 36 to 48 hours, and were significantly related to mf densities. Side-effects in DEC patients were mainly testicular and epididymal pain and swelling, unrelated to mf densities, which began at day 2 and continued to day 7.(ABSTRACT TRUNCATED AT 250 WORDS)

A review of the treatment of bacterial meningitis.

This is review of our experience in the treatment of meningitis carried out at the Naval Medical Research Unit No. 3 (NAMRU-3), Cairo, Egypt since 1967. We have demonstrated that the serum and cerebrospinal fluid concentrations of ampicillin and its efficacy when used in the treatment of meningitis are comparable whether they are administered intravenously or intramuscularly. The third generation cephalosporin ceftriaxone was found to be very safe and effective when administered intramuscularly once a day in the treatment of the different types of acute bacterial meningitis. Aztreonam given intramuscularly was successful in the treatment of Gram-negative meningitis caused by multi-resistant organisms. The fatality rates and morbidity were significantly reduced in patients with meningitis when dexamethasone was given in conjunction with antibacterial chemotherapy.

Epidemiology, prevalence and clinical diagnosis of meningitis at Abbassia Fever Hospital, Cairo, 1966-1989.

The United States Naval Medical Research Unit No. 3 and the Abbassia Fever Hospital in Cairo, Egypt have together diagnosed and treated 7809 patients admitted to a meningitis ward since 1966. Aetiological diagnosis was based on clinical evaluation and laboratory studies. Marked increases in annual admissions in 1970-1972, 1980-1982 and 1987-1988 were related to increases in admissions due to meningococcal disease, while in 1977-1981 the increase was due to encephalitis related to Rift Valley fever. Better, rapid diagnostic procedures are needed to enable effective treatment to be given earlier and to reduce mortality rates.

Laboratory diagnosis of bacterial meningitis.

This overview summarizes studies conducted since 1970 on the laboratory diagnosis of bacterial meningitis at the Naval Medical Research Unit No. 3. These investigations demonstrated that counterimmunoelectrophoresis (CIE), agglutination of sensitized staphylococcal cells or latex particles, and enzyme-linked immunosorbent assay (ELISA) effectively detect and identify specific antigens in the cerebrospinal fluid of patients with meningococcal, pneumococcal, and Haemophilus meningitis. ELISA was the most sensitive of these methods and CIE the least sensitive. ELISA was also used to measure antibodies to meningococcal outer membrane protein antigens in patients. Finally, high rates of group A meningococcal nasopharyngeal carriage were found in group A meningococcal meningitis patients and populations associated with group A patients, but not in populations that were not associated with group A disease.

Treatment of travellers' diarrhoea: zaldaride compared with loperamide and placebo.

OBJECTIVE: To compare zaldaride maleate, a calmodulin inhibitor with gastrointestinal antisecretory properties, with loperamide and a placebo in the treatment of travellers' diarrhoea. DESIGN: Randomized, double-blind, double-dummy study. SETTING: Study clinic staffed by European residents on Nile cruise ships. PATIENTS: Tourists (n = 436) who acquired travellers' diarrhoea during the Nile cruise. INTERVENTIONS: (1) Zaldaride 20 mg four times daily, (2) zaldaride 2 x 20 mg as initial loading dose followed by three doses of 20 mg on the first day and four doses of 20 mg on the second day, (3) loperamide 2 x 2 mg loading dose following by a flexible dosage of 2 mg after each unformed stool (maximum of 16 mg daily), (4) placebo. MAIN OUTCOME MEASURES: Number of unformed stools, rate of improvement of patients with diarrhoea, rate of relief from diarrhoea. RESULTS: Among the 331 compliant and fully evaluated patients, the zaldaride with loading dose group showed no significant differences in cure rates from the loperamide group. For most parameters, zaldaride without a loading dose and the placebo resulted in significantly lower cure rates. CONCLUSIONS: A zaldaride regimen including a loading dose was shown to be well tolerated and as effective as loperamide.

Foodborne outbreak of hepatitis A: clinical and laboratory features of acute and protracted illness.

During a 1974 foodborne outbreak of viral hepatitis type A among Navy recruits, we evaluated clinical and laboratory features prospectively in 130 affected persons. The ratio of anicteric to icteric persons identified during the outbreak was 1:3.5 but illness was relatively mild in this population of young adults. Infrequently reported in association with type A hepatitis, rash and arthralgias (but not arthritis) were reported by 14 and 10% of affected persons, respectively. Fourteen weeks after onset of acute illness, 8.5% of patients had persistently elevated aminotransferase activities and underwent percutaneous liver biopsy. Morphologic features included piecemeal necrosis, but clinical, biochemical, and histological evidence of disease resolved within five months to one year after the outbreak. Fecal shedding of hepatitis A virus began during the preicteric stage, did not persist beyond the second day of jaundice (even in patients with protracted illness), and was not detected in anicteric patients. Feces and serum obtained during the late incubation period, but not urine, were infectious in chimpanzees. Antibody to hepatitis A virus developed during convalescence, and serum anticomplementary activity was noted during acute illness. Failure of T-lymphocytes to bind sheep erythrocytes and form rosettes was observed, was found to be modulated in several cases by an intrinsic lymphocyte defect and in others by the presence in serum of an extrinsic immunoregulatory serum lipoprotein, "rosette inhibitory factor," which persisted in patients with slow resolution.

Ceftriaxone versus chloramphenicol in the treatment of enteric fever.

Fifty-five patients with culture-proven Salmonella typhi and paratyphi enteric fever were assigned to one of two therapeutic regimens. Group I received ceftriaxone 60-80 mg/kg/day intramuscularly for 5-7 days, those in group II received chloramphenicol 50-80 mg/kg/day orally in 4 divided doses for 12-14 days. both groups were comparable as regards age, sex, severity and duration of symptoms prior to admission. A significant reduction in the mean number of days taken for patients to become afebrile, disappearance of clinical signs and symptoms, duration of therapy and hospital stay were observed in patients receiving ceftriaxone as compared to those receiving chloramphenicol. None of the patients receiving ceftriaxone relapsed, while three patients receiving chloramphenicol relapsed. No major reactions were seen with either drug.

Cefixime in the treatment of enteric fever in children.

Cefixime in a dose 20 mg/kg/day, orally, divided into two doses 12 h apart for a minimum of 12 days, was administered to 50 children with proven S. typhi septicaemia. Forty four of the patients were infected with strains of S. typhi resistant to multiple antibiotics including chloramphenicol, ampicillin and trimethoprim-sulfamethoxazole. All patients responded rapidly to treatment and were cured clinically and bacteriologically. Fever subsided within a mean of 5.3 days (range 3-8 days). Only two of the 50 patients treated relapsed during the 8 week follow-up period. No serious adverse reactions attributable to the drug were observed. Cefixime proved to be an effective oral drug in this open treatment trial and was associated with minimal side effects. It may provide a therapeutic alternative to the treatment of Salmonella infection with organisms multi-resistant to the standard drug regimens. Its oral formulation may provide an efficient alternative to parenteral therapy in less severely ill patients who can tolerate oral feeding.

Aztreonam compared to chloramphenicol in the treatment of enteric fevers.

Fifty-seven patients, twenty-six males and thirty-one females, aged 6 to 50 years (mean 12.6 years) with proven Salmonella typhi or S. paratyphi A septicaemia, were treated in an open randomized parallel study with either aztreonam or chloramphenicol. Aztreonam was given intramuscularly at a level of 50 to 80 mg/kg body weight per dose every 8 h for 7 days to thirty patients. Chloramphenicol was given orally in a dose of 50 to 70 mg/kg body weight every 6 h for 12 days to twenty-seven patients. All patients responded rapidly to treatment, becoming afebrile and asymptomatic within 5.5 to 6.4 days. Only one patient on aztreonam relapsed following treatment, whereas three patients relapsed after chloramphenicol treatment. There were no serious side effects with either drug.

Norfloxacin compared to trimethoprim/sulfamethoxazole for the treatment of travelers' diarrhea among U.S. military personnel deployed to South America and West Africa.

A randomized treatment trial of travelers' diarrhea was carried out among U.S. military personnel participating in routine exercises in several port cities in South America and West Africa. A 5-day, twice daily course of either norfloxacin (400 mg) or trimethoprim/sulfamethoxazole (TMP/SMX, 160/800 mg) was given to 142 volunteers. At the end of 5 days of treatment, diarrhea had resolved in 100% of 73 patients receiving norfloxacin and 97.1% (67/69) receiving TMP/SMX. A probable bacterial pathogen was determined in 44% of 142 subjects: 49% of the norfloxacin group and 39% of the TMP/SMX group. The most common pathogens detected were enterotoxigenic Escherichia coli in 20% of cases and rotavirus in 15%. Resistance to TMP/SMX was present in 20 (27%) bacterial isolates, while no resistance to norfloxacin was found. Eight of 10 patients in the TMP/SMX treatment group who had TMP/SMX-resistant bacterial enteropathogens improved clinically. Both norfloxacin and TMP/SMX were clinically effective in the treatment of travelers' diarrhea in this military population.

The use of the bromine partition test in the diagnosis and prognosis of tuberculous meningitis.

The bromine partition test was successfully used to differentiate cases of proven tuberculous meningitis from patients with aseptic and non-tuberculous meningitis. Forty patients, 22 males and 18 females aged 5 to 30 years (mean 13.5 +/- 6.2), were included in the study. Nineteen patients were confirmed to have tuberculous meningitis, 12 had aseptic meningitis, and 9 bacterial meningitis. All patients received 0.6 mci/kg of bromine 82 administered through a nasogastric tube as ammonium bromide dissolved in 5 ml of isotonic sodium chloride. The serum to CSF bromine ratio was then calculated 48 hours after the dose. The test was then repeated 8 days later in patients with bacterial meningitis and 8, 90, and 180 day later in patients with tuberculous meningitis. The test was very useful in quickly differentiating cases of aseptic from bacterial and tuberculous meningitis and was also a useful prognosticator in patients with severe tuberculous meningitis.

The value of the tuberculin skin test in patients with tuberculous meningitis.

To determine the clinical utility of the tuberculin purified protein derivative (PPD) skin test in patients suspected of having tuberculous meningitis (TBM), the test was applied on admission to 180 patients suspected of having tuberculous meningitis and to 50 patients with proven bacterial meningitis admitted to the Abbassia Fever Hospital, Cairo, Egypt, during the period 1987 to 1989. Admission tuberculin positivity in evaluated groups revealed the following: overall suspect TBM cases--17% (31/180), culture-confirmed TBM cases--19% (16/83), and culture-confirmed acute bacterial meningitis cases--14% (7/50). Repeat PPD skin test at 60 days in surviving presumptive/confirmed TBM cases revealed a significant increase in tuberculin positivity to 62% (58/93) from admission (p < 0.001). Evaluation of PPD positivity by clinical stage of TBM revealed 36% positivity in alert patients as compared to 12% positivity in comatose patients (p = 0.01). Admission tuberculin skin testing as a diagnostic aid for clinical management of tuberculous meningitis is of limited utility in our study population because of the high prevalence of tuberculin positivity in the Egyptian population (potential false positive correlation with the acute presentation) and the advanced stage of TBM at presentation to Egyptian public hospitals (potential false negative correlation).