Thoracic empyema in children: clinical presentation, microbiology analysis and therapeutic options.

Thoracic empyema is an accumulation of purulent fluid in the pleural space presenting as a complication of bacterial pneumonia. The aims of the study were to present the incidence, demographic results, clinical presentation, laboratory and microbiology results, imaging and the therapeutic options. From January 1992 until December 2009 we collected data of children hospitalized with empyema in our medical center in north of Israel. Empyema was found in 53 pediatric patients. The median age of the patients was 3 years and 31 (58%) were male. Forty one (77%) of the cases were diagnosed in the last nine years. Fever, cough and respiratory distress were the most frequent clinical signs. In 29 (55%) patients pleural effusion was found at admission. Chest ultrasound was performed in 44 (83%) of the patients. Causative organisms were confirmed by culture in 35 patients. Positive culture was found in 17 (32%) patients in the pleural fluid. Streptococcus pneumoniae was the leading pathogen. The drugs the patients received at admission were penicillin in 21 cases, cefuroxime in19 cases and ceftriaxone in 11 cases. During hospitalization a change of antibiotic therapy was required, using mainly ceftriaxone and clindamycin. The pleural purulent fluid was drained by video assisted thoracoscopy surgery in 34 (64%) patients. All the children recovered. The incidence of empyema as a complication of community acquired pneumonia had increased in the last decade in our region. Streptococcus pneumoniae is the most common pathogen. Third generation cephalosprins and clindamycin can be suggested as a good empiric treatment.

Sixth Nerve Palsy in Children Etiology, Long-Term Course, and a Diagnostic Algorithm.

BACKGROUND: Acute onset strabismus is worrisome for parents and physicians. This condition is sometimes attributed to sixth cranial nerve palsy, which may be secondary to various etiologies. Debate still exists about the appropriate diagnostic approach. OBJECTIVE: The objective of this study was to describe the common etiologies of sixth nerve palsy in our pediatric population and to suggest a clear, implementable diagnostic algorithm. METHODS: The authors conducted an electronic medical review of files of patients admitted to the pediatric department at Emek Medical Center between January 2014 and April 2020. They reviewed the medical records from the study period of patients with the following diagnoses according to the International Classification of Diseases 9: sixth nerve palsy, acute infective polyneuritis, Guillain-Barré syndrome, benign intracranial hypertension, malignant neoplasm of the brain, strabismus, myasthenia gravis, and multiple sclerosis. The authors extracted information regarding clinical presentation, previous history, and diagnostic work-up, including serological testing, cerebrospinal fluid testing, and neuroimaging. Final diagnosis and clinical follow-up were assessed. RESULTS: Seventeen patients with sixth nerve palsy were identified. The most common etiologies were increased intracranial hypertension and anti-GQ1B syndrome (3 patients each). CONCLUSIONS: This is a retrospective study of patients diagnosed in one medical center. The suggested algorithm was not validated on a prospective study. The etiologies of sixth nerve palsy in children are variable. The authors suggest performing neuroimaging in all patients and considering serum and cerebrospinal fluid testing in selected patients. Initial neuroimaging combined with laboratory testing is useful and provides rational tools for proper diagnosis.

Campylobacter gastroenteritis in children in north-eastern Israel comparison with other common pathogens.

Gastroenteritis is common among children. Campylobacter jejuni is one of the main causative bacterial pathogens, together with Shigella, Salmonella and invasive Escherichia coli. Campylobacteriosis is a zoonotic, usually self-limited disease that does not always require antibiotic treatment. In cases of protracted diarrhoea in healthy children or immunocompromised patients, antibiotic treatment is recommended, and the drug of choice is still macrolides, with very low resistance rates in Campylobacter species. However, it is crucial to isolate the causative organism, because some cases, such as Shigella encephalitis, call for initiation of empiric antibiotic treatment. In this study, we compared the incidence, epidemiology, clinical findings and laboratory results of gastroenteritis with dysentery caused by these organisms in children in our area. C. jejuni was found to be the leading pathogen in children hospitalized with bacterial gastroenteritis, followed by Shigella and Salmonella. Macrolides were the drug of choice for Campylobacter, and ceftriaxone and ciprofloxacin were the best empiric treatments for Shigella and Salmonella, respectively.

Growth hormone deficiency in children with antenatal Bartter syndrome.

Background Bartter syndrome is a group of rare autosomal-recessive renal disorders characterized by hypokalemic hypochloremic metabolic alkalosis associated with severe growth failure; the exact causes for growth retardation are unclear. GH deficiency (GHD) has been reported in a few cases of Bartter syndrome. The aim of our study was to determine the prevalence of GHD in children with antenatal Bartter syndrome and to assess their response to GH therapy. Methods Ten patients aged 1.5-14.5 years and diagnosed with antenatal Bartter syndrome were enrolled. Seven children with short stature underwent GH stimulation tests. Results Common presenting symptoms were failure to thrive and polyuria. The mean patient height at study entry was -2.7 standard deviation (SD) (range 0.89 to -5.95) and mean weight (SD) was -1.7 (range 1.89 to -4.11). A decline in height and weight (SD) was observed over the years. GHD was diagnosed in four children and GH therapy was started in all of them. Two patients responded very well and gained >1 SD in height, one patient stopped therapy due to non-adherence and one had a poor response. Conclusions In addition to other important causes for poor growth in antenatal Bartter syndrome, our findings suggest that GHD should also be considered as a cause of growth retardation and therefore, clinical assessment of the GH axis is recommended. GH therapy has a role in the treatment of growth failure in some individuals with Bartter syndrome.

The utility of next generation sequencing in the correct diagnosis of congenital hypochloremic hypokalemic metabolic alkalosis.

Persistent hypokalemic hypochloremic metabolic alkalosis represents a heterogeneous group of genetic disorders of which the most common is Bartter syndrome (BS). BS is an inherited renal tubulopathy caused by defective salt reabsorption in the thick ascending loop of Henle, which results in persistent hypokalemic hypochloremic metabolic alkalosis. Here we report a 10-year-old girl of a consanguineous family. She presented prenatally with severe polyhydramnios and distended bowel loops. Thereafter, she displayed failure to thrive and had recurrent admissions due to dehydration episodes associated with diarrhea, and characterized by hypokalemia, hypochloremia and metabolic alkalosis. BS was considered her working diagnosis for several years despite negative genetic analysis of the known genes associated with BS. Whole exome sequencing identified a novel homozygous c.1652delT deleterious frameshift mutation in the SLC26A3 gene, which confirmed the diagnosis of congenital chloride diarrhea (CCD), a rare autosomal recessive disease that mimics biochemically BS. A review of twelve additional reported cases of CCD that were initially misdiagnosed as BS, emphasizes CCD in the differential diagnosis of BS, and highlights the clinical discrepancies between these two entities. Taken together, our report further emphasizes the typical clinical features of CCD, and the importance of next generation sequencing in the diagnosis of syndromes with genetic heterogeneity. We suggest including SLC26A3 in the extended BS targeted gene panels.

Antibiotic consumption successfully reduced by a community intervention program.

BACKGROUND: The association between antibiotic use in the community and antimicrobial resistance is known. Attention has recently focused on the type of agents being prescribed. OBJECTIVES: To implement, evaluate and compare the efficacy of two community intervention programs--continuous versus seasonal medical education--oriented to primary care physicians with emphasis on the appropriate use of antimicrobial drugs. METHODS: From October 2000 to April 2003 we conducted two interventions: a) a monthly educational campaign in selected clinics promoting appropriate diagnosis of common infectious diseases and prudent antibiotic use (continuous intervention group); and b) a massive educational campaign, conducted before two consecutive winters, promoting the judicious use of antibiotics for treating respiratory infections (continuous intervention group and seasonal intervention group). Sixteen similar clinics were randomized (8 to each group). The total antibiotic use was measured as defined daily dose/1000 patients/day, and compared between the groups. RESULTS: The total use of antibiotics decreased between 1999-2000 and 2002-2003 in both groups, but slightly more significantly in the continuous intervention group. The DDD/1000 patients/day for the seasonal group in 1999-2000 was 27.8 vs. 23.2 in 2002-2003; and for the continuous group 28.7 in 1999-2000 vs. 22.9 in 2002-2003, a reduction of 16.5% and 20.0% respectively (P < 0.0001). The main change in antibiotic use was noted for broad-spectrum antibiotics. CONCLUSIONS: We present a successful community intervention program aimed to reduce unnecessary antibiotic use. Amplification of this type of intervention is imperative to stop the increase in antimicrobial resistance.

Acute otitis media in infants less than three months of age: clinical presentation, etiology and concomitant diseases.

OBJECTIVE: Acute otitis media (AOM) in the neonatal period can be difficult to diagnose. This infection can be isolated and localized, or it may be associated with serious bacterial infections or other illnesses. The objectives of this study were to determine the clinical presentation, etiology, susceptibility pattern, and frequency of bacteremia, meningitis and other serious bacterial infections associated with the first episode of AOM in young infants. METHODS: From July 2002 to August 2004, infants less than 12 weeks of age with confirmed AOM underwent tympanocentesis with culture of the middle ear fluid. Sepsis work-up was performed in all infants, and they were admitted to the pediatric department. Parenteral antibiotic therapy with a combination of ampicillin and gentamicin was initiated. RESULTS: Sixty-eight infants were diagnosed with AOM. The median age was 43+/-17 days, 17 infants (25%) were less than 4 weeks of age. Fever was present in 45 (66%) of the patients. Meningitis or bacteremia was not diagnosed in any of the cases. Concomitant urinary tract infection was diagnosed in six (8.8%) cases and broncholitis in seven (10.4%). Forty-seven bacterial pathogens were isolated from the middle-ear fluid. Streptococcus pneumoniae was the leading pathogen with 18 isolates (38%), followed by non-typable Haemophilus influenzae with nine (19%). Fourteen of the S. pneumoniae (78%) isolates were susceptible to penicillin and the other four (22%) were intermediately resistant. Three (33%) of the nine H. influenzae isolates were beta-lactamase producers. CONCLUSIONS: In our study, AOM in infants less than 3 months of age is a localized infection and it is not associated with severe bacterial infections. S. pneumoniae and H. influenzae are the leading pathogens. In our region, most of S. pneumoniae strains are still susceptible to penicillin. Although only small number of patients were under 4 weeks of age, the results of the present study raise the question of whether the current policy of a full sepsis work-up in neonates with AOM is relevant.

[Brucellosis: clinical presentation, diagnosis, complications and therapeutic options].

Brucellosis is a zoonotic disease that causes systemic symptoms and can involve many organs and tissues. The major sources of infection are consumption of unpasteurized diary products and occupational contact. Brucella is a small, gram-negative coccobacillus that grows slowly in vitro. There are four species of brucella that are pathogenic for humans; in Israel Brucella melitensis is still the most frequent organism. There are several methods to identified the organism and make the diagnosis (1) isolation of brucella from blood, tissue specimens, body fluids and bone marrow; (2) agglutination test and (3) polymerase chain reaction (PCR) that has recently been shown to be a promising tool for the diagnosis of acute disease. Involvement of the musculoskeletal system is the most common complication of brucellosis, while meningitis and endocarditis are life-threatening complications. The standard treatment for acute and chronic brucellosis is a combination of doxycycline with a second drug such as rifampicin or gentamicin, in order to cure, prevent complications and relapse. Although the rate of occurrence is ever-decreasing due to vaccination of animals, nonetheless, the disease has not been eradicated in Israel. This review focuses on the clinical presentation, diagnosis, and mainly on complications of brucellosis and the available therapeutic options.

Brucellosis Outbreak in Children and Adults in Two Areas in Israel.

Two parallel outbreaks of Brucella melitensis infection occurred in 2014 in two geographical areas in Israel. In two medical centers in northern Israel and one medical center in Jerusalem, 102 patients (58 children, 47 adults) were diagnosed with brucellosis. Most patients (N = 76, 72%) were Muslim Arabs, 28 (27%) were Druze, and one was Jewish. The source of infection was often traced to cheese from the Palestinian Authority. Biovar-1 was evident in 98% in northern Israel but only in 42% in Jerusalem. Most common manifestations were fever (82%) and osteoarticular symptoms (49%). The major differences between the geographic areas were ethnicity and duration until diagnosis. Compared with adults, children had higher rates of hospitalization (93% versus 64%, P = 0.001), osteoarticular symptoms (60% versus 36%, P = 0.05), elevated alanine aminotransferase (12% versus 0%, P = 0.01), and lower C-reactive protein (2.28 ± 2.08 versus 5.57 ± 6.3l mg/dL, P = 0.001). Two unrelated brucellosis outbreaks occurred in 2014 in two different geographic areas of Israel and were limited to sections of the Arab and Druze populations. Most of the demographic and clinical aspects of patients were not affected by geographic variability. Clinical and laboratory differences were found between children and adults emphasizing the nonuniformity of the disease in different age groups. Effective control of unpasteurized dairy foods, health education programs, and improved regional cooperation are required to control brucellosis in Israel.

Procalcitonin as a diagnostic aid in osteomyelitis and septic arthritis.

OBJECTIVES: Plasma procalcitonin (PCT) increases rapidly during bacterial infections but remains low in viral infections and other inflammatory processes. High plasma PCT typically occurs in children with bacterial meningitis, severe bacterial infections, particularly in cases of septic shock or bacteremia, and in renal parenchymal damage. The aim of this study was to test the usefulness of plasma PCT analysis in the diagnosis of osteomyelitis, septic arthritis, and other skeletal inflammatory diseases in pediatric patients admitted because of fever and limping. METHODS: White blood cell count, erythrocyte sedimentation rate, C-reactive protein, and PCT levels were measured in children admitted to the pediatric department with fever, limping, and suspected osteomyelitis or septic arthritis. PCT levels were measured by an immunochromatography assay, based on monoclonal and polyclonal antibodies against katacalcin. RESULTS: Forty-four children were evaluated: 12 (27.3%) were diagnosed with osteomyelitis, 11 (25%) had septic arthritis, 5 children (11.4%) were diagnosed as a soft tissue infection, and transient synovitis or reactive arthritis was diagnosed in another 6 children (13.6%). Four children (9.1%) were diagnosed as having juvenile rheumatoid arthritis, and 6 (13.6%) with different diseases. PCT value was elevated in 7 patients (58.3%) with osteomyelitis, and only 3 children (27.2%) with the diagnosis of septic arthritis had a mildly elevated value. Among the children with other diagnosis, there were no positive PCT values (P < 0.001 between skeletal infection and all other diagnosis). CONCLUSIONS: In this study, PCT was found to be a useful marker in the diagnosis of osteomyelitis and not in septic arthritis. A larger group of patients needed to be studied to confirm our findings.

Community-acquired urinary tract infection in hospitalized children: etiology and antimicrobial resistance. A comparison between first episode and recurrent infection.

Urinary tract infection (UTI) is common in infants and children, and Escherichia coli is the leading pathogen. The aims of this study were to compare first episode of UTI with recurrent infection, reveal organisms that cause UTI, uropathogen resistance, and presence of bacteria producing extended-spectrum ß-lactamase (ESBL). The first-UTI group included 456 children. E coli was the leading pathogen (80.5%), and Pseudomonas aeruginosa was found in 1.5%. The uropathogens were resistant to gentamicin (3.41%) and cefuroxime (5.71%), and highly resistant to cefamezin (37.39%). The recurrent-infection group included 106 children. E coli was also the leading pathogen, but 7.5% of the isolates were P aeruginosa (P = .002 compared with first-episode group); 6.6% were ESBL-producing bacteria compared with 1.1% in the first-episode group (P = .002). E coli is the leading pathogen in both groups. P aeruginosa and ESBL-producing bacteria were more common in the recurrent infection group.

Long-term follow-up of women hospitalized for acute pyelonephritis.

Long-term outcome of acute pyelonephritis (AP) in adults is unknown. We evaluated the frequency of renal damage 10-20 years after hospitalization for AP in adult women and the utility of technetium Tc 99m-labeled dimercaptosuccinic acid (Tc 99m-DMSA) scanning for detection of renal scars; 63 of 203 women hospitalized with AP during 1982-1992 were included in the study. Tc 99m-DMSA scanning detected renal scarring in 29 women (46%). Multivariate analysis showed that pregnancy and hypoalbuminemia (albumin level, <3.2 g/dL) at hospitalization were independent risk factors for subsequent development of renal scars. At follow-up, hypertension was observed in approximately one-fifth of patients, regardless of renal scarring status. Four women with scars had a glomerular filtration rate of < or =75 mL/min; none of them developed severe renal impairment. In conclusion, the risk of developing renal scarring after AP in adult women is high. However, clinically relevant renal damage is rare 10-20 years after AP. Tc 99m-DMSA scanning is useful for detecting renal scars in adults but is not routinely needed in practice.

Acute neonatal suppurative parotitis: case reports and review.

We describe two cases of neonatal suppurative parotitis caused by Staphylococcus aureus. Only 32 cases of neonatal suppurative parotitis (72% male) have been described in the English literature in the last 35 years. Thirty-eight percent were premature babies, only 41% were febrile and the causative agent in most cases was S. aureus. Recovery was achieved in 78% of the patients with antibiotic therapy without drainage.

Improved antimicrobial susceptibility of community-acquired uropathogens in northern Israel (1995-1999-2002).

Since antimicrobial therapy for the treatment of community-acquired urinary tract infection is given empirically, knowledge of local antimicrobial sensitivity patterns is essential for clinicians. This study compares the susceptibility to antimicrobial drugs, of all urinary isolates from outpatients processed at the Ha'Emek Medical Center during 1995, 1999 and 2002. No significant changes in the susceptibility to ceftriaxone and ciprofloxacin were seen over this period of time. There was a significant increase in susceptibility to amoxycillin-clavulanate, TMP-SXZ, cefuroxime and nitrofurantoin. MIC(90) values of all drugs except amoxicillin-clavulanate remained stable. In contrast to a worldwide increase in resistance, we observed not only a halt in this trend, but also an improvement in antimicrobial susceptibility of uropathogens in northern-Israel.

Susceptibility of Streptococcus pyogenes to two macrolides in northern Israel.

In the present study, the minimal inhibitory concentration (MIC) of azithromycin and roxithromycin for 200 Streptococcus pyogenes isolates from outpatients with tonsillopharyngitis were determined using Etest. All but one (99.5%) of the isolates were sensitive to both antibiotics; the MIC of the resistant isolate being 12 mg/l to azithromycin and 32 mg/l to roxithromycin. In this region, macrolides remain the drug of choice for the treatment of patients with S. pyogenes tonsillitis who present allergy to penicillin. The routine testing of susceptibility of S. pyogenes to macrolides in northern Israel is not justified.

Streptococcal necrotizing fasciitis with toxic shock syndrome following cervical adenitis.

In the recent years an increase of serious invasive infections due to Group A Streptococcus have been reported. Necrotizing fasciitis is a rapidly progressive soft tissue infection characterized by necrosis of the subcutaneous tissues and superficial fascia. We report a case of necrotizing fasciitis and toxic shock syndrome following cervical adenitis in a previously healthy 11-month-old boy. Cultures from blood and the necrotic lymph node grew Group A Streptococcus. Group A Streptococcus belonging to M1 serotype and producing streptococcal pyrogenic exotoxin, SPE A was identified. Full recovery was achieved by aggressive treatment, which included intensive care support, extensive surgical debridement of necrotic lesions and antibiotic treatment with the combination of penicillin and clindamycin.

Acute mastoiditis in children: Pseudomonas aeruginosa as a leading pathogen.

OBJECTIVE: Acute mastoiditis is a serious bacterial infection of the temporal bone and is the most common complication of otitis media. The goal of this study is to assess the clinical features, pathogens, management, and outcome of acute mastoiditis in children in northern Israel. METHODS: A systematic review of medical records of all children who were admitted with acute mastoiditis from January 1990 through December 2000. RESULTS: Fifty-seven children were included. Median was age: 36 months. In 26 patients (45.6%) mastoiditis complicated the first episode of acute otitis media (AOM). Twenty-five children (44%) received antibiotic treatment prior to admission. Frequent symptoms included mastoid area erythema in 54 children (94.7%), proptosis of the auricle in 52 children (91.2%) and fever in 43 children (75.4%). Middle ear, and subperiostal culture yielded growth of pathogen in 30 children (75%), two cultures yielded more then one pathogen. The most frequent pathogens were: Pseudomonas aeruginosa in 10 children (25%), Streptococcus pneumoniae in eight children (20%), Group A streptococcus in six children (15%). The highest incidence of Streptococcus pneumoniae was found in children who did not suffer from AOM before admission (35 vs. 5%). Fifty-two (91.2%) children were cured with antibiotic treatment alone. Seventeen children underwent computed tomography (CT) of the mastoid. Mastoid bone destruction was demonstrated in six children and subperiostal abscess in eight. Mastoidectomy was performed in five children. CONCLUSIONS: The diagnosis of acute mastoiditis can be made on clinical basis alone requiring CT only when complications are suspected. Half of the children admitted with acute mastoiditis had no previous history of recurrent AOM. In those children S. pneumoniae was the leading pathogen while P. aeruginosa was more prevalent in children with recurrent AOM. Most of the children recovered with medical therapy alone, without surgical intervention.