A predictive model to estimate the risk of serious bacterial infections in febrile infants.

UNLABELLED: Low risk criteria have been defined to identify febrile infants unlikely to have serious bacterial infection (SBI). Using these criteria approximately 40% of all febrile infants can be defined as being at low risk. Of the remaining infants (60%) only 10%-20% have an SBI. No adequate criteria exist to identify these infants. All infants aged 2 weeks-1 year, presenting during a 1-year-period with rectal temperature > or = 38.0 degrees C to the Sophia Children's Hospital were included in a prospective study. Infants with a history of prematurity, perinatal complications, known underlying disease, antibiotic treatment or vaccination during the preceding 48 h were excluded. Clinical and laboratory variables at presentation were evaluated by a multivariate logistic regression model using SBI as the dependent variable. By using likelihood ratios a predictive model was derived, providing a post test probability of SBI for every individual patient. Of the 138 infants included in the study, 33 (24%) had SBI. Logistic regression analysis defined C-reactive protein (CRP), duration of fever, standardized clinical impression score, a history of diarrhoea and focal signs of infection as independent predictors of SBI. CONCLUSION: CRP, duration of fever, the "standardized clinical impression score", a history of diarrhoea and focal signs of infection were the independent, most powerful predictors of SBI in febrile infants, identified by logistic regression analysis. Although the predictive model is not validated for direct clinical use, it illustrates the clinical potential of the used technique. This technique offers the advantage of assess the probability of SBI in every individual infant. This probability will form the best basis for well-founded decisions in the management of the individual febrile infant.

[Problems in the use, cleaning and maintenance of nebulization equipment in the home situation]. / Problemen met gebruik, reiniging en onderhoud van vernevelapparatuur in de thuissituatie.

OBJECTIVE: To determine whether jet nebulizers used at home for the treatment of children with asthma are used optimally. DESIGN: Descriptive. SETTING: Outpatient clinic for child pulmonary diseases of the Academic Hospital/Sophia Children's Hospital Rotterdam and outpatient clinic for child diseases of the Baronie Hospital Breda, the Netherlands. METHOD: Thirty-nine children aged 0-13 years and their parents were interviewed at home, and medication cup, saline and aerosol were cultured for bacterial analysis. The pressures of the compressor and nebulizer were measured with a manometer, and the particle size of the aerosol of 10 jet nebulizers was measured by laser technique. RESULTS: The suppliers of the nebulizer did not provide clear instructions on user-related aspects and technical maintenance of the jet nebulizer. Many patients used damaged and poorly functioning, contaminated jet nebulizers. Contamination by potentially pathogenic micro-organisms was present in 50% of the saline, medication cups and aerosols (Klebsiella, Enterobacter, Pseudomonas, Serratia, Escherichia coli). The operating pressure of compressor and nebulizer was below the requirements in more than 50% of the jet nebulizers. In addition, we found that the aerodynamic mass median diameter increased considerably as the nebulizer became older. In 6/10 nebulizers the particle size was below 5 microns. CONCLUSION: A periodical checkup of user-related aspects and technical quality of jet nebulizers is necessary. The quality of the instruction to users about the procedure for cleaning and maintenance of the jet nebulizer should be improved.

Staphylococcal pneumonia in childhood: will early surgical intervention lower mortality?

Staphylococcus aureus pneumonia (SAP) continues to be a serious bacterial infection which is associated with a high incidence of complications. We retrospectively reviewed the case records of 36 infants and children admitted with SAP to the Sophia Children's Hospital between 1970 and 1992 to analyse changes over time in the clinical presentation, diagnostic work-up, management and complications. Fifteen of these 36 children (42%) were less than 1 year old. Fever (97%) and respiratory distress (83%) were the most common symptoms at the initial presentation. Chest X-ray findings on admission or during hospitalisation included pleural effusion (75%), pneumothorax (47%), and abscess and/or pneumatocele (39%). Diagnostic and/or therapeutic thoracentesis of pleural fluid was performed in 17 of the 36 patients (47%). Twenty-one patients (58%) needed chest tube drainage. Twelve had a thoracotomy (33%). Artificial ventilation was needed in 13 of the patients (36%). Extrapulmonary complications included convulsions in 6 patients (17%) and osteomyelitis in 2 children (6%). The mean duration of hospitalization was 36 days. Two of the 36 children died (6%). The low mortality rate in this study may be the result of the relatively high rate of thoracotomy and of improvements in supportive treatment.

[Gram staining and bacterial culture of stomach contents of the full-term neonate in prolonged status of ruptured membranes is not useful]. / Gram-preparaat en bacteriekweek van de maaginhoud van de voldragen pasgeborene bij langdurig gebroken vliezen niet zinvol.

In an effort to evaluate the management of full-term neonates born after prolonged rupture of the membranes, we studied 159 full-term newborn infants born 24 hours or more after rupture of the membranes retrospectively. Gram stain and bacterial culture of a gastric aspirate of the neonates were significantly related; however, the predictive value of the Gram stain was low, both for a positive test (46%) and for a negative test (70%). A significant relation was not found between the Gram stain (presence of bacteria or greater than or equal to 4 leucocytes per high power field) or the bacterial culture on the one hand and the occurrence of clinical symptoms of infection on the other. In all cases the decision to treat the newborn with antibiotics was made on the basis of the clinical symptoms alone. In our opinion the routine study of Gram stain and bacterial culture of a gastric aspirate of full-term neonates born after prolonged rupture of the membranes is not useful; observation alone is sufficient.

Childhood meningitis caused by enterococci and viridans streptococci.

Selected clinical and laboratory parameters were studied respectively in patients with meningitis caused by enterococci and viridans streptococci in an academic children's hospital. During a nine-year period (1981-1989), enterococci or viridans streptococci were isolated from the cerobrospinal fluid (CSF) of 48 patients. In nine of these 48 patients, enterococci or viridans streptococci were the causative agents of meningitis. These nine children constituted 2.0% of 450 patients with bacterial meningitis in this period. All nine children suffered from underlying diseases; neurosurgical procedures were performed in six of these patients, of whom four had ventricular drains. A head trauma preceded the development of meningitis in another patient. Drainage of the lacrimal duct was associated with the development of meningitis in another patients. One child concurrently suffered from severe gastroenteritis. CSF leukocyte count and CSF protein levels were moderately elevated, whereas CSF glucose levels were either slightly decreased or within the normal range. Meningitis due to enterococci or viridans streptococci is seen predominantly in children under the age of one year. Predisposing factors, including neurosurgical procedures, head trauma and severe gastroenteritis, are usually present in these patients. The prognosis for recovery is generally good.

Antibiotic resistance in Haemophilus influenzae: mechanisms, clinical importance and consequences for therapy.

Invasive and non-invasive infections caused by Haemophilus influenzae are frequently diagnosed in children below the age of 5 years. The treatment of choice for these infections was ampicillin. However, since the early 1970s the increasing prevalence of resistance to ampicillin and other antibiotics has necessitated major changes in antibiotic therapy. This article summarizes some of the important clinical features of diseases caused by H. influenzae. The epidemiology, the problems with in vitro susceptibility testing and the mechanisms of resistance to major antibiotics are reviewed. The consequences of antibiotic resistance for the treatment of diseases caused by H. influenzae are discussed.

[Lung infections with atypical features]. / Longinfecties met atypische aspecten.

The clinical difference between a lobar pneumonia caused by pneumococci or other bacterial agents and lower respiratory tract infections presenting with atypical symptoms is important. Mycoplasma pneumoniae, chlamydia species, Coxiella burnetii and several viruses amongst others are micro-organisms which cause atypical symptoms. All the time new types of micro-organisms like Ureaplasma urealyticum are found as a cause of pneumonia with atypical symptoms. Special diagnostic tools like cultures, serological or antigen detection are often needed to determine the exact causative agent. Clinical data are important to suspect a specific micro-organism.

Disinfecting effect of a disposable lubricant during cystoscopy.

To study the disinfecting effect of the lubricant Instillagel for the urethra in children, bacteriologic tests of the urethra were performed immediately before and after cystoscopy in 100 children. In addition urine cultures were taken during and after cystoscopy. The culture of the urethra before cystoscopy was positive in 75 children. For 46 of these children the second culture after cystoscopy plus Instillagel appeared to be sterile while in 20 children a considerable reduction in the number of bacteria was found. Out of 92 children with an initially sterile urine culture, the culture of the urine voided immediately after the cystoscopy appeared to be contaminated in 2 while several weeks later an infected urine was found in 5 children. From this study we may conclude that during cystoscopy Instillagel has a good disinfecting effect for the urethra in children.

Tobramycin in patients with cystic fibrosis. Adjustment in dosing interval for effective treatment.

The efficacy of the dosing regimen of tobramycin was investigated in 28 patients with cystic fibrosis who had an acute exacerbation of chronic pulmonary infection with Pseudomonas aeruginosa. The initial dose of tobramycin was 3.3 mg/kg of body weight three times daily (ie, 10 mg/kg/day). A highly significant relationship was found between the serum concentration of tobramycin before the dose and the change in the forced expiratory volume in one second (FEV1), both measured on the tenth day of treatment (rs = 0.75; p less than 0.001). In nine of the 16 patients who had a six-hour serum concentration of 1 mg/L or less on the tenth day of treatment, the eight-hour dosing interval of tobramycin was shortened to achieve a serum concentration of tobramycin of about 1 mg/L before the dose. In the other seven patients, the dosage of tobramycin was not changed. On the 20th day, seven of the nine patients in whom the dosing interval was shortened exhibited an increase in FEV1 of 20 percent or more. Such an increase was observed only in one of the seven patients in whom the dosing interval was not reduced (p less than 0.05). We conclude that individualizing the dosage of tobramycin in patients with cystic fibrosis results in a better clinical outcome.

[Is juvenile seborrheic dermatitis a candidiasis? Studies of a possible link with microbial infections]. / Is juveniele seborrhoïsche dermatitis een candidide? Onderzoek naar mogelijk verband met microbiële infecties.

Infantile seborrheic dermatitis (ISD), a disease occurring in the first months of life, is an erythematosquamous skin disease of unknown origin. This article presents results of microbial studies in 20 patients with ISD. Isolation of candida in a high percentage may indicate a primary role of this micro-organism in the etiology of this disease. It is striking that this disease often starts after disturbing the microbial colonization of the intestinal tract. Often ISD develops during the transition of breastfeeding to humanized cow milk.

Chequerboard titrations: the influence of the composition of serial dilutions of antibiotics on the fractional inhibitory concentration index and fractional bactericidal concentration index.

Chequerboard titrations carried out with modified serial dilutions of antibiotics such that consecutive concentrations in these series were four times smaller than those in two-fold serial dilutions enable MICs and MBCs to be determined with greater accuracy. Interaction indices calculated by this method can differ markedly from those calculated on the basis of two-fold serial dilutions. The differences calculated in this study ranged from -0.30 to +1.06.

The efficacy of the combination of Timentin and tobramycin in the treatment of patients with bacteraemia.

Twenty-eight patients with bacteraemia were treated with Timentin, a combination of ticarcillin and clavulanic acid, and tobramycin. According to a simple physiological classification scheme 20 patients were moderately and eight severely ill. Clinical cure was achieved in 15 of 20 moderately ill and in four of eight severely ill patients. The nine therapeutic failures were due to non-removable foreign material (2 cases), abscesses that were not effectively evacuated (5 cases), urolithiasis (1 case), and decubitus ulcer (1 case). One of these cases was complicated by infection with a Klebsiella strain with Timentin and tobramycin MICs of 64 mg/l. Thirteen of 31 bacterial isolates from blood were resistant to greater than or equal to 128 mg/l of ticarcillin of which 11 were susceptible to less than or equal to 64 mg/l of Timentin. The addition of Timentin to tobramycin offered a better coverage in vitro than ticarcillin combined with tobramycin against the strains isolated from the blood of the patients included in this study.

Infantile seborrheic dermatitis. Morphological and immunopathological study.

The pathomechanisms of infantile seborrheic dermatitis (ISD) are unknown. An allergic reaction to candidal antigens is one of the hypotheses. The skin of 6 patients suffering from ISD was studied by immunostaining techniques. The lymphocytic infiltrate was composed of Leu4-reactive T cells in which Leu3a-reactive (helper/inducer) cells predominated. Direct immunofluorescence studies revealed no significant deposits of immunoglobulins or complement factors. No candidal antigens could be demonstrated, either in epidermis or in dermis, although candida species were cultured from different sites in 4 of the 6 patients.

Pharmacokinetics of tobramycin in patients with cystic fibrosis. Implications for the dosing interval.

The pharmacokinetics of tobramycin were evaluated in 15 patients (8 to 22 years of age) with cystic fibrosis (CF). A dose of 3.0 to 3.3 mg/kg of body weight was given intravenously over 20 minutes, and concentrations in serum were followed up to eight hours after initiation of the infusion. In the calculation of pharmacokinetic parameters, a two-compartment open model was used. The elimination half-life of the drug was highly inversely correlated with age (p less than 0.0004), and body weight (p less than 0.00002). Total body clearance (TBC), and volume of distribution at steady state (VDSS) were directly correlated with age and body weight. However, when TBC and VDSS were corrected for BSA, no correlation could be demonstrated. The mean one-hour and eight-hour serum concentrations of tobramycin were 5.40 and 0.45 microgram X ml-1, respectively. Between patients, considerable differences were found in the time after administration at which the serum concentration decreased below 1 microgram X ml-1. This interpatient variation has clinical implications for tobramycin therapy in CF, in particular for the dosing interval.

Quantitative study of the aerobic and anaerobic faecal flora in neonatal necrotising enterocolitis.

Faeces from 24 neonates with proved necrotising enterocolitis (NEC), from 12 with clinically suspected NEC, and from 41 control infants were quantitatively cultured under aerobic and anaerobic conditions. An important difference in colonisation with Klebsiella was found between the NEC groups and the control group. Although the cause of NEC is unknown, colonisation with Klebsiella seems to increase the risk.

Plasma prekallikrein and endotoxemia in liver cirrhosis.

In liver disease low prekallikrein levels may be found which has been suggested to be due to diminished synthesis. However, it may also be due to endotoxemia accompanying liver disease. To study the last possiblity prekallikrein, endotoxins and Normotest were determined in 18 cirrhosis patients. The relation between the prekallikrein concentration (after 15 min activation) and the Normotest was significant (r = + 0.72, P less than 0.001). Endotoxemia was only found in the more severe forms of liver disease (Normotest below 60%). During endotoxemia the prekallikrein levels were significantly lower than when no endotoxins were present in the blood of the same patients. The Normotest did not differ significantly in these patients in relation to the presence or absence of endotoxins. The activation of prekallikrein was slower in the more severe forms of liver disease. This might be due to reduced levels of factor XII and high molecular weight kininogen. In conclusion the reduced prekallikrein level in liver cirrhosis may be due to both diminished synthesis and endotoxemia. In the more severe forms of liver disease the time necessary to activate prekallikrein is increased.