The impact of an enteroviral RT-PCR assay on the diagnosis of aseptic meningitis and patient management.

BACKGROUND: Enterovirus (EV) is a major cause of aseptic meningitis and non-specific febrile illness in children. Since the majority of patients are hospitalized for possible bacterial infection, a rapid test for the diagnosis of enteroviral meningitis (EVM) may reduce hospitalizations and unnecessary treatments. OBJECTIVE: To review the impact of an EV reverse transcriptase-polymerase chain reaction (RT-PCR) assay for the diagnosis of EVM on patient management. STUDY DESIGN: CSF from 1056 patients admitted to the hospital between 1998 and 2001 was tested using EV RT-PCR. The results were correlated with CSF counts, diagnosis, test turnaround time (TAT) and length of hospital stay (LOS). RESULTS: EV RT-PCR was positive for 113 patients (11%). Of these cases, 92% occurred during the summer months and 77% were in children <19 years of age. Children <3 years old with EVM frequently had non-specific clinical findings and lacked pleocytosis. There was a significant correlation between decreasing LOS and TAT (r(2)=0.97, P<0.001). CONCLUSION: RT-PCR testing for EVM is an important tool to aid in the diagnosis of children with non-specific febrile illness. This test impacted patient management as measured by shortened patient stays, which should translate into significant health care savings.

A one-step RT-PCR assay using an enzyme-linked detection system for the diagnosis of enterovirus meningitis.

BACKGROUND: Enteroviruses are the most common cause of meningitis in the United States, with an estimated 50000-75000 cases each year. Enteroviral meningitis (EVM) is frequently a diagnosis of exclusion, as viral cultures lack sensitivity and require prolonged incubation periods. OBJECTIVE: To develop a sensitive and rapid test for the diagnosis of EVM. STUDY DESIGN: A rapid, one-step, reverse transcriptase-polymerase chain reaction (RT-PCR) was used in a prospective analysis of 160 patients who had cerebrospinal fluid (CSF) tested for enterovirus. RESULTS: Of the 160 patients, 14 were excluded due to missing CSF viral culture data. A total of 14 were CSF culture positive (10 with pleocytosis) and 19 were PCR positive (15 with pleocytosis). The ability to detect enterovirus by either culture or PCR correlated significantly with the white blood cell count in the CSF (P=0.001). Based on a clinical definition of enterovirus culture positive and pleocylosis: ten had definite EVM and 12 had probable EVM (pleocytosis without any other cause). Four had possible EVM (CSF culture positive without pleocytosis) and 18 had pleocytosis due to other causes. PCR was positive in all ten patients with definite EVM. Five out of 12 patients with probable EVM and three out of four patients with possible EVM. No patients with pleocytosis due to other causes were PCR positive and one patient that was defined as EVM negative (culture negative and no pleocytosis) was PCR positive. Overall, PCR was positive in 18 out of the 26 patients with a likelihood of EVM, while CSF culture was positive in only 14 cases. Our results demonstrated that RT-PCR enhances the sensitivity of enterovirus detection in CSF (69 vs. 54% for culture). CONCLUSION: The diagnosis of EVM is difficult to make clinically: the enhanced sensitivity and rapid turn around time of PCR will be of great clinical benefit.

Potential mechanisms for failure to eradicate group A streptococci from the pharynx.

OBJECTIVE: To investigate the relative efficacy of orally administered cefadroxil and penicillin V in the treatment of group A streptococcal (GABHS) pharyngitis and the mechanism(s) responsible for failure of antimicrobial therapy to eradicate GABHS from the pharynx. STUDY DESIGN: A prospective, randomized clinical trial was conducted in four pediatric offices in which 462 patients with acute pharyngitis and positive culture for GABHS were randomly assigned to receive cefadroxil (n = 232) or penicillin V (n = 230). RESULTS: Bacteriologic treatment success rates for patients in cefadroxil and penicillin groups were 94% and 86%, respectively. However, among patients classified clinically as likely to have bona fide GABHS pharyngitis, there was no difference in bacteriologic treatment success rates in cefadroxil and penicillin groups (95% and 94%, respectively). Among patients classified clinically as likely to be streptococcal carriers, bacteriologic treatment success rates in cefadroxil and penicillin groups were 92% and 73%, respectively. The presence of beta-lactamase and/or bacteriocin-producing pharyngeal flora had no consistent effect on bacteriologic eradication rates among patients in either penicillin or cefadroxil treatment groups or among patients classified as having either GABHS pharyngitis or streptococcal carriage. CONCLUSIONS: Neither beta-lactamase nor bacteriocin produced by normal pharyngeal flora are related to bacteriologic treatment failures in GABHS pharyngitis. Cefadroxil seems to be more effective than penicillin V in eradicating GABHS from patients classified as more likely to be streptococcal carriers. However, among patients we classified as more likely to have bona fide GABHS pharyngitis, the effectiveness of cefadroxil and penicillin V seems to be comparable.

Respiratory syncytial virus immune globulin treatment of RSV lower respiratory tract infection in previously healthy children.

OBJECTIVE: To evaluate the efficacy of high titer respiratory syncytial virus (RSV) immune globulin (RSVIG) in the treatment of previously healthy children hospitalized with proven RSV lower tract infection (LRI). METHOD: Infants and young children /=2. 5 were enrolled. RESULTS: One hundred and one previously healthy children hospitalized with RSV LRI received either 1500 mg/kg of RSVIG (RespiGam, MedImmune Inc, Gaithersburg, MD) or albumin placebo in a randomized, double-blind, placebo-controlled trial. Forty-six RSVIG and 52 recipients of placebo met all eligibility criteria. Demographic characteristics of the two groups were similar. More RSVIG recipients (46% vs 29%) had an SaO2 /=3.0) had 1.6 fewer hospital days and 2.7 days less ICU stays. CONCLUSION: RSVIG infusions seemed safe and generally well tolerated. Although some beneficial effect trends were seen for those with more severe disease who were treated there was no evidence that treatment with RSVIG resulted in reduced hospitalization and reduced ICU stays in all children with RSV disease.

Respiratory syncytial virus (RSV) immune globulin intravenous therapy for RSV lower respiratory tract infection in infants and young children at high risk for severe RSV infections: Respiratory Syncytial Virus Immune Globulin Study Group.

OBJECTIVES: To evaluate the efficacy of high-titer intravenous respiratory syncytial virus immune globulin (RSVIG) in the treatment of children at high risk for severe RSV infection who were hospitalized with proven RSV. METHODS: Infants and young children younger than 2 years with bronchopulmonary dysplasia, chronic lung disease, congenital heart disease, or prematurity (<32 weeks' gestational age), hospitalized with a history of lower respiratory tract infection (LRI) of less than 4 days, were enrolled in this study. Patients were randomized in a blinded fashion to receive either 1500 mg/kg RSVIG or placebo in equal volumes. They were evaluated daily for safety and respiratory scores and for RSV nasal shedding. RESULTS: One hundred seven high-risk children were randomized--54 in the RSVIG group and 53 in the placebo group. Of these children, 51 in each group were considered evaluable. Children with pulmonary disease, congenital heart disease, or prematurity were equally distributed between the two treatment groups. However, two important differences were found in baseline variables between the two groups: there were more patients in the placebo group who had histories of previous LRI and there was a trend toward more severe disease at study entry in the RSVIG group. This was manifested by a higher entry respiratory score in the RSVIG group than in the placebo group (3.4 +/- 0.2 vs 3.1 +/- .01). A higher proportion of children in the RSVIG group (47%) than in the placebo group (28%) required intensive care at entry and mechanical ventilation at study entry (31% RSVIG-treated vs 18% placebo-treated patients). No significant difference was found between groups in the mean unadjusted duration of hospitalization (RSVIG group, 9.10 +/- 1.18 days; control group, 8.17 +/- 1.08 days). When the mean was adjusted for entry respiratory score, likewise, no difference was observed between each group (8.41 +/- 0.97 vs 8.89 +/- .99 days). The lack of efficacy observed in the study primary endpoint was observed in all diagnostic groups. No differences between the RSVIG and placebo groups were observed in the following secondary endpoints: duration of intensive care unit stay, duration of intensive care unit stay for RSV, mechanical ventilation, or supplemental oxygen. No significant differences in adverse events were reported in the RSVIG group (16 children) when compared with the control group (10 children). CONCLUSION: RSVIG treatment was safe but not efficacious in the treatment of children with bronchopulmonary dysplasia, congenital heart disease, or premature gestation who were hospitalized with RSV LRI.

Candida albicans arthritis one year after successful treatment of fungemia in a healthy infant.

Fungal arthritis in pediatric patients is rare and is most often associated with hematogenous spread to the affected joint. It is generally seen concomitant with, or shortly after, fungemia. We report a case of an immunocompetent patient in whom candidal arthritis developed 1 year after initial fungemia. The initial candidiasis was considered to be adequately treated with amphotericin B. The Candida isolates from the neonatal fungemia and subsequent arthritis were the some as identified by electrophoretic karyotype, restriction fragment length polymorphism analysis, and antifungal susceptibility testing. Pediatric candidal fungemia, arthritis, and their treatments are discussed.

Cat scratch disease in two children presenting with fever of unknown origin: imaging features and association with a new causative agent, Rochalimaea henselae.

OBJECTIVE: To report the clinical course, imaging findings, and method of diagnosis of two patients with systemic manifestations of cat scratch disease, presenting with fever of unknown origin. DESIGN: Case study. PATIENTS: Two children with fever of unknown origin who had multiple lesions in the liver and spleen, shown on ultrasound, computed tomography, and magnetic resonance imaging. Initial diagnoses were Kawasaki disease (case 1) and metastatic neuroblastoma (case 2). RESULTS: Biopsy material showed granulomatous hepatitis in both patients. The diagnoses were confirmed by positive assays for Rochalimaea henselae, currently thought to be the causative agent of cat scratch disease. CONCLUSION: Cat scratch disease presenting as fever of unknown origin is now well described and can be more readily diagnosed because of the availability of new serologic assays, as well as polymerase chain reaction assays for R henselae DNA in tissue specimens.

Measles antibodies in women and infants in the vaccine era.

The present investigation was done to determine whether measles enzyme immune assay (EIA) absorbency values were lower in women born in the vaccine era after 1963 and their infants in an upstate New York metropolitan area, an area of low measles incidence during the past 10 years compared with women born before the measles vaccine era who had natural measles. Aliquots of 202 sera from mother-infant pairs collected for other purposes from November 1990 to June 1991 at Albany Medical Center Hospital were tested by EIA. The demographic data available for analysis were maternal age and infant gestational age. Measles mean absorbency values were analyzed according to maternal age. Of 202 mother-infant pairs, 30% of mothers and 17% of their infants were seronegative (EIA < 0.16). Mothers born before 1963 and their infants had significantly higher mean EIA absorbency values than mothers born after 1963 and their infants (P < 0.002). The percent seropositive for measles antibodies by EIA for mothers born before 1963 and their infants, 87% and 94%, respectively, was significantly higher than the percent seropositive for mothers born after 1963 and their infants, 61% and 69%, respectively (P = 0.0001). Since the mean measles antibodies as measured by EIA absorbency were significantly lower in the mothers born after 1963 and their infants compared with women born before the vaccine era, the strategy for measles control in the future may have to include lowering the age of infant immunization.

Relatedness of coagulase-negative staphylococci causing bacteremia in low-birthweight infants.

OBJECTIVE: To investigate coagulase-negative staphylococcus (CONS) causing bacteremia in a neonatal intensive care unit (NICU). DESIGN: A 14-month retrospective review of 47 infants in the NICU with CONS bacteremia was undertaken to determine CONS glycocalyx production, plasmid pattern, total DNA restriction fragment polymorphism, and clinical risk factors. RESULTS: The isolates included 32 Staphylococcus epidermidis, six Staphylococcus haemolyticus, four Staphylococcus warneri, four Staphylococcus saprophyticus, and one Staphylococcus hominis. Sixty-five percent of S epidermidis produced glycocalyx; other species did not. Oxacillin resistance (52%) and the antibiograms of the CONS were consistent with other units in the hospital. Five similar CONS plasmid patterns were found among 16 isolates; 31 isolates had unique patterns. Extractions of total DNA from these isolates were digested using HindIII, HaeIII, and BstEII. Those with similar restriction fragment length patterns could not linked as nosocomially transmitted among infants with bacteremia. CONCLUSION: Our observations suggest that multiple strains of CONS infect infants in the NICU who have similar risk factors. Although current infection control practices limit transmission of a pathogen, they do not prevent CONS bacteremias.

Prevention of gram-positive sepsis in neonates weighing less than 1500 grams.

A prospective, randomized study to evaluate the effectiveness of a continuous low-dose vancomycin infusion to prevent nosocomial gram-positive bacteremia was initiated within the first 2 weeks of life in neonates weighing < 1500 gm. Seventy-one infants received constant infusion of vancomycin (25 micrograms/ml) mixed with their total parenteral nutrition solution; 70 infants served as control subjects. The groups were clinically similar in birth weight, estimated gestational age, and severity of illness. Administration of vancomycin was begun at a mean age of 5.4 +/- 2.9 days. Infants had mean serum vancomycin concentrations of 2.4 micrograms/ml, and received vancomycin for a mean of 11 +/- 7 days. No vancomycin-resistant organisms were detected in surveillance cultures during the 2-year study period. Twenty-four of seventy control infants, in comparison with 1 of 71 infants receiving vancomycin, had gram-positive bacteremia (p < 0.001). The addition of a low dose of vancomycin to alimentation fluids virtually eliminated the incidence of gram-positive bacteremia in an at-risk population of very low birth weight infants. However, the widespread use of vancomycin in total parenteral nutrition solution is not recommended until better data on the emergence of vancomycin-resistant organisms are available.

Transmission of varicella-zoster virus from a vaccinee with leukemia, demonstrated by polymerase chain reaction.

A 5-year-old white boy in remission from acute lymphoblastic leukemia who was receiving maintenance anticancer chemotherapy had approximately 200 vesicular skin lesions 1 month after receiving live attenuated varicella vaccine. About 2 to 3 weeks later, a mild illness resembling varicella occurred in his susceptible siblings and in three of his classmates. Vaccine-type varicella-zoster virus was demonstrated by polymerase chain reaction in swab specimens from vesicular lesions in his two siblings, in whom antibody to varicella-zoster virus also developed.

Correlation between antibody affinity and serum bactericidal activity in infants.

Nearly one-half of infants immunized with Haemophilus influenzae b capsular polysaccharide (polyribosylribitol phosphate; PRP)-protein conjugate produce low-affinity antibody. To test the hypothesis that antibody affinity is linked to biologic function, sera were obtained before and 1 month after immunization of 18-month-old infants with PRP-diphtheria toxoid conjugate vaccine. Correlation was attempted of anti-PRP affinity, concentrations of anti-PRP, and anti-outer membrane proteins and of immunoglobulin isotype with bactericidal activity. Nine subjects produced anti-PRP of low affinity (K less than 10(4) l/mol), and 11 had higher affinity antibodies (average K, 2.8 x 10(4) l/mol). By multiple regression analysis, antibody affinity was the only variable significantly related to the bactericidal activity of serum after immunization with the conjugate vaccine (r = .71; P = .04). Thus, serum anti-PRP from a substantial proportion of infants appeared functionally deficient in association with low-affinity antibody.

Comparison of 6 and 8 hourly tobramycin dosing intervals in treatment of pulmonary exacerbations in cystic fibrosis patients.

The efficacy and toxicity of a shortened tobramycin dosing interval in the treatment of exacerbations of Pseudomonas aeruginosa pulmonary infection in cystic fibrosis patients were evaluated prospectively. Patients ages 13 to 30 years received 34 treatment courses and were randomized by pairs to receive tobramycin administered either every 6 or 8 hours. Peak serum concentrations were adjusted to 8 to 10 micrograms/ml; thus a larger total daily dosage was administered to patients receiving tobramycin every 6 hours. The shorter dosing interval was associated with better pulmonary function at follow-up and significantly longer time before next hospital admission for a pulmonary exacerbation. During the study hospitalization there were no differences in pulmonary function tests, clinical score, sputum carriage of P. aeruginosa, toxicity or necessary length of hospitalization. A 6-hour tobramycin dosing interval was more efficacious than an 8-hour dosing interval in the treatment of cystic fibrosis patients.

Haemophilus influenzae type b anticapsular antibody responses to PRP-pertussis and PRP-D vaccines in Alaska native infants.

To evaluate immune responses in Alaska Native infants at high risk for invasive Haemophilus influenzae type b (Hib) disease, we studied PRP-pertussis and PRP-D conjugate vaccines in this population relative to responses in white infants in California and New York. Infants were immunized at two, four, and six months of age (both vaccines). In the PRP-pertussis trial, there were no significant differences in antibody levels at any age between Alaska Native infants and infants from California. Only 50% of the infants had a twofold or greater antibody rise after three doses. In the PRP-D trial, antibody levels at two months of age (presumably maternally acquired) were significantly higher for Alaska Native infants compared with infants from New York (P = .002). There were no significant differences in antibody levels after any of the three doses. Among Alaska Native infants there was no significant difference in antibody response based upon degree of ethnic purity.