Nosocomial and community acquired infections in malnourished Jamaican children - abstract

Infection is a contributing or initiating factor in children with inadequate food intake who develop malnutrition, and malnutrition by virtue of immunosuppression leads to further episodes of infection. In this prospective study, 206 community acquired and 73 nosocomial infections occurring in 50 hospitalised severely malnourished children were investigated. This represented an average of 5.6 episodes of infection per child. Predominant community acquired infections in the 50 children included gastroenteritis (68 percent), otitis media (60 percent), rhinopharyngitis (60 percent), oral candidiasis (46 percent), skin infections (40 percent), pneumonia (28 percent), bacteraemia (24 percent), and bacteriuria (18 percent). The most frequent nosocomial infections were rhinopharyngitis (34 percent), lower respiratory tract infections (24 percent) and septicaemia (18 percent). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen and Klebsiella sp. were recovered from the majority of urines. Coagulase Negative Staphylococcus was the most frequent aetiological agent of bacteraemia, 12 of the 13 episodes were associated with fever +/- leucocytosis and in six episodes this organism was recovered from two or more blood culture sets. The lack of clinical signs and symptoms, and the atypical presentation in some of the infected malnourished children were attributed to impairment of the acute inflammatory response. Nasal, throat and axillary swabs taken on admission revealed significant colonisation with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Two of the four deaths were attributed to infection. The role of Cryptosporidium, an enteric pathogen which is prevalent in immunocompromised hosts, was further investigated. Cryptosporidium was isolated from the stools of 19.5 percent (15/77) malnourished children compared to 2.4 percent (10/436) well-nourished children, who were more likely to present with fever, vomiting, prolonged diarrhoea and dehydration. Community acquired non-bacterial respiratory tract infections were further investigated from paired sera in 83 moderately malnourished children. In 60 percent of the children with a history of respiratory tract disease and 25 percent of those without reported disease, a specific non-bacterial infection was diagnosed. Multiple aetiological agents were identified in 6 of the 42 chidren with respiratory disease. The most common micro-organisms observed were: Para-influenza 1,2 or 3 (in 15 children), Influenza H1N1, H2N3 or "B" in 12, Adenovirus in 10, Respiratory Syncitial Virus in 7 and Mycoplasma Pneumoniae in 6 children. These three studies report a high prevalence of common and unusual infections, especially Cryptosporidium enteritis and Coagulase Negative Staphylococcus bacteraemia, occurring in these immunocompromised children. Diagnosis of infection requires a high index of suspicion and a comprehensive screening system (AU)

Nosocomial and community acquired infections in malnourished children

A total of 206 community-acquired and 73 nosocomial infections in 50 malnourished Jamaican children were studied prospectively. Predominantly community-acquired infections in the 50 children, included gastroenteritis (68 percent), otitis media (60 percent), rhinopharyngitis (60 percent), oral candidiasis (46 percent), skin infections (40 percent), pneumonia (28 percent), bacteraemia (24 percent) and bacteriuria (18 percent). The most frequent nosocomial infections were rhinopharyngitis (34 percent), lower respiratory tract infections (24 percent) and septicaemia (18 percent). In those infections where an aetiological agent was identified, Giardia lamblia was the commonest enteric pathogen, Staphylococcus epidermidis, the most frequent blood culture isolate and Klebsiella sp. were recovered from the majority of urines. The lack of clinical signs and symptoms and atypical clinical presentation in some infected malnourished children were attributed to impairment of the acute inflammatory response. Diagnosis of infection in these children required a high index of suspicion and a comprehensive screening system. Nasal throat and axial swabs taken on admission revealed significant colonization with coliforms and pneumococcus; however, these swabs were not useful as indicators of potentially infective organisms. Four of the fifty children died and two of these deaths were attributed to infection. (AU)

Neonatal group B streptococcal septicaemia in a developing country

During a 3-year study at the neonatal intensive care unit, University Hospital of the West Indies, the incidence of group B streptococcal (GBS) septicaemia was 13.6/1,000 admission and 1.4/1,000 live births. GBS accounted for 35 percent of blood culture isolates and was the most frequent cause of septicaemia. Underlying disease or other possible predisposing factors were identified in 16 of 25 neonates with GBS septicemia. Comparison of early onset and late onset disease indicated an increase incidence of prematurity, prolonged rupture of membranes, and respiratory distress in the former and predominance of meningitis associated cases in the latter. Mortality was 50 percent for early onset cases, 29 percent for late onset cases and 36 percent overall. Antimicrobial therapy and preventive measures which may be appropriate for a developing country are discussed.(AU)

Cryptosporidiosos in well-nourished and malnourished children

During a 5-month period, 513 stool samples submitted to the enteric laboratory at the University Hospital of the West Indies were examined for Cryptosporidium. Oocysts were detected in 4.9 percent of all stools, 7.3 percent of diarrhoeal stools, 19.5 percent of stools from malnourished children and 23.7 percent of stools from malnourished children with diarrhoea. Cryptosporidium was the sole pathogen detected in all 25 positive stools, and was the second most frequent enteric isolate. All cases of cryptosporidiosis occurred in children less than 2.5 years of age. All 15 malnourished children were admitted to hospital where they presented with dehydration (87 percent), vomiting (93 percent), fever (100 percent) and diarrhoea which lasted an average of 15.3 days. Two of these children died. In contrast, dehydration (20 percent), vomiting (40 percent) and fever (50 percent) were less common and diarrhoea less protracted in well-nourished children, four of whom were admitted to hospital. This preliminary report suggests that cryptosporidial gastroenteritis presents with increased frequency and severity in malnourished compared with well-nourished Jamaican children.(AU)

Transferable antibiotic resistance at the University Hospital of the West Indies

One hundred and twenty gram-negative bacteria recovered from clinical specimens and resistant to at least one antimicrobial were tested for transferable antibiotic resistance. Organisms from 9 different genera with an average of 3.9 resistance markers were mated with a recipient strain of E. coli. Ninety-one isolates (76 percent) were able to transfer an average of 3.0 resistance markers to the recipient. Transfer occurred most often in Serratia (100 percent), and at least often in Acinetobacter (20 percent). Resistance markers with the highest transmission rates were tetracycline (67.6 percent), trimethoprim (65.1 percent), and cephaloridine (62.5 percent) whereas lower rates were seen with ampicillin (52.4 percent), gentamicin (55.5 percent), tobramycin (46.6 percent) and amikacin (30 percent). (AU)

Salmonellosis at the University Hospital of the West Indies

During 1982-83, there were 367 cases of salmonellosis at the University Hospital of the West Indies, caused by 50 different serotypes. Multiresistant strains of Salmonella ohio accounted for 19.3 percent of isolates, compared with 12 percent, 9.8 percent and 9.5 percent for Salmonella derby, Salmonella typhimurium and Salmonella typhi, respectively, Salmonella wre recovered from stool (303), blood (48), skin and soft tissue (7), urine (6), post-mortem material (2), sequestra (1), and sputum (1). Most infections occurred in younger age groups with 63 percent in children < 1 year if age. Twenty patients developed locallising infections. The 48 blood culture isolates included 25 S. tryphi and 23 other salmonella species. Fifteen patients with non-typhoid bloodstream infections developed septicaemia, and 13 of these had underlying disease, whereas only 1 of 8 bacteraemic patients had underlying disease. All S. ohio isolates were resistant to chloramphenicol, ampicillin, cotrimoxazole, neomycin and carbenicillin, and resistance determinants were transferred to E. coli K12J53-2. It was concluded that non-typhoid salmonellas were responsible for a significant degree of morbidity during the period of this study (AU)

Cryptosporidiosis in well-nourished and malnourished Jamaican children - abstract

During a 5-month period, 513 stool samples submitted to the enteric laboratory of the University Hospital of the West Indies were examined for Cryptosporidium. Oocysts were detected in 4.9 percent of all stools, 7.9 percent of diarrhoeal stools, 19.4 percent of stools from malnourished children and 25.4 percent of stools from malnourished children with diarrhoea. Cryptosporidium was the sole pathogen detected in all 25 positive stools, and was the second most enteric isolate. All cases of cryptosporidiosis occurred in children less than 2.5 years of age. The fifteen malnourished children excreting cryptosporidium presented with dehydration (87 percent), vomiting (93 percent), fever (100 percent) and diarrhoea which lasted for an average of 15.7 days. Two of these children died. In contrast, dehydration (20 percent), vomiting (40 percent) and fever (50 percent) were less common and diarrhoea less protracted in well-nourished children, 4 of whom were hospitalised for an average of 3 days. This preliminary report suggests that cryptosporidial gastroenteritis presents with increased frequency and severity in malnourished compared with well-nourished children.(AU)

Topical antibiotics in chronic sickle cell leg ulcers - abstract

Previous studies have indicated that chronic leg ulcers in homozygous sickle-cell (SS) disease usually contain at least one of the common skin pathogens, Staphylococcus aureus, Pseudomonas aeruginosa or Beta haemolytic streptococci. These organisms are usually sensitve t a mixture of neomycin, bacitracin, and polymyxin B, and a randomised controlled crossover trial of these topical antibiotics has been performed in 30 patients with chronic leg ulcers and SS disease. During the first 8 weeks, the mean ulcer area decreased to 51 percent (SD 34 percent) of initial ulcer size in the treatment group compared to 75 percent (SD 37 percent) in the control group, the difference being significant at the 5 percent level. On crossover, accelerated healing was noted in the group previously receiving control therapy, comparison of the healing rates in the two phases showing a highly significant difference (p<0.005). The results suggest that these topical antibiotics may have a place in the therapy of chronic leg ulceration associated with sickle-cell disease (AU)

Neonatal septicaemia at the University Hospital of the West Indies - abstract

Seventy-one cases of neonatal septicaemia were recorded at the University Hospital of the West Indies between June 1982 and May 1985. The 72 bacterial strains isolated comprise 42 gram-positive and 30 gram-negative organisms, with Group B streptococcus (GBS), Klebsiella pneumoniae and Staphylococcus aureus being the most frequent. There were only 5 cases of E. coli septicaemia. Twenty-six percent of cases (including 24 percent of GBS infections) were early onset 91 percent occurred during the first three weeks of life. Early onset septicaemias were associated with prematurity, prolonged rupture of membranes, respiratory distress and high mortality. A focus of infection was identified in 64 percent of septicaemias the majority of which were associated with infections of the respiratory tract, gastrointestinal tract, central nervous system and skin. A predisposing factor was noted in 71 percent of cases and 12.6 percent of cases were related to infection outbreaks. The efficacy of pencillin at 50,000u/kg/d for the treatment of GBS septicaemia was questionable. Gentamycin was associated with 43 percent treatment failure rate in the gram-negative septicaemias. Mortality was 40 percent for E. coli septicaemias, 36 percent for GBS septicaemias, 46 percent for early onset septicaemias and 21 percent overall.

Multiresistance Salmonella Ohio infections at the University Hospital of the West Indies

During 1982-83 there was a substantial increase in the number of S. ohio infections at the University Hospital of the West Indies, which coincided with the appearance of strains resistance to chloramphenicol, cotrimoxazole, ampicillin, neomycin and carbenicillin. Multiresistance strains of S. ohio accounted for 19.3 percent of all salmonella isolates during this period and all of 40 strains tested were able to transfer resistance determinants to E. coli K12 J 53-2. S. ohio was cultured from stool (60), blood (5), wounds and abscesses (4) and postmortem material (2). Eighty-six percent of S. ohio infections occurred in children of 3 years old or less. There was a high incidence of gastroenteritis in malnourished children, a 14 percent incidence of localizing infections and a 7 percent incidence of septicaemia. Two infants with severe gastroenteritis and bronchopneumonia died. There were a number of unusual infections including two cases of septicaemia in children receiving chloramphenicol for Haemophilus infleunzae meningitis, a scrotal abscess secondary to extravastion of urine and infected scabies in a child with marasmic kwashiorkor.(Summary)

Bacteriology of sickle cell leg ulcers

The bacteria isolated on aerobic and anaerobic culture were compared in 80 unilateral ulcers in patients with homozygous sickle cell (SS) disease, 62 superficial skin lesions and in 30 diabetic ulcers. In SS disaese the bacterial flora was predominantly aerobic and polymicrobial with Staphylococcus aureus, Psuedomonas aeruginosa and beta haemolytic streptococci being the major isolates. Repeat sampling of 26 ulcers over a period of 23 weeks indicated the persistence of these organisms, either singly or in combination in 21 ulcers.Although a variety of Enterobacteriaceae were recovered no single genus predominated and these organisms did not normally persist on follow up. Simultaneous swabs from bilateral ulcers revealed similar if not identical flora in most cases, indicating good predictive value of a single swab in patients with multiple ulcers. Corynebacterium diphtheriae was recovered from 8 ulcers and 4 of these strains were toxigenic. By contrast the superficial skin lesions grew mainly S. aureus and beta haemolytic streptococci, and the diabetic ulcers yielded a mixed growth of streptococci, Enterobacteriaceae and anaerobes. The recovery of known skin pathogens from most sickle cell leg ulcers, the persistence of these organisms, and the presence of associated lymphadenopathy, indicates that infection may be a significant factor in the pathology of these lesions

Flavobacterium odoratum

A 6-week-old infant admitted to the University Hospital of the West Indies with hydrocephalus later developed ventriculities. A heavy growth of Flavobacterium odoatum susceptible to gentamicin and cefotaxime was recovered from the ventricular fluid. Since intraventricular therapy was envisaged, a pudenz reservoir was installed and ventricular fluid aspirated every 24 h to monitor treatment. Initial therapy consisted of intravenous cefotaxime, 50 mg/kg q.i.d. for 4 days. No significant reduction in the number of organisms in the ventricular fluid was achieved with this regimen. Intravenous therapy was therefore discontinued. On day 5 intraventricular therapy began with 5 mg cefotaxime 24 h for 6 days, followed by 1 mg/24 h for 4 days. Daily monitoring of intraventricular fluid indicated a high degree of antibacterial activity with rapid elimination of bacteria. Ventricular fluid remained sterile 10 days after therapy stopped. The Pudenz reservoir was removed, a ventriculoperitoneal shunt installed, and the patient discharged from hospital 4 days later without noticeable sequelae.(AU)

Nocardiosis in patients treated with corticosteroids: a report on three cases

Three cases pulmonary nocardiosis in patients receiving corticosteroids are described. Early diagnosis and appropriate therapy produced a favourable response in one case compared with a fatal outcome in 2 patients where the diagnosis was delayed and dissemination had occurred. In none of these 3 cases was a clinical diagnosis of nocardiosis entertained, the organism being detected in each instance by the laboratory. Problems associated with the diagnosis and treatment of nocardiosis in patients recieving immuno-suppressive therapy are discussed (AU)

Corynebacterium diptheriae in sickle cell leg ulcers in Jamaica

Bacterial cultures of leg ulcers from 90 patients with SS disease demonstrated 9 with Corynebacterium diptheriae. Follow-up swabs revealed a further 4 cases. All strains were of the gravis variety and 9 of the 13 isolates were toxigenic. The affected ulcers were not remarkable in appearance and no patient was clinically toxic. A variety of other organisms were isolated from the wound, most commonly Pseudomonas aeruginosa. Carriage of C. diptheriae tended to be brief. The significance and therapy of cutaneous diptheria are reviewed (AU)

Antibiotic resistance of N. gonorrhoeae in Jamaica - abstract

A total of 885 women and 515 men, who were symptomatic, were screened by culture for gonorrhoea. Men were screened initially with Gram stain. Of these, 313 women and 440 men were proven to have uncomplicated gonorrhoea and were randomly assigned to treatment with procaine penicillin (4.8 mega units) or ampicillin (3.5g) each with probenecid (1g). Of this number, 61 women and 120 men were subsequently excluded from the study, leaving 252 women and 320 men for analysis. In this report, only the first 148 men are analysed. Test of cure (TOC) was performed 3-7 days post-treatment. One hundred and eighty women and 129 men completed treatment and follow-up within this period. The TOC was done after 7 days in 72 women and 19 men; these late returnees were analysed separately. Eliminating the late TOC cases, the total failure rates for penicillin and ampicillin were 4.8 percent and 4.3 percent respectively; for men 5.2 percent and 7.0 percent, for women 4.5 percent and 2.2 percent. Of the 14 failures to both regimes followed up within 7 days, 5 had PPNG infections, 2 were reinfections and 1 had pelvic complications. Urethral swabs from males and endocervical swabs from females were inoculated on to Thayer-Martin medium and gonococcal isolattes were identified by standard methods. Isolates were tested for penicillinase production using chromogenic cephahalosporin. Using the agar dilution technique and supplemented Protease No. 3 agar, the MICs to penicillin, ampicillin, spectinomycin, tetracycline, erythromycin, sulfamethoxazole-trimethoprim (19:1), cefuroxime and thiamphenicol were determined on isolates from these patients. Preliminary data on the determination of auxotype indicated that the prototrophic and proline-requiring groups comprised over 60 percent of the isolates tested to date. However, several other auxotype groups, especially Orn- and Pro-Cit-Ura-, were prevalent as well. Plasmid analysis of the strains indicated that all the Pro-Cit-Ura- isolates were plasmid-free, a result noted by others, and that 26 percent of the isolates carried transfer plasmids. To date, 16 PPNG cases have been detected among the 440 male cases, and 1 among 277 female cases. The PPNG isolates harboured either the African (3.2 Md) or the Asian (4.8 Md) penicillinase-producing plasmids. This is the first time that PPNG strains have been identified in Jamaica (AU)

Multi-resistant salmonella ohio infections at the University Hospital of the West Indies - abstract

During 1982-83, there was a substantial increase in the number of S.ohio infections at the University Hospital of the West Indies, which coincided with the appearance of strains resistant to chloramphenicol, cotrimoxazole, ampicillin, neomycin and carbenicillin. Multi-resistant strains of S.ohio accounted for 71 of the 367 salmonella isolates during this period (19.3 percent). All of the 40 strains tested were able to transfer resistance determinants to E. coli, K12J53-2. S.ohio was cultured from stool (60), blood (5), wounds and abscesses (4), and post-mortem material (2). Eighty per cent of infections occurred in children less than two years of age and was often associated with gastroenteritis in malnourished children. Two infants with severe gastroenteritis and bronchopneumonia died. There were a number of unusual S.ohio isolates, including 2 cases of septicaemia in children receiving chloramphenicol for H. influenzae meningitis, a scrotal abscess secondary to extravasion of urine and infected scabies in a child with marasmic kwashiorkor. The emergence of a multi-resistant S.ohio capable of transferring antibiotic resistance to other organisms is of particular concern where S.typhi is endemic (AU)

Infections in malnourished children - abstract

Specific nutrient deficiencies may increase susceptibility to and severity of infection. This is particularly evident in young children admitted to hospital with malnutrition. This prospective study documents the community and hospital-acquired infections in 47 malnourished children admitted to the University Hospital of the West Indies. The study group comprised 26 boys and 21 girls aged 5 to 23 months, of whom 28 had oedematous malnutrition. A total of 131 infections were diagnosed on admission with each child having at least one identifiable focus of infection. Thirty-two (68 percent) had gastroenteritis, 27 (57 percent) had otitis media and 25 (53 percent) presented with upper respiratory tract infections. Twelve children (25 percent) were bacteraemic and two of these had polymicrobial bacteraemia. Bladder aspirates were positive in 8 of 11 children with bacteruria and 6 of these yielded more than one organism. Ten children (21 percent) had giardiasis and there were individual cases of E. coli peritonitis, pneumococcal meningitis and tuberculous urinary tract infection. Twenty-nine children (62 percent) acquired hospital infections, including 12 upper and lower respiratory tract infections and 6 episodes of small bowel overgrowth. Hospital-acquired staphylococcal bacteraemia was diagnosed in 8 of 10 patients with positive blood cultures. Cytomegalovirus pneumonitis septicaemia and influenza A encephalitis with disseminated intravascular coagulation accounted for 2 of 3 deaths. In view of the high incidence of single and multiple infections in malnourished children, it was concluded that a comprehensive screening system should be used to identify and monitor infections in these patients. Malnourished children are often immunocompromised and may be prone to infections with unusual organisms. Therefore, every effort should be made to identify aetiological agents so that appropriate antimicrobial therapy may be administered (AU)

Antibiograms of gram-negative bacteria recovered from clinical specimens at the University Hospital of the West Indies (August, 1982 - January, 1983)

The sensitivity patterns of gram-negative organism were recorded over a six-month period from August 1982 to January 1983, and percentage sensitivities were calculated for urine and non-urine isolates. Sensitivity patterns did not differ substancially from those previously reported. However, urine isolates were shown to be significantly more resistant to antimicobials when compared with non-urine isolates. Multiresistant strains of Serratia marcesens demonstrated considerable resistance to all anibiotics except amikacin. Analysis of data on a monthly basis revealed significant changes in the antibiograms of E. coli and Acinetobacter sp. Antimicrobials on restricted usage maintained a high level of activity with the exception of tobramycin. (AU)