Single-dose amoxicillin therapy with follow-up urine culture. Effective initial management for acute uncomplicated urinary tract infections.

To learn whether a single dose of amoxicillin is safe, effective therapy for acute uncomplicated urinary tract infections, 388 symptomatic nonpregnant women were randomly grouped to receive oral amoxicillin, either as a single 3 g dose of 250 mg three times a day for two weeks. Patients had quantitative as well as dip-slide cultures of urine and tests for antibody-coated bacteria in urine. Follow-up urine cultures were obtained one week after completion of treatment. Results of antimicrobial susceptibility and antibody-coated bacterial tests did not alter the randomized therapy. Among 162 patients with bacteriologically confirmed infections, cure rates were 60.6 percent (43 of 71) for single-dose versus 73.6 percent (67 of 91) for two-week treatment (p = 0.07). Although more antibody-coated bacteria-negative patients (89.6 percent; 26 of 29) were cured overall, a substantial proportion of antibody-coated bacteria-positive patients were also cured by both single-dose (59.3 percent; 32 of 54) and 14-day therapy (64.6 percent; 42 of 65). There were fewer adverse effects in the single-dose treatment group. We conclude that a single 3 g dose of amoxicillin, with follow-up urine culture, provides safe and effective management for acute uncomplicated urinary tract infections in nonpregnant women.

Ventriculoperitoneal shunt-associated infection due to Haemophilus influenzae.

We report two children with ventriculoperitoneal shunt infections due to Haemophilus influenzae, type b. One child was cured with systemic and intraventricular antimicrobial therapy alone. The other child had persistently positive ventricular fluid cultures, ultimately required shunt removal in addition to antimicrobial therapy, and still had a relapse, which responded to antimicrobial therapy alone. In treating children with this problem we recommend removal of the shunt apparatus unless there is prompt sterilization of ventricular fluid and clinical improvement. Systemic antimicrobial therapy should be continued for two to four weeks.

Respiratory syncytial virus infection in children with bronchopulmonary dysplasia.

Little is known about the risk of severe illness from respiratory syncytial virus infection in children with bronchopulmonary dysplasia. A prospective study was done of the natural history of respiratory syncytial virus infection in 30 children less than 2 years of age with bronchopulmonary dysplasia who were in a home oxygen program. Surveillance to identify children with acute respiratory symptoms was done by weekly telephone interview. Symptomatic children were examined, oxygen saturation was determined by oximetry, and nasopharyngeal lavage fluid was collected for virus cultures and rapid respiratory syncytial virus antigen tests. During the 4-month study period (December to April), 27 children had one or more acute respiratory illnesses, and respiratory syncytial virus developed in 16/27 (59%). Passive smoking and greater than or equal to four members in the home increased the risk of symptomatic respiratory syncytial virus (P less than .01 and P less than .03, respectively). Of 16 children, 11 (69%) required hospitalization. Of the 11 hospitalized children with respiratory syncytial virus, nine were either still receiving oxygen at home or required oxygen therapy within the previous 3 months v none of five nonhospitalized children (P less than .005). Five of the hospitalized children were greater than 12 months of age and five had respiratory syncytial virus infection previously that had been confirmed by culture results. Hospitalizations were prolonged and complicated. Seven of 11 children were hospitalized for greater than 1 week; four were admitted to the intensive care unit; four were treated with ribavirin aerosol, and two needed mechanical ventilation. There were no deaths.(ABSTRACT TRUNCATED AT 250 WORDS)

Immunization of high-risk infants younger than 18 months of age with split-product influenza vaccine.

Influenza is an important cause of serious illness in very young children with cardiopulmonary disease. A 4-year study was conducted at two centers to assess immunogenicity and safety of influenza split-product vaccine in children aged 3 to 18 months with bronchopulmonary dysplasia and congenital heart disease. A total of 113 children were studied: 62 children 3 to 5 months of age and 51 children 6 to 18 months of age. Sera were drawn prior to first and second immunization and 3 weeks after second immunization and were tested by hemagglutination inhibition; protection was defined as greater than 1:32. Ninety-five children were surveyed for adverse reactions. Seroresponses were age and antigen specific. Best responses for all ages were to A/Mississippi (H3N2) (97%). Children older than 6 months of age had better seroresponses to A/Leningrad (H3N2) (73%, P less than .03) and B/Victoria (62%, P less than .02) than did children younger than 6 months of age. Seroconversion rates to the remaining antigens were low. Only 9% of children experienced adverse reactions; all but one were mild. The immunologic mechanisms responsible for preventing serious influenzal disease and more effective immunization strategies need to be defined for very young high-risk children.

Probable graft-vs-graft reaction in an infant after exchange transfusion and marrow transplantation.

A newborn with graft-vs-host (GVH) disease following an exchange transfusion was treated by attempting to eradicate the incompatible graft and to reconstitute the child hematologically and immunologically with a bone marrow transplant. The patient was a female term infant (blood group B, Rh+ Coombs test positive) who received a one-unit group O, Rh- exchange transfusion from an unrelated female donor for hyperbilirubinemia due to ABO incompatibility on day 2. Signs of acute GVH disease began on day 8 and the clinical diagnosis was supported by skin biopsy. With antithymocyte globulin and high dose dexamethasone, the GVH reaction improved somewhat. Cyclophosphamide, 200 mg/kg total dose, was given over four days followed by a marrow graft from a brother who was HLA-A, B identical, and probably also D locus compatible in mixed lymphocyte culture. All signs of GVH resolved with cyclophosphamide treatment and hematologic reconstitution was evident by 14 days after transplant. Two weeks later the GVH reaction and aplastic anemia recurred and Y chromatin was detected in only 6% of marrow cells. The infant died on day 80. Autopsy showed disseminated candidiasis, disseminated cytomegalovirus infection, thymic dysplasia, hypoplastic marrow, and other histopathologic changes consistent with GVH disease. The persistence of female cells in blood and bone marrow and the destruction of the reconstituted marrow suggest that the original incompatible transfusion-derived graft was not eliminated and that it ultimately rejected the histocompatible marrow graft.

Serum antibody response to pneumococcal vaccine in children with nephrotic syndrome.

Children with nephrotic syndrome are susceptible to serious pneumococcal disease and may be immunodeficient on the basis of abnormal humoral immune responses to natural antigens or immunoglobulin loss during relapse. As part of an ongoing study to evaluate pneumococcal anticapsular antibody concentration and immunologic competence, 27 steroid-responsive and six steroid-resistant patients with nephrotic syndrome, and 12 age-matched control subjects, were vaccinated with polyvalent pneumococcal vaccine. Antibody responders were defined as patients with at least a twofold increase in antibody after vaccination as well as an antibody concentration greater than 200 ng of anticapsular antibody nitrogen per milliliter (ngN/ml) after vaccination. Pneumococcal antibody concentrations before and after vaccination were significantly depressed in steroid-resistant patients when compared with control subjects (P less than .002) and with the steroid-responsive nephrotic syndrome group (P less then .001). Steroid-responsive nephrotic children who were not receiving corticosteroid therapy at the time of vaccination had significantly higher antibody concentrations to five pneumococcal types before vaccination and to seven types after vaccination compared with control subjects (P less than .05). Fewer steroid-responsive patients receiving corticosteroids achieved antibody concentrations greater than or equal to 200 ngN/ml against type 19F compared with patients not receiving steroids or with control subjects (P less than .05). These results suggest that pneumococcal vaccine is immunogenic in children with steroid-responsive nephrotic syndrome and may protect these patients from disease due to pneumococcal types contained in the vaccine.

Syringe preparation technique and minor adverse reactions to diphtheria-tetanus-pertussis immunization.

Minor local reactions and subcutaneous abscesses following diphtheria, tetanus and pertussis immunization have been attributed to vaccine left in the subcutaneous needle path from vaccine coating the needle. Various syringe preparation techniques have therefore been advocated to prevent reactions. To evaluate these recommendations we compared rates of minor reactions in 200 children randomly assigned to one of three groups that differed only in the handling of the filled syringe: in Group 1 the needle was changed before injection; in Group 2 the needle was wiped with sterile gauze before injection; in Group 3 the same needle was used to draw up and to inject the dose and was not wiped. Overall 27% of children had febrile (greater than 38 degrees C) reactions, 62% became fussy and 79% had a local reaction. Rates of reactions were nearly identical in the three groups, except that children in group 2 receiving their second dose or more of diphtheria-tetanus toxoid-pertussis vaccine were more likely to become febrile at greater than 38 degrees C (32%) or fussy (78%) (P less than 0.05 and P less than 0.02, respectively). We conclude that changing needles does not reduce the rate of minor local and systemic reactions. Wiping needles may increase the rate of reactions.

Comparison of nasopharyngeal washings and swab specimens for diagnosis of respiratory syncytial virus by EIA, FAT, and cell culture.

Respiratory secretions for viral diagnosis are often collected with nasopharyngeal (NP) swabs, although many laboratories recommend NP aspirates or washings. We compared results using NP washings and NP swabs in three diagnostic RSV tests, a rapid RSV EIA antigen test (Abbott Laboratories), an indirect fluorescent antibody test (FAT) with rabbit antiserum, and virus culture (HEp-2 cells). Paired samples were collected from 121 children with suspected RSV bronchiolitis or pneumonia. A minitip swap was passed into the nasopharynx for 10 sec, rotated and withdrawn. The opposite nares was irrigated with approximately 1 ml of saline and aspirated using a syringe and plastic feeding tube. Fifty-one children (42%) grew RSV in culture, 49 from NP washings versus 27 from NP swabs (p less than 0.001). Fifty-three (44%) were positive by FAT, 52 from NP washings versus 12 from NP swabs (p less than 0.001). Fifty-eight children (48%) had positive RSV EIA tests, 57 from NP washings versus 35 from NP swabs (p less than 0.001). Detection by EIA was more sensitive than culture regardless of the method of specimen collection. We conclude that NP washings are superior to NP swabs for RSV culture and rapid diagnosis by EIA or FAT.

Pediatric blood cultures.

The clinical and laboratory issues important in pediatric blood cultures are similar to those in adult blood cultures with a few noteworthy exceptions. The collection of an uncontaminated specimen and an ample volume of blood is more difficult, especially in neonates. In addition, children often have previously received oral antibiotics or a broad-spectrum parenteral antibiotic. The relative frequencies of the pathogens causing bacteremia in children are different in important ways from in adults. Haemophilus influenzae b, although much less common than in the past, is still an important pediatric pathogen. Meningococcemia is relatively more common in children than in adults, and enterobacteriaceae and anaerobes are relatively less common. Group B streptococci, E. coli, coagulase-negative staphylococci, and Candida sp. are the principal pathogens in neonates. More changes in the distribution of blood-borne pathogens can be expected in the future with the introduction of new or more effective vaccines against the pneumococcus, meningococcus, and, possibly, group B streptococcus. In suspected community-acquired bacteremia in otherwise normal children, a single aerobic blood culture of adequate volume is sufficient. Sick neonates, hospitalized children with indwelling intravascular devices, and immunocompromised children may need multiple blood cultures, paired cultures from an indwelling vascular catheter and a peripheral vein, or use of special media. There is no single optimal system for pediatric blood cultures. The BACTEC systems have been adopted as a single system in many hospitals serving both children and adults because of the favorable results reported in children and the preference of using a single automated system. To maximize the detection of bacteremia and fungemia, some laboratories may wish to combine a BACTEC system with a second complementary system, such as the Isolator. Anaerobic, mycobacterial, and other special blood culture media should be reserved for selected patients.

Detection of Borrelia in acridine orange-stained blood smears by fluorescence microscopy.

Tick-borne borreliosis (relapsing fever) can be an important, unsuspected cause of febrile illness. The diagnosis is generally made by identifying Borrelia spirochetes in stained peripheral blood smears. Since Borrelia may be difficult to detect with Romanowsky stains, an alternative method, using acridine orange (AO), was used to screen blood smears. Duplicate blood smears of seven patients were examined with the AO technique and Romanowsky stains. In all seven cases spirochetes were easily identified with the AO-stained smears compared with only five cases with Romanowsky stains. In a double-blind laboratory experiment, six of ten duplicate smears from a single patient with mild spirochetemia were positive by AO, whereas only two of ten were positive by Romanowsky stain. We concluded that the AO stain is simple, rapid and more sensitive than Romanowsky methods for detecting cases of low-level spirochetemia.

Comparison of virus culturing and immunofluorescence for rapid detection of respiratory syncytial virus in nasopharyngeal secretions: sensitivity and specificity.

I compared the fluorescent antibody test for respiratory syncytial virus in nasal secretions to virus cultures (N = 310). The sensitivity, specificity, and predictive value (+) were 95.1%, 86.5%, and 88.5%, respectively.

Severe facial injuries to infants due to unprovoked attacks by pet ferrets.

Three infants were attacked by pet ferrets and sustained severe facial injuries. Two of the children had their ears bitten off and required reconstructive surgery. The attacks were unprovoked. Two of the children were asleep in their cribs when they were bitten. Although ferrets are increasingly popular pets, we believe that they are not suitable pets for families with small children. Physicians should be aware that ferrets may unpredictably injure infants and that no effective rabies vaccine for ferrets is yet available.

Toxic effect of calcium alginate swabs on Neisseria gonorrhoeae.

Calcium alginate (CA)-tipped swabs have been reported to interfere with the recovery of herpes simplex virus, Chlamydia trachomatis, and Ureaplasma urealyticum and may cause cytotoxicity in cell culture. To determine whether CA swabs also inhibit the growth of Neisseria gonorrhoeae, we carried out a series of experiments using either CA swabs that were toxic or nontoxic in a cell culture cytotoxicity assay or nontoxic rayon or cotton swabs. Leaving a toxic CA swab in 3 ml of Mueller-Hinton broth inoculated with 10(4) CFU/ml caused rapid killing within 6 h at 37 degrees C; colony counts of five strains were less than 1% of those of Mueller-Hinton broth controls. When the tips of toxic CA swabs were inoculated directly and kept at 37 degrees C without holding medium, the swabs were sterile at 6 h. If the same swabs were placed in Amies medium with charcoal, organisms could still be recovered at 6 h. Toxicity was less at room temperature than at 37 degrees C. Inhibition of growth of N. gonorrhoeae was not seen with rayon or cotton swabs. The toxic component was neither the CA fiber nor the aluminum wire but probably the glue used to attach the fibers. We concluded that some lots of CA swabs kill N. gonorrhoeae in vitro. Survival of N. gonorrhoeae is improved with nontoxic swabs, particularly cotton swabs, and Amies medium with charcoal regardless of swab type.