Renal ultrasound evaluation of urinary tract infections in children.

Ultrasonography of the kidney may replace the intravenous pyelogram as the study of choice in identifying treatable abnormalities in children with urinary tract infection. In a series of 64 consecutive children with urinary tract infection in whom an intravenous pyelogram, renal ultrasound, and voiding cystogram were performed, only one treatable abnormality (calyceal dilation) was identified by intravenous pyelogram, and it was not detected by ultrasound. Eleven children showed vesicoureteral reflux on the cystogram. In an additional 43 children in whom intravenous pyelogram was done only if the ultrasound or cystogram were abnormal, there were five abnormal cystograms. Four treatable abnormalities were identified by ultrasound, and there were confirmed by the intravenous pyelogram. Ultrasound should replace the intravenous pyelogram in children with a normal cystogram because of its accuracy, safety, and high patient acceptance. We have also documented a significant volume increase with acute infection in one or both kidney(s) of those children having upper urinary tract infection. Fifteen of 18 children with upper urinary tract infection had volume increases of 30% or more in at least one kidney; whereas only four of 21 children with lower urinary tract infection had increases of greater than 30% (P less than .005). Ultrasound volume measurements provide a new, noninvasive method for identifying the probable site of urinary tract infection.

Bacterial etiology of conjunctivitis-otitis media syndrome.

Simultaneous cultures of conjunctivae and middle ear exudates were obtained from 20 episodes of the syndrome of purulent conjunctivitis and otitis media. Paired cultures from 18 episodes yielded Haemophilus influenzae at both sites. In two cases with prior topical antibacterial therapy of the conjunctivitis, H influenzae was isolated from the middle ear exudate only. Biotyping and outer membrane protein analysis of H influenzae isolates from five patients demonstrated that: conjunctival and middle ear strains were concordant in all cases, and all five patients had different strains. The conjunctivitis-otitis media syndrome is most often caused by strains of nontypable H influenzae of diverse clonotype.

Live attenuated varicella vaccine in healthy 12- to 24-month-old children.

We studied live attenuated Oka/Merck varicella vaccine in 147 seronegative children 12 to 24 months of age and their 94 seronegative older siblings 2 to 12 years of age. The vaccine side effects were mild, consisting of a papular rash in 15 of 147 (10.2%) children 12 to 24 months and seven of 94 (7.4%) siblings. In a subset of 12- to 24-month-old children, modified fluorescent antibody test for membrane antigen was not detectable at seven days postimmunization but was detectable in 50% by 14 days and in 100% by 21 days. Within 6 weeks, 96.6% of children 12 to 24 months and 94.7% of siblings seroconverted. The geometric mean titer did not vary with age at immunization. One-year blood samples were obtained from 70 children 12 to 24 months of age who seroconverted; 92.9% retained detectable antibody. The geometric mean titer had decreased from 55.7 to 18.6. Of these 70 children, 34% had been exposed to varicella since immunization, and two cases of varicella were observed in seroconverters. Both cases were mild, with less than 50 vesicles. Oka/Merck varicella vaccine appears to be safe, highly immunogenic, and protective against 96% of exposures to natural varicella during the first year after vaccination in infants. Those cases of varicella that develop in immunized children appear substantially reduced in severity.

Therapy of acute otitis media caused by Branhamella catarrhalis. Preliminary report.

Since 1980, we have observed an increased incidence of otitis media caused by Branhamella catarrhalis. The outcome of therapy of acute otitis media caused by this organism has been studied in a number of randomised clinical trials. 75% of isolates produced beta-lactamase. Failure to sterilise B. catarrhalis-infected middle ear exudates occurred in 3 of 11 patients treated with amoxycillin or bacampicillin, 2 of 19 treated with cefaclor, but in no patients treated with co-trimoxazole (n = 10) or amoxycillin-clavulanic acid (Augmentin), [n = 9]. All treatment failures were associated with beta-lactamase-producing strains of B. catarrhalis. The emergence of antibiotic-resistant strains of B. catarrhalis in acute otitis media indicates the need for a re-evaluation of initial antibiotic therapy of this infection. This may be particularly true for areas where there is a high incidence of strains which elaborate beta-lactamase.

Isoelectric focusing of beta-lactamases from sputum and middle ear isolates of Branhamella catarrhalis recovered in the United States.

Branhamella catarrhalis obtained from the sputum of 146 patients with lower respiratory tract disease and from middle ear fluids of 26 children with otitis media were evaluated for beta-lactamase activity and the enzymes were characterised by isoelectric focusing (IEF). 71% (103 of 146) of the sputum isolates and 77% (20 of 26) of the ear isolates produced beta-lactamase. By IEF, the beta-lactamases of 113 of 123 (92%) strains revealed patterns identical with the Ravasio type strain, having unique enzyme bands at pIs of 6.4 and 6.65. The remaining 10 isolates (8%) produced patterns similar to the 1908 type strain with a unique band of activity having a pI of 6.55. In addition, the 1908 types revealed a band of minor enzyme activity with a pI of 7.55 that was absent from the Ravasio types. All strains tested shared major enzyme bands with pIs of 5.1, 5.3, 5.55 and 6.1. These results indicate that the most common beta-lactamase(s) produced by clinical isolates of B. catarrhalis in the United States are similar to those produced by the Belgian Ravasio type strain.

Antibacterial therapy and middle ear effusions.

Antimicrobial drugs chosen for their activity against the causative pathogens of otitis media provide effective treatment for acute attacks. Prolonged administration of some of these agents has recently been shown to be of value in the prevention of symptomatic otitis. The role of drug therapy in the management of chronic or recurrent middle ear effusion is unknown at present.

Ipsilateral acoustic reflexes in infants.

Ipsilateral acoustic reflex thresholds were studied in otoscopically normal ears of infants 2 weeks to 12 months old. Probe tones of 220 and 660 Hz and pure tone activators were used. Reflex recordings were free of activator artifact and were measured using quantitative standards. Reflexes were detected in 85% to 95% of infant ears for 500, 1,000, and 2,000 Hz activators but were present in only 76% of ears at 4,000 Hz. Median thresholds of 80 to 85 dB hearing level were obtained with all activators and both probe tones. There were no differences in proportions of reflexes obtained with the two probe tones. With a 500-Hz activator, thresholds at 220 Hz were lower than those at 660 Hz, while no threshold differences were demonstrated between probe tones at other activators. No relationship was demonstrated between age in the first year of life and presence or threshold of reflexes. Ipsilateral acoustic reflex measures have potential use in the identification of hearing loss and middle ear disease in infancy.

Otitis media in the newborn infant.

Otitis media occurs frequently in newborn infants and often is associated with systemic infection. Patients studied at the Boston City Hospital have provided preliminary data on the otoscopic findings, tympanometric patterns and etiologic agents characteristic of otitis in this age group.

Antibacterial therapy for acute otitis media: a critical analysis.

Twenty-five published trials of antibacterial therapy for acute otitis media were reviewed according to 13 methodologic standards for the design of clinical trials. Randomized, controlled trials, often with the double-blind technique, have been widely applied to assess efficacy. Bias can be further avoided by prognostic stratification according to known risk factors and by the measurement and analysis of patient compliance with treatment. A less frequently recognized problem is the insensitive trial. Bacteriologic diagnosis of the middle ear exudate before therapy can improve the sensitivity of clinical trials. The eradication of pathogens from the middle ear may be a more sensitive measure of outcome than the reduction of ear effusion. The analysis of type II statistical error should be included in trials that reveal no difference between antibacterial agents. The evaluation of new antibacterial agents for this important health problem requires rigorous research design.

Tympanometry in the diagnosis of middle-ear effusion.

Tympanometry measures the flow of sound energy in the external ear canal under conditions of changing ear-canal pressure. To evaluate this technic as a means of detecting middle-ear effusion, we studied acoustic susceptance and conductance in 91 children. We made the measurements using tones of 220 and 660 Hz over a pressure range of -300 to +300 mm of water. The mean value for susceptance at 660 Hz gave best results: 83 of 84 tympanograms of ears with middle-ear effusion had values less than 0.16 millimhos (mmho). Among 128 studies of normal ears, 113 had values greater than or equal to 0.16 mmho (P less than 0.001). We conclude that a mean acoustic susceptance at 660 Hz less than 0.16 mmho in a child four months of age or older indicates the presence of middle-ear effusion.

Ipsilateral and contralateral acoustic reflexes in neonates.

Ipsilateral and contralateral acoustic reflexes were studied in neonates using 220 and 660 Hz probe tones and 500, 1000, 2000, and 4000 Hz activators. Activator sound pressure level was measured in all ears. Ipsilateral and contralateral reflexes were detected three times more frequently with a 660 Hz probe tone than with a 220 Hz probe tone. The maximum detection rate (76%) occurred with 1000 and 2000 Hz ipsilateral activators and the 660 probe tone. There was no significant difference between neonatal and adult ipsilateral thresholds at 500, 1000, and 4000 Hz. Neonatal intrameatal sound pressure levels for ipsilateral activators were found to be significantly higher than would be indicated from the otoadmittance meter manufacturer's specifications.

Persistence of middle-ear effusion after acute otitis media in children.

We observed the frequent occurrence of persistent middle-ear effusion in children with acute otitis media and followed them according to standard procedures for otologic diagnosis. We performed a life-table analysis to identify risk factors for such persistent disease. Sixty-two patients were free of middle-ear effusion at one or more clinic visits two to 13 weeks after presentation and were considered cured; 45 had effusion at all clinic visits during this period and were defined as having persistent effusion. The life-table analysis showed that the relative risk for persistence was 3.8 times higher in children less than 24 months of age as compared with children 24 months of age or older (P less than 0.001) and that this risk was 2.8 times greater for white as compared with black children (P less than 0.01). Other factors examined were not identified as significant risk factors. Persistent middle-ear effusion may be associated with impaired hearing and appears to be the most important sequela of otitis media.