Angela Galloway

Community acquired pneumonia—a prospective UK study

BACKGROUND There are few data on paediatric community acquired pneumonia (PCAP) in the UK. AIMS To investigate the aetiology and most useful diagnostic tests for PCAP in the north east of England. METHODS A prospective study of hospital admissions with a diagnosis of PCAP. RESULTS A pathogen was isolated from 60% (81/136) of cases, and considered a definite or probable cause of their pneumonia in 51% (70/136). Fifty (37%) had a virus implicated (65% respiratory syncytial virus) and 19 (14%) a bacterium (7% group A streptococcus, 4% Streptococcus pneumoniae), with one mixed infection. Of a subgroup (51 patients) in whom serum antipneumolysin antibody testing was performed, 6% had evidence of pneumococcal infection, and all were under 2 years old. The best diagnostic yield was from paired serology (34%, 31/87), followed by viral immunofluorescence (33%, 32/98). CONCLUSION Viral infection accounted for 71% of the cases diagnosed. Group A streptococcus was the most common bacterial infective agent, with a low incidence of bothMycoplasma pneumoniae andS pneumoniae. Pneumococcal pneumonia was the most common bacterial cause of pneumonia in children under 2 years but not in older children. Inflammatory markers and chestx ray features did not differentiate viral from bacterial pneumonia; serology and viral immunofluorescence were the most useful diagnostic tests.

Environmental Monitoring for Gastroenteric Viruses in a Pediatric Primary Immunodeficiency Unit

ABSTRACT The aim of this study was to determine if gastroenteric viruses were present on surfaces and equipment in a pediatric primary immunodeficiency unit (PPIU) by environmental sampling using swabs and subsequent nucleic acid extraction and reverse transcriptase PCR assays. A PPIU was chosen, and 11 swabs were taken at the same sites every 2 weeks for 6 months. Nested/heminested PCR assays were used to screen for astroviruses (AsV), noroviruses (NoV), and rotaviruses (RV). AsV, NoV, and RV were detected at multiple swab sites during the study period. NoV was the most frequently detected virus on environmental surfaces; however, RV was detected on 79% and NoV on 50% of swabbing dates during the study period. Toilet taps were the most contaminated sites. Fecal samples from selected patients in the unit were also screened during the study period, and patients excreted AsV, NoV, and RV at times during the study. New cleaning schedules and changes in some of the PPIU sanitary furniture have been suggested as a means of reducing environmental contamination.

Contamination of the Hospital Environment with Gastroenteric Viruses: Comparison of Two Pediatric Wards over a Winter Season

ABSTRACT The aims of this study were to examine the extent of gastroenteric virus contamination in a pediatric primary immunodeficiency (PPI) ward and a general pediatric ward over a winter season and to determine whether changes to hospital infection control interventions would have an impact on environmental contamination levels within pediatric units. Environmental swabs were collected weekly from 11 sites in both wards from 15 December 2005 to 3 March 2006 and examined for the presence of norovirus (NoV), astrovirus, and rotavirus (RV) by reverse transcriptase PCR. Viruses were detected in 17% and 19% of swabs from both wards. Virus contamination for NoV and RV decreased from 20% to 6% and 15% to 10% of swabs, respectively, in the PPI ward from the 2004 study by Gallimore et al. (C. I. Gallimore, C. Taylor, A. R. Gennery, A. J. Cant, A. Galloway, M. Iturriza-Gomara, and J. J. Gray, J. Clin. Microbiol. 44:395-399, 2006). Overall, changes to cleaning protocols were deemed to have reduced the level of environmental contamination with gastroenteric viruses, but contamination still occurred due to a breakdown in infection control procedures indicated by contamination in areas frequented by parents but used only occasionally by staff.

Unsuspected Pneumocystis carinii pneumonia at presentation of severe primary immunodeficiency.

BACKGROUND Pneumocystis carinii is an important pathogen in immunodeficiency but may be an unrecognised cause of respiratory compromise. OBJECTIVES To ascertain the incidence of P cariniipneumonia (PCP) at presentation of severe combined immunodeficiency (SCID), whether it had been diagnosed, and the effect of treatment on outcome. SETTING The supraregional paediatric bone marrow transplant unit for primary immunodeficiencies at Newcastle General Hospital. METHODS Retrospective case note review of infants referred with a diagnosis of SCID from 1992 to 1998. RESULTS Ten of 50 infants had PCP at presentation; only one was diagnosed before transfer. Eight were diagnosed by bronchoalveolar lavage and two by lung biopsy. In only one was P cariniiidentified in nasopharyngeal secretions. Five required ventilation for respiratory failure but all were successfully treated with co-trimoxazole and methylprednisolone with or without nebulised budesonide. Nine survived to bone marrow transplantation and four are long term survivors after bone marrow transplantation; no deaths were related to PCP. CONCLUSIONS PCP is a common presenting feature of SCID but is rarely recognised. Bronchoalveolar lavage or lung biopsy are needed for diagnosis. Treatment with co-trimoxazole is highly successful.

Best practice in primary care pathology: review 2.

This second best practice review examines five series of common primary care questions in laboratory medicine: (1) laboratory testing for allergy, (2) diagnosis and monitoring of menopause, (3) the use of urine cytology, (4) the usefulness of the erythrocyte sedimentation rate, and (5) the investigation of possible urinary tract infection. The review is presented in a question–answer format. The recommendations represent a précis of guidance found using a standardised literature search of national and international guidance notes, consensus statements, health policy documents, and evidence based medicine reviews, supplemented by MEDLINE EMBASE searches to identify relevant primary research documents. They are standards but form a guide to be set in the clinical context. Most are consensus rather than evidence based. They will be updated periodically to take account of new information.

Mycobacterium mucogenicum from the Hickman line of an immunocompromised patient

Gram stain of a positive blood culture is the clinician’s first indication of a possible causative infective organism and a guide to suitable antimicrobial therapy prior to cultural and phenotypic identification with susceptibility test results. Occasionally interpretation of a Gram stain can be difficult; if there is a low bacterial load, no organisms may be seen. Such a case is reported, where a positive blood culture taken from the Hickman line of an immunocompromised patient flagged as positive at 5 days’ incubation, but no organisms were seen on Gram film. On subculture, a slow growing Gram-positive bacillus was isolated which was initially misidentified and reported as a “diphtheroid” species. The actual identity of this organism and further isolates was later elucidated as Mycobacterium mucogenicum, a rapidly growing non-tuberculous mycobacterium.

Practical hematopoietic stem cell transplantation

1 Why hematopoietic stem cell transplantation and for whom?. A. J. Cant, C. Craddock and R. Skinner. 2 Pre-transplant assessment. M. Slatter and S. Fox. 3 The transplant. R. Skinner, A. Lennard and P. Veys. 4 Care of the transplant patient. C. Charley and W. Larmouth. 5 Prevention of infection during hematopoietic stem cell transplantation. W. Larmouth and A.Galloway. 6 Bacterial, fungal, and parasitic infections in the transplant patient. G. Jones, J. Clark and A. Galloway. 7 Virus infections in the HSCT patient. C. Taylor and A. Turner. 8 Management of febrile neutropenia and system-specific infections. G. Jones, J. Clark and A. Galloway. 9 The role of intensive care in the management of hematopoietic stem cell patients. B. Fulton and A. Gascoigne. 10 Graft-vs.-host disease and post-transplant lymphoproliferative disease. M. Abinun and J. Cavet. 11 Gastrointestinal, respiratory and renal/urogenital complications of HSCT. M. Abinun and J. Cavet. 12 Follow up in the first year after hematopoietic stem cell transplantation. A.R. Gennery and M.P. Collin. 13 Immune recovery following hematopoietic stem cell transplantation and vaccination. A.R. Gennery, D. Barge and G. Spickett. 14 Prevention of infection following discharge after hematopoietic stem cell transplant. H. Harvey and A. Reed. 15 Social and psychological aspects of care. M. Allan and D. Holder. 16 Long-term follow up of transplant recipients. R. Skinner and G. Jackson. 17 Hematopoietic stem cell transplantation - the future. A.J. Cant and G. Jackson. Index

Salmonella Michigan soft tissue infection in an immunocompromised child.

A rare case of soft tissue infection due to Salmonella Michigan in an immunocompromised child is reported. The same organism was isolated from a tortoise kept in the home. Immunocompromised patients are especially susceptible to reptile-associated salmonellosis and should be advised appropriately.

Value of bronchoalveolar lavage before haematopoietic stem cell transplantation for primary immunodeficiency or autoimmune diseases

Pulmonary infection, often insidious, is frequent in primary immunodeficiency (PID) and acquired immunodeficiency. Pulmonary complications are serious obstacles to success of haematopoietic SCT (HSCT) for these conditions. Bronchoalveolar lavage (BAL) permits identification of lower respiratory tract pathogens that may direct specific treatment and influence prognosis. There are no reports about the utility of pre-HSCT BAL for immunodeficient patients. We prospectively studied the value of ‘routine’ BAL before commencing transplantation in patients undergoing HSCT for severe immunological disease. Routine non-bronchoscopic BAL was performed under general anaesthetic, a few days before commencing pre-HSCT cytoreductive chemotherapy. Patients were categorized as symptomatic or asymptomatic with respect to pulmonary disease or infection. Samples were sent for microbiological processing. Complications arising from the procedure, pathogens isolated and treatments instituted were recorded. Results were available from 69/75 patients transplanted during the study period; 26 (38%) had pathogens identified (six asymptomatic patients), 10 (14.5%) developed complications post-procedure (two asymptomatic patients)—all recovered, 21 had management changes. There was no statistically significant difference in the number of positive isolates from severe combined or other immunodeficient patients, or of symptomatic or asymptomatic patients. Routine non-bronchoscopic BAL is safe in immunodeficient patients about to undergo HSCT, and leads to management changes.

Does cefotaxime eradicate nasopharyngeal carriage of N meningiditis.

We enrolled 43 children admitted with an unequivocal clinical diagnosis of meningococcal sepsis into a study to determine whether cefotaxime eradicated nasopharyngeal carriage of Neisseria meningitidis . In 28 cases (70%) the diagnosis was confirmed by positive culture from blood, nose, throat, or skin scraping, detection of meningococcal DNA in blood by polymerase chain reaction, or convalescent meningococcal serology. All children were treated with intravenous cefotaxime for seven days. …