D. Isaacs

Late-onset infections of infants in neonatal units

Objective: To examine regional variations in the incidence of late‐onset neonatal infections in Australian and New Zealand neonatal units.

Comparison of influenza A and influenza B virus infection in hospitalized children

Background: Influenza A and B viruses were cocirculating in Australia in the winter of 1997.

The reliability of serological tests for the diagnosis of genital herpes: a critique

&NA; The reliability and limitations of the currently used routine tests for herpes simplex virus type 2 (HSV‐2) antibody in Australia are reviewed. Six case reports illustrate the clinical dangers of overinterpretation of the currently available kits and the need for a readily available specific HSV‐2 antibody test. In Sydney, HSV‐2 causes approximately 85% of primary genital herpes and >95% of recurrent genital herpes. Due to the extensive serological cross‐reactivity between HSV‐1 and HSV‐2, currently available “type specific” commercial assays cannot reliably distinguish between the 2. Isolation of herpes simplex virus (HSV) or detection of HSV antigen in vesicle fluid is the preferred diagnostic test but may be overlooked or patients may have no visible lesions. The only accurate techniques for detecting HSV‐2 specific antibody are the Western blot assay and an enzymatic immunoassay using glycoprotein G (gG‐2), a component of the HSV‐2 envelope. These tests, which still are restricted to research laboratories can be used to accurately identify people with previous exposure to HSV‐2 (IgG) or to diagnose primary infection where virus isolation has not been performed or is impossible. Current commercially available antibody tests may have extensive cross‐reactivity.

A cluster of cases of neonatal coxsackievirus B meningitis and myocarditis

Three babies were referred with enteroviral meningitis and myocarditis during a 4‐month period. During this same period there was an increased frequency of coxsackievirus B type 2 isolates reported to the National Centre for Disease Control. Myocarditis was simultaneous with meningitis in one baby, but delayed by 10 weeks in another, in whom myocarditis mimicked myocardial infarction. Two of the three mothers experienced abdominal pain, one with antepartum haemorrhage, which has been described previously with coxsackievirus infection in pregnancy. Diagnosis was made in two babies by polymerase chain reaction on cerebrospinal fluid.

Antibiotic management of pneumococcal infections in an era of increased resistance

Abstract: Pneumococci are a leading cause of bacterial meningitis and bacteraemia, as well as pneumonia, otitis media and sinusitis in childhood. These organisms recently have shown a dramatic increase in antibiotic resistance. Penicillin‐resistant pneumococci are of special concern as they are often resistant to other unrelated antibiotics. This is of particular significance to Aboriginal children who have among the highest rates of pneumococcal infection in the world. Laboratories should now test all invasive pneumococcal isolates for penicillin and third generation cephalosporin resistance. Local treatment guidelines are required for pneumococcal infections, especially for meningitis, taking into account the prevalence of resistant strains within the community. At present, penicillin and amoxycillin remain the drugs of choice for pneumococcal infections, with the exception of meningitis where initial empirical therapy must be with a third generation cephalosporin. Judicious antibiotic use, which avoids over‐prescribing and unnecessary use of broad‐spectrum agents, improved living standards in underprivileged communities and introduction of an effective conjugate vaccine, able to reduce the rates of pneumococcal infection and hopefully colonization, may limit the spread of resistant strains.

Complications of central venous access devices in children with and without cancer

Objective: Complications of indwelling central venous access devices (CVAD) were assessed in 63 children with cancer and 35 without cancer.

Use of simple clinical parameters to assess severity of bronchiolitis

: To determine whether simple clinical parameters could be used to predict the severity of acute bronchiolitis and the need for supplemental oxygen therapy.

Acyclovir for the prevention and treatment of varicella zoster in children, adolescents and pregnancy

Abstract: Varicella causes a mild, self‐limiting childhood disease that may reactivate years later as shingles. In immuno‐compromised patients with altered cell mediated immunity, and rarely in healthy individuals, varicella results in a life‐threatening infection. The antiviral drug, acyclovir, substantially reduces the mortality and risk of severe disease in these groups of patients. Early commencement of acyclovir is recommended for children with both varicella and altered cell mediated immunity, newborns during the first 2 weeks of life, preterm infants in the neonatal nursery, and severe varicella or shingles (including ocular zoster) in any patient, as well as during pregnancy. Acyclovir may be considered in children with serious cardiopulmonary disease or chronic skin disorders where varicella may exacerbate the underlying disease or increase the risk of secondary bacterial sepsis. Acyclovir, however, is not recommended for healthy individuals without severe disease, as a prophylactic agent against varicella, for asthmatics receiving aerosolized or low‐dose oral steroids and/or as treatment of the post‐varicella syndromes. When acyclovir is prescribed it should be given intravenously to those with severe disease, those at risk of dissemination and in children younger than 2 years of age.

Lumbar puncture in suspected neonatal sepsis

Objective: The importance of lumbar puncture (LP) as part of the evaluation of suspected neonatal sepsis is assessed, as it may be the only positive diagnostic test in about 10% of septic babies with meningitis but negative blood cultures. However, LP may compromise respiratory function, and the interpretation of cerebrospinal fluid (CSF) may not be straightforward.

Lumbar punctures in suspected bacterial meningitis: too many or too few?

Children aged 1 month to 14 years admitted to the Royal Alexandra Hospital for Children during a 10 month period with suspected meningitis were studied prospectively. The aims were to determine how often lumbar puncture (LP) was delayed or never done, in relation to the outcome of all children, in order to determine the risks of LP and the risks of not doing LP. Of 218 children with suspected meningitis, LP was performed immediately in 195 (89.4%). Meningitis was diagnosed in 49 of these (bacterial 18, viral 31). No child developed cerebral herniation due to immediate LP. There were 11 traumatic taps and two children required repeated attempts. Lumbar puncture was delayed, but performed at a later time in 17 children, of whom three had proven bacterial meningitis, 1 had presumed bacterial meningitis but no organism was detected and 13 had alternative diagnoses. Six children never had an LP, although ventricular cerebrospinal fluid was obtained from two Four of these six children had presumptive bacterial meningitis, one had tuberculous meningitis presenting with acute hydrocephaius and diagnosed post‐mortem, and one had a very poor neurological outcome and no final diagnosis was reached. Of the 27 children with bacterial meningitis, LP was performed immediately in 18, or two‐thirds. There were only minor adverse effects of immediate LP. Delayed LP probably resulted in failure to identify the organism in one child with bacterial meningitis, but did not adversely affect outcome in any child. Of the six children in whom LP was never performed, in only one was no final diagnosis reached. There was no evidence of excessive morbidity attributable to performing too many or too few lumbar punctures.