Edgar Mohs

Single dose antibiotic therapy is not as effective as conventional regimens for management of acute urinary tract infections in children

One hundred thirty-two children with acute urinary tract infection were randomly assigned to receive trimethoprim-sulfamethoxazole in one dose, two doses daily for 3 days or two doses daily for 7 days. The patient characteristics, etiologic agents and frequency of roentgenologic abnormalities were similar for the three treatment groups. There was no significant difference in bacteriologic cure rates for the single dose regimen (93%) and multidose regimens (96%). The difference in rates of recurrent urinary tract infection between the single dose (20.5%) and 3-day (5.6%) and 7-day (8%) regimens was statistically significant (P = 0.033). A single dose of trimethoprim-sulfamethoxazole is inadequate treatment for infants and children with acute urinary tract infection.

Microbiology of acute otitis media in Costa Rican children.

BACKGROUND Because of the increasing number of resistant middle ear pathogens reported from different centers worldwide, an active surveillance of the microbiology and susceptibility pattern of middle ear pathogens is required for proper antimicrobial recommendations among different regions of the world. OBJECTIVE To study the microbiology and susceptibility pattern of middle ear pathogens obtained from Costa Rican children with acute otitis media. METHODS Between 1992 and 1997 a diagnostic tympanocentesis was performed in 398 Costa Rican patients with acute otitis media. Middle ear fluid was obtained for culture and minimal inhibitory concentrations were determined by the E-test technique in those isolates obtained between October, 1995, and January, 1997. RESULTS The most common pathogens cultured were Streptococcus pneumoniae (30%), Haemophilus influenzae (14%), Staphylococcus aureus (4%) and Streptococcus pyogenes (4%). Moraxella catarrhalis was uncommon. Beta-lactamase production was low (3.7%) among the H. influenzae isolates but frequent among the Staphylococcus aureus (57.1%) and M. catarrhalis (100%) strains. Overall 9 of 46 S. pneumoniae isolates (19.6%) exhibited decreased susceptibility to penicillin of which 8 isolates (17.4%) showed intermediate and one strain (2.2%) high level resistance. Among the penicillin-susceptible S. pneumoniae isolates, susceptibility to the following antimicrobials was: 81%, azithromycin; 89%, clarithromycin; and 100%, ceftriaxone and trimethoprim-sulfamethoxazole (TMP-SMX). Among the penicillin-resistant S. pneumoniae isolates the percentage of susceptible strains was 89% for azithromycin, clarithromycin and ceftriaxone and 67% for TMP-SMX. CONCLUSIONS Based on this microbiologic information the agents considered first line drugs in the treatment of acute otitis media in Costa Rica remain amoxicillin or TMP-SMX.

Amikacin in Newborn Infants: Comparative Pharmacology with Kanamycin and Clinical Efficacy in 45 Neonates with Bacterial Diseases

The pharmacokinetic properties of amikacin (BBK8) were similar to those of kanamycin in newborn infants. Peak serum concentrations of both drugs were in the range of 15 to 25 μg/ml with the exception of kanamycin in babies weighing greater than 2,000 g at birth where peak levels were 12.5 to 15 μg/ml. Volumes of distribution, plasma clearances, and serum half-life values were comparable for the two drugs. The clinical and bacteriological responses to amikacin therapy were assessed in 45 neonates with bacterial diseases. A case fatality rate of 26% was observed in infants with septicemia and/or meningitis, whereas no deaths occurred among 22 infants with urinary tract and mucocutaneous infections. Cultures from infected sites were sterile within 72 h of initiating amikacin therapy in 47% of the infants, continued positive for greater than 72 h in 31%, and were not reevaluated during therapy in 22%. The clinical response was judged to be satisfactory in 92% of the surviving infants. The efficacy of amikacin was comparable to that of kanamycin or gentamicin in neonatal bacterial diseases.

Antimicrobial therapy for children with chronic suppurative otitis media without cholesteatoma.

This study was designed to determine the middle ear bacterial pathogens, the frequency of serum immunoglobulin deficiency and the efficacy of medical management in patients with chronic suppurative otitis media without cholesteatoma. This was an open noncomparative clinical trial performed at the National Childrens Hospital, San Jose, Costa Rica, and included 186 patients older than 2 months of age with a confirmed diagnosis of chronic suppurative otitis media without cholesteatoma. Middle ear cultures and serum for immunoglobulin determinations were obtained on admission. The first 40 patients were treated only with ceftazidime and from patient 41 and up, if a Grampositive organism was cultured, oxacillin was added to (for combined infection) or replaced ceftazidime. Parenteral antibiotics and suction twice daily were continued until three days after the middle ear became dry. Trimethropimsulfamethoxazole prophylaxis was administered during the follow-up period. Middle ear bacterial cultures were positive in 166 patients. Pseudomonas sp. (35.6%), enteric Gram-negative organisms (28.7%) and Gram-positive cocci (26%) were the most common organisms. Immunoglobulin determinations were below normal in 3 of 69 (4.3%) evaluable patients. Dryness of the ear was achieved in 174 patients (93.5%) including 130 of 139 patients treated with ceftazidime, 28 of 28 patients treated with oxacillin and 14 of 14 patients treated with ceftazidime and oxacillin. Recurrent otorrhea developed in 39 (23.4%) patients. Twice-daily canal aspiration and parenteral ceftazidime for Gram-negative organisms and/or oxacillin for Gram-positive bacteria for 3 days after dryness of the middle ear followed by prophylactic oral antimicrobials are effective for treatment of most chronic suppurative otitis media without cholesteatoma patients.

Evolution of paradigms of child health in developing countries.

In 1982 Costa Rica had an infant mortality of 18 per 1000 live births and a life expectancy at birth of 76 years for women and 72 years for men. In the evolution of infant health in Costa Rica two paradigms were identified. One developed in the decades before 1970 and the other during the 1970s. The necessity of conceptualizing a third new paradigm compatible with health needs of the present and the immediate future is recognized. The first or “malnutrition paradigm” was orthodox in its derivation; it identified the lack of food as the underlying base for the major health problems and placed its emphasis on institutional medicine. The paradigm was influenced by foreign schools of nutrition and pediatrics and led to the development of an infrastructure for the delivery of medical services and the programs for food distribution. The “infectious disease paradigm” recognized infectious diseases as the main determinants of morbidity, mortality and malnutrition in childhood. The strategies derived from such a revolutionary paradigm aimed at the control and eradication of infectious diseases, and they resulted in a rapid improvement of child nutrition and health. However, the infectious disease paradigm does not seem to reduce infant mortality below the present level. Thus the “holistic health paradigm” is proposed in which the control and prevention of infectious diseases are maintained but priority is given to the prevention of perinatal problems, noninfectious diseases and various disabilities. This paradigm copes with life styles, individual responsibility and coordination of public and private health and medical care. The paradigm focuses on emerging health problems that in the past were not apparent or were masked by the prevalence of malnutrition and infectious diseases. The dramatic results observed in Costa Rica and in a few other tropical countries show that health can be improved without undergoing urbanization and industrialization. The malnutrition paradigm should be discarded. The infectious disease paradigm should guide public health action in underdeveloped countries to ensure a reduction in malnutrition and infant mortality. The holistic health paradigm is the option for countries like Costa Rica in which a further improvement of present health status no longer depends on control of infectious diseases alone.

General theory of paradigms in health.

In Costa Rica, three sequential health paradigms have been identified over the last 50 years. The first began to develop during the 40s and has been called that of the deficiency diseases, since with a diachronic approach it placed excessive emphasis on malnutrition. The second began in 1970 and it is know a that of the infectious diseases, since through a holistic or synchronic approach, it underlined the importance of infections in high rates of morbidity and mortality. The third and last is the paradigm of the chronic diseases, it appeared in the 80s and is presently in process, doing battle with the chronic ailments, life styles, and environment, and it also utilizes a holistic approach. The recognition of these three paradigms has permitted Costa Rica a rapid advance in improving the health of its population, to the point that with a per capita outlay of

Adverse reactions to vancomycin used as prophylaxis for CSF shunt procedures

130 (U.S. dollars), it has indices similar to those of the industrialized nations. This particular experience could be useful for other less developed countries that are still applying the paradigm of the deficiency diseases.