Jacob A. Lohr

Invasive Group A Streptococcal Infections in North Carolina: Epidemiology, Clinical Features, and Genetic and Serotype Analysis of Causative Organisms

During 1994 and 1995, an increase in the number and severity of group A streptococcal (GAS) infections was noted in North Carolina. Ninety-six patients had GAS recovered from blood and other sterile body fluids, abscesses, and soft tissue. The overall case fatality rate was 11% but was much higher in patients with toxic shock syndrome (55%) and necrotizing fasciitis (58%). Recent invasive GAS isolates were compared with pre-1994 invasive isolates and temporally related pharyngeal isolates by M protein serotyping, pulsed field gel electrophoresis (PFGE), and polymerase chain reaction amplification of the streptococcal pyrogenic exotoxin A gene. Serotypes M1 and M3 accounted for 50% of recent invasive isolates (1994-1995) and 58% of pharyngeal isolates (1994). The latter isolates demonstrated PFGE patterns that were identical to invasive M1 and M3 strains, suggesting that pharyngeal infections may have served as a reservoir for virulent GAS clones.

Efficacy of topical antibiotic therapy in acute conjunctivitis in children

We studied 102 children aged 1 month to 18 years in a randomized, double-blind trial designed to determine both the natural history of bacterial conjunctivitis and whether topical antibiotic therapy is beneficial. Affected eyes were treated four times a day for 7 days with drug (polymyxin-bacitracin ophthalmic ointment) or placebo. Eighty-four patients had proved bacterial conjunctivitis (Haemophilus influenzae 61, Streptococcus pneumoniae 22, both one); 66 of these received only topical therapy. By 3 to 5 days, 21 of 34 (62%) patients receiving topical antibiotic were clinically cured, whereas only nine of 32 (28%) patients given placebo were cured (P less than 0.02). By 8 to 10 days, 31 (91%) of the patients given antibiotic and 23 (72%) of the placebo group were cured (P = NS). The bacterial pathogen was eradicated by day 3 to 5 in 71% and by day 8 to 10 in 79% of patients given antibiotic, compared to 19% and 31% of the placebo group (P less than 0.001). Acute bacterial conjunctivitis is a self-limited disease, but topical antibiotic therapy with polymyxin-bacitracin shortens the duration of clinical disease and enhances eradication of the causative organism from the conjunctiva.

Hospital-acquired urinary tract infections in the pediatric patient: A prospective study

To determine through a prospective study the characteristics of hospital-acquired urinary tract infections (HAUTI) in children, 525 children subjected to bladder catheterization during a hospital admission were identified through surveillance of 12,316 admissions during a 24-month period. Urine culture results were available for 296 (56.4%) of the catheterized patients. In addition 12 noncatheterized children with a documented HAUTI were identified. The clinical courses of all patients with a HAUTI were followed for at least 6 months after their last HAUTI during the study period. Forty-four patients, 1 week to 17 years of age, with 1 or more HAUTI during a hospital unit admission were identified. A total of 51 HAUTI occurred. Thirty-nine (76.5%) of the infections occurred in patients subjected to catheterization. Thirty-two (10.8%) of 296 catheterized patients developed a HAUTI. Forty-three (84.3%) of the 51 infections were single organism infections. One HAUTI was associated with a wound infection with the same organism and one with a concurrent bacteremia with the same organism. Relapses were seen after 4 HAUTI. One reinfection was identified. There were no deaths directly associated with a HAUTI. Hospitalized children subjected to urinary tract catheterization are at significant risk for HAUTI. Complications are infrequent and not life-threatening.

Explanation for false-positive urine cultures obtained by bag technique.

OBJECTIVE To test whether a urine bag technique, previously shown in circumcised male infants 1 month to 1 year of age to yield no false-positive cultures, would give similar results in newborns (females and circumcised and uncircumcised males). DESIGN Prospective study in which periurethral and urine specimens were obtained from healthy newborns. After the periurethral specimen was obtained, the perineum was washed and a urine bag applied. The urine bag was removed immediately after voiding and the urine was cultured. SETTING Normal newborn nursery and pediatric hospital. SUBJECTS Ninety-eight healthy full-term newborns (49 female and 49 male) admitted to the normal nursery during a 4-month period. MAIN RESULTS Isolation of a pathogen from the bag urine reflected periurethral flora. In 20 (95%) of the 21 urine specimens from which a pathogen was isolated, the same pathogen was detected on the periurethra. Sixteen of the 21 urine cultures were falsely positive (> 10(4) colony-forming units of pathogen per milliliter). In 50 (98%) of the 52 urine samples that yielded no growth, the periurethral culture was also negative. In the remaining 25 urine samples in which nonpathogens were detected, the periurethra yielded nonpathogens or no growth. Thus, if a pathogen was isolated from a bag urine sample, the same pathogen was detected on the periurethra 95% of the time. Conversely, if the bag urine sample was negative for a pathogen, the periurethral culture was negative 100% of the time. The presence of a pathogen on the periurethra was more common in female than male neonates (16 of 49 vs four of 49; P = .004), and none of the 14 circumcised male neonates had a pathogen detected on their periurethra or in their urine. CONCLUSION This study explains the finding of false-positive cultures with the bag technique. Pathogens detected in bag urine samples reflected pathogens on the periurethra. Until a bag collection technique that avoids contamination by periurethral flora can be developed, urethral catheterization and suprapubic aspiration remain the methods of choice for obtaining a urine specimen in female and uncircumcised male neonates.

Evaluation of bivalent live attenuated influenza A vaccines in children 2 months to 3 years of age: safety, immunogenicity and dose-response

1126 children, 2 months to 3 years old, received a single intranasal dose of 10(4), 10(6), or 10(7) TCID50 of cold adapted (ca) A/Kawasaki/9/86 (H1N1) and A/Beijing/352/89 (H3N2) or placebo, in a double blind, placebo-controlled, safety and immunogenicity trial. No reactogenicity attributable to vaccine was demonstrated. A single bivalent 10(6) or 10(7) dose produced high rates of seroconversion to H1N1 (77%) and H3N2 (92%) in seronegative children > 6 months old; serologic responses were lower to H1N1 (P < 0.001) and H3N2 (P = 0.01) in younger infants. A single 10(6) dose of bivalent ca influenza A vaccine can be immunogenic in children, but response is age dependent.

Safe babies: a qualitative analysis of the determinants of postpartum smoke-free and relapse states.

This qualitative study explores smoking cessation during pregnancy and the factors that contribute to remaining smoke-free and relapsing. Ninety-four women attending prenatal clinics in central North Carolina who had quit smoking before 30 weeks gestation were enrolled in an observational study that included a face-to-face interview at 4 months postpartum. Results were analyzed for common themes in the two groups: those who remained smoke-free and those who had relapsed. Fetal health motivated pregnant women to quit smoking, while stress, socializing with smokers, cravings, and easy access to cigarettes tempted women to smoke. Women who remained smoke-free postpartum overcame temptations by continuing to acknowledge the health benefits of not smoking and having a strong internal belief system, significant social support, negative experiences with renewed exposure to cigarettes, and concrete strategies for dealing with temptations. For women who relapsed postpartum, factors having the greatest influence on relapse included easy access to cigarettes, lack of social and financial support, insufficient resources for coping with the challenges of childrearing, physical addiction, reliance on cigarettes as a primary form of stress management, and feelings of regret, shame, or low self-esteem. Recommendations for relapse prevention include assessing women who quit during pregnancy for low or high risk of relapse and offering comprehensive interventions and case management for those at higher risk to address the physical, mental, behavioral, and social contexts leading to relapse.

Hospital-acquired infections in pediatric burn patients.

To determine the epidemiologic characteristics of hospital-acquired infections (HAI) in pediatric burn patients, we retrospectively reviewed hospital charts of pediatric burn patients from two similar burn units. All patients less than 18 years of age admitted to the burn unit from January 1, 1980 to July 10, 1988, were enrolled. Charts were analyzed for age, sex, burn injury (type, depth, burn surface area), and hospital course (burn wound therapy, use of indwelling catheters or tubes, infectious complications, antibiotic use, cause of death if patient died). Statistical analysis was done using a logistic regression model. Of the 224 children admitted, 32 (14%) had 58 infections during their stay in the burn unit. There was no significant difference in age, sex, race, burn type or use of wound excision between patients with or without infection. Patients who acquired an infection were more likely to have sustained a ≥20% full-thickness burn (14/32 vs 3/192 without infection), a smoke inhalation injury (10/32 vs 8/192), or have an indwelling device (29/32 vs 77/192). Thirteen (22%) of the 58 infections were burn wound infections due to Staphylococcus aureus or Pseudomonas aeruginosa, 12 (21%) were urinary tract infections due to Enterobacteriaceae, 11 (19%) were pneumonias caused by S aureus, Streptococcus pneumoniae or Pseudomonas sp, and 10 (17%) were bacteremias caused by S aureus or coagulase-negative staphylococci. The infection rate in pediatric patients hospitalized for burn injury in our study was significantly lower than the infection rate described for adult burn patients. As in adult patients, burn wound infections, pulmonary infections, and catheter-associated bacteremias are the most common infections in burned children. However, urinary tract infections are more frequent in the pediatric population. Risk factors (≥20% full-thickness burns, indwelling devices) and causative organisms are similar in both age groups.

Effect of periurethral colonization on the risk of urinary tract infection in healthy girls after their first urinary tract infection.

We examined whether periurethral colonization with bacterial pathogens predicts recurrent urimary tract infection (UTI) in girls at risk for infection. Periurethral and urine cultures were obtained weekly from each of seven healthy toilet-trained girls (3 to 6 years of age, normal urimary tract) during the 6 months after their first UTI, when the risk of UTI is 35%. Periurethral and urine isolates of Escherichia coli were grouped into electrophoretic types (ETs) by multilocus enzyme electrophoresis. Fifty-three (43%) of the 122 periurethral cultures were positive for a pathogen (median, 6 positive cultures/patient). Two patients each experienced 2 UTI. Positive periurethral cultures were as common in the five uninfected patients as in the two infected patients (9 of 32 vs. 44 of 90, P = 0.06). In only 1 of the 4 UTI was the infecting organism detected on the periurethra in the 2 weeks prior. Mutilocus enzyme electrophoresis of the 104 periurethral and urine E. coli isolates from the 7 patients revealed 22 ETs. Such a diversity of ETs suggests that the flora of the periurethral region is colonized by mul-

Diagnostic Review : Prolonged Fever of Unknown Origin

From: Department of Pediatrics, University of Virginia Hospital, Charlottesville, Virginia 22901. THE CLINICAL DILEMMAS presented by adult American patients with prolonged fever of unknown origin have been the subject of numerous reviews and in-depth discussions.’-’ As for children, IVIcClung9 and Pizzo, Lovejoy, and Smithl° have highlighted certain aspects of prolonged unexplained fever which are unique to this age. We here describe 54 such children with prolonged fever of unknown origin, with the view toward expediting the diagnostic workup of such children.

Pediatric Fever of Unknown Origin

1. James W. Antoon, MD, PhD* 2. Nicholas M. Potisek, MD† 3. Jacob A. Lohr, MD†† 1. *Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of Illinois at Chicago, Chicago, IL. 2. †Department of Pediatrics, Division of Pediatric Hospital Medicine, Wake Forest School of Medicine, Winston-Salem, NC. 3. ††Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, University of North Carolina School of Medicine, Chapel Hill, NC. Pediatricians often confuse fever without a source and fever of unknown origin. After completing this article, readers should be able to: 1. Adopt a systematic approach to evaluation and management of fever of unknown origin in patients of various ages. Fever is a common complaint in children. In most cases, fevers are due to self-limited viral infections and require no more than symptomatic treatment. Sometimes fever is due to common bacterial infections that are diagnosed by history and physical examination and require antibiotic treatment without laboratory evaluation. In a few clinical situations, the cause of fever is not easily identified. Fever without a source (FWS) may need further evaluation that includes laboratory tests or imaging. Rarely, the fever is more prolonged, requires more intensive evaluation, and falls in the category of fever of unknown origin (FUO). There is often confusion about the terms FUO and FWS. Distinguishing between FUO and FWS is important and is based on duration of fever. FWS can progress to FUO if no cause is elicited after 1 week of fever. The current incidence and prevalence of pediatric FUO remain unclear. Several factors contribute to the difficulty in determining the epidemiology, including the lack of a standardized definition, clinical criteria, and coding using the International Classification of Diseases-9 code for the condition. Furthermore, the causes of FUO often have an overlapping collection of symptoms and insidious disease courses. The general direction of the evaluation varies based on patient presentation, geographic location, associated symptoms, environmental exposures, physician experience, and available testing techniques. Body temperature is primarily controlled by the hypothalamus via regulation of pulmonary, skin, and metabolic …