John F. Marcinak

Clindamycin treatment of methicillin-resistant Staphylococcus aureus infections in children.

Background. Methicillin-resistant Staphylococcus aureus (MRSA) with a narrower antibiotic resistance pattern have emerged. There is a risk for the appearance of resistance during clindamycin therapy of erythromycin-resistant MRSA infections because of the linked resistance mechanisms. Methods. We analyzed clindamycin-susceptible MRSA organisms from children (1987 to 2000) along with clinical data. Antibiotic susceptibilities of organisms were tested, pulsed field gel electrophoresis (PFGE) was done and the linked resistance mechanism was detected by the D test. Results. An average of 11 clindamycin-susceptible MRSA per year were obtained from children since 1993. Of 88 isolates 33 (38%) were erythromycin-resistant. The latter were less often community-acquired (45%vs. 69%), more often from infants <1 month of age (24%vs. 4%) and less likely to be in the community acquisition-associated PFGE Group 1 (62%vs. 87%) than those that were susceptible. The D test was positive in 31 of 33 erythromycin-resistant isolates. A 9-month-old boy with pneumonia/empyema caused by a clindamycin-susceptible, erythromycin-resistant, D test-positive MRSA developed a PFGE-identical clindamycin-resistant isolate and clinical relapse during clindamycin treatment. In contrast a 12-year-old girl with abscesses caused by a similar MRSA developed another abscess after clindamycin therapy, but the organism was unchanged in susceptibility. Conclusions. Erythromycin resistance was present in 38% of clindamycin-susceptible MRSA in children, and clindamycin resistance was detected during treatment in one child. Clindamycin remains a treatment option if the clinician is notified of the risk by the microbiology laboratory and the clinical situation is suitable.

Community-acquired and clindamycin-susceptible methicillin-resistant Staphylococcus aureus in children

BACKGROUND Recognition of children with community-acquired (CA) infections caused by clindamycin-susceptible, methicillin-resistant Staphylococcus aureus (MRSA) prompted a retrospective study in two Chicago hospitals conducted from 1987 through 1997. METHODS Laboratory records of MRSA isolates, antibiotic susceptibilities and information from patient medical records were reviewed. RESULTS One hundred eleven MRSA isolates from 103 children were studied with 51 isolates CA and 77 susceptible to clindamycin. The CA infections were less frequently associated with prior surgery (P = 0.0039) or a foreign body (P = 0.0001), and clindamycin-susceptible MRSA infections were less frequently associated with a foreign body (P = 0.001) compared with nosocomially acquired or clindamycin-resistant MRSA infections. Clindamycin-susceptible MRSA sources were mostly skin, wound or abscess (69%). Soft tissue diagnoses predominated (70%), but 16% were serious invasive infections. Ninety percent of clindamycin-susceptible MRSA were susceptible to erythromycin and/or trimethoprim-sulfamethoxazole. Antibiotic undertreatment (45%) or overtreatment (17%) of children with the clindamycin-susceptible MRSA occurred, but clindamycin appeared to be effective when used. CONCLUSION The impact of these organisms could be substantial if they become more frequent or widespread. S. aureus is a potential pathogen in large numbers of pediatric patients; microbiologic evaluation and both presumptive and definitive treatment of all these children may need to be changed.

Immunogenicity, safety, and predictors of response after a pneumococcal conjugate and pneumococcal polysaccharide vaccine series in human immunodeficiency virus-infected children receiving highly active antiretroviral therapy

Background: The immunogenicity and safety of 2 doses of pneumococcal conjugate vaccine (PCV) and 1 dose of pneumococcal polysaccharide vaccine (PPV) were evaluated in human immunodeficiency virus (HIV)-infected children receiving highly active antiretroviral therapy (HAART). Methods: Children 2 to <19 years, receiving stable HAART for ≥3–6 months, with HIV RNA PCR <30,000–60,000 copies/mL, received 2 doses of PCV and 1 dose of PPV at sequential 8-week intervals. Antibodies to pneumococcal serotypes (STs) 1 (PPV only) and 6B, 14, 19F, and 23F (PCV and PPV) were measured by ELISA. Results: Two hundred sixty-three subjects were enrolled, of whom 225 met criteria for inclusion in the primary dataset. Antibody concentrations were low at entry, despite previous PPV in 75%. After vaccination, 76%–96% had concentrations ≥0.5 &mgr;g/mL and 62–88% ≥1.0 &mgr;g/mL to the 5 STs (geometric mean concentrations [GMCs] = 1.44–4.25 &mgr;g/mL). Incremental gains in antibody concentration occurred with each vaccine dose. Predictors of response included higher antibody concentration at entry, higher immune stratum (based on nadir CD4% before HAART and CD4% at screening), lower entry viral RNA, longer duration of the entry HAART regimen, and age <7 years. Response was more consistently related to screening CD4% than nadir CD4%. Seven percent had vaccine-related grade 3 events, most of which were local reactions. Conclusions: Two PCVs and 1 PPV were immunogenic and safe in HIV-infected children 2 to <19 years who were receiving HAART. Responses were suggestive of functional immune reconstitution. Immunologic status based on nadir and, especially, current CD4% and control of HIV viremia were independent determinants of response.

Clonal Features of Community-Acquired Methicillin-Resistant Staphylococcus aureus in Children

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Hospital-based directly observed therapy for HIV-infected children and adolescents to assess adherence to antiretroviral medications.

BACKGROUND. The introduction of highly active antiretroviral therapy for HIV led to significant declines in HIV-associated morbidity and mortality in children. Nonadherence to antiretroviral therapy is the leading cause of treatment failure in HIV-infected patients. The ability to recognize nonadherence is suboptimal, and differentiating it from other causes of inadequate viral suppression may be difficult. OBJECTIVES. The purpose of this work was to examine the efficacy of hospital-based directly observed therapy in assessing adherence to antiretroviral medications in HIV-infected children and adolescents suspected of nonadherence and failing other interventions. METHODS. The medical charts of all HIV-infected patients admitted to the University of Chicago Comer Childrens Hospital for directly observed therapy from July 2004 to June 2006 were reviewed. Patients were hospitalized for 7 days. Data collected included demographics, clinical and immune class category, previous and current antiretroviral medications, viral resistance tests, HIV-1 RNA viral load, and CD4+ T-cell number and percentage before and after directly observed therapy. RESULTS. There were 9 perinatally infected patients with a total of 13 admissions. The median age was 13 years, and 8 had been treated with multiple antiretroviral regimens. Three common patterns of changes in the viral load over time were observed. In the first, the viral load dropped at the end of the directly observed therapy period and stayed low thereafter. In the second, the drop in the viral load seen at the end of the period was not sustained. In the third, there was no change in the viral load during or after the directly observed therapy period. Compared with the viral load at admission, the viral load at the end of directly observed therapy was lower in 8 patients with a mean ± SD decrease of 0.8 ± 0.55 log10 copies per mL. CONCLUSIONS. Short, hospital-based directly observed therapy was helpful in confirming nonadherence to antiretroviral medications, therefore impacting future therapeutic decisions in HIV-infected children and adolescents. Short, hospital-based directly observed therapy should be considered in patients with poor virological control for whom outpatient interventions have failed.

Chronic vulvovaginitis caused by antibiotic-resistant Shigella flexneri in a prepubertal child.

A 7-year 8-month-old girl was diagnosed with a prolonged course of vulvovaginitis caused by Shigella flexneri. The child was symptomatic with intermittent vaginal bleeding, dysuria and foul smelling vaginal discharge for a 3-year period. Initial attempts to resolve the infection with successive courses of antibiotic therapy using ampicillin, trimethoprim-sulfamethoxazole, cefixime and amoxicillin/clavulanic acid failed. The childs infection was finally resolved by a 14-day course of ciprofloxacin.

HIV knowledge and attitudes toward HIV testing of South Side Chicago Housing Authority residents.

High HIV infection rates in the United States are increasingly due to heterosexual risk behaviors, with increased rates in blacks and women. A survey of HIV knowledge and attitudes about HIV testing was conducted in an inner-city public housing population that included a convenience sample of residents of South Side Chicago Housing Authority facilities. The questionnaire addressed knowledge about HIV transmission and disease, health care options, condom use, prior HIV testing, and preferred places for HIV testing and education. Five hundred residents, ages 13-50 years completed the survey, during the period from November 2002 until April 2003. Eighty-three percent of the respondents were female and 50% of those surveyed were from 18-30 years of age. Race/ethnicity was not questioned in order to improve response rate. A comparable sample conducted earlier showed that population was 99% black race. Most respondents were knowledgeable about HIV transmission risk factors, although misinformation about transmission, treatment and prevention existed. Knowledge that HIV therapy is available was high (71%), while 25% thought an HIV vaccine was available and 13% thought there was a cure for HIV. Two thirds of sexually active respondents reported condom use in the past year. Three quarters reported previous testing for HIV and 90% of those tested returned for results. Most respondents wanted to learn more about HIV risk factors, testing and treatment but preferred primary care clinics to specialized places for HIV testing. Targeted HIV education interventions in the public housing facilities or primary care clinics are warranted.

Blastomyces antigen detection for monitoring progression of blastomycosis in a pregnant adolescent.

Although disseminated blastomycosis is a rare complication in pregnancy, delay in diagnosis and treatment can be fatal. We investigate the use of the Blastomyces urine antigen in diagnosis following disease progression in the intrapartum, postpartum, and neonatal periods. We describe a case of disseminated blastomycosis in a pregnant adolescent and review the pertinent literature regarding treatment and monitoring blastomycosis in pregnancy and the neonatal periods. This is the first reported case in which the Blastomyces urine antigen is utilized as a method of following disease activity during pregnancy confirming absence of clinically evident disease in a neonate. Urine antigen detection for blastomycosis can be useful for following progression of disease in patients with disseminated blastomycosis in both the intrapartum and postpartum periods.

Incidence of sexually transmitted diseases and Pap smear results in female homeless clients from the Chicago Health Outreach Project.

Homeless persons have difficulty gaining access to health care. In 1985 the Chicago Health Outreach Project was created to improve their access to health care. Staff and client reviews indicated that female homeless clients required increased outreach efforts. Consequently, a mobile womens health unit was developed in 1990. Review of 128 records of 104 female homeless clients indicated that 30% of Pap smears done were abnormal, with atypia (14%) and inflammation (10%) the most common findings. The incidence of chlamydia, gonorrhea, and trichomoniasis was 3%, 6%, and 26%, respectively. There was a significant association between the presence of trichomoniasis and an abnormal Pap smear. These results emphasize the importance of providing regular gynecological care to homeless women. Research is needed on the implications of abnormal Pap smears and sexually transmitted diseases for this population of female homeless clients.

Clinical Malaria and Sickle Cell Disease Among Multiple Family Members in Chicago, Illinois

Malaria is a disease of global importance and accounts for up to 500 million cases per year. Nearly all malaria cases in the United States occur among persons who have traveled to areas with ongoing malaria transmission. Among the cases of malaria reported in the United States in 2000–2005, 695 were in US residents under the age of 18 years. The association of malaria with the sickle cell hemoglobin is well described in Africa but is a rare occurrence in the United States. Here we report 5 cases of Plasmodium falciparum malaria in siblings of a family who had traveled to Africa without taking chemoprophylaxis. Two of the children had sickle cell anemia, and 1 of them developed severe life-threatening malaria and hemolysis. The 3 other siblings had sickle cell trait, 2 of whom had complicated malaria. Patients who have sickle cell disease and are infected with malaria are prone to hyperhemolytic crisis; therefore, this complication should be anticipated. The patients we describe emphasize the significance of prompt recognition of malaria and comorbidities and institution of appropriate treatment. The importance of antimalarial prophylaxis should be communicated to parents of children who are traveling to endemic areas as part of routine child care.