Lawrence A. Ross

Imipenem/cilastatin treatment of bacterial meningitis in children.

The safety and efficacy of imipenem/cilastatin were evaluated in 21 children, ages 3 to 48 months, with bacterial meningitis. Eradication of bacteria from the cerebrospinal fluid was demonstrated within 24 hours of antibiotic therapy in all but 2 patients who had Haemophilus influenzae type b meningitis and ultimately achieved bacteriologic cure after 2 to 3 days of imipenem/cilastatin therapy. Cerebrospinal fluid penetrations of imipenem and cilastatin were determined at various times after drug administration with mean cerebrospinal fluid: serum ratios of 14 and 10% for imipenem and cilastatin, respectively. The study was terminated when 7 (33%) patients developed seizure activity after antibiotic therapy was administered. The usefulness of imipenem/cilastatin for the treatment of bacterial meningitis in children may be limited by a possible increased incidence of drug-related seizure activity.

Investigation of an epidemic of invasive aspergillosis: utility of molecular typing with the use of random amplified polymorphic Dna probes

When seven immunocompromised patients developed invasive aspergillosis during construction at a hospital, new methods were performed to compare fungal isolates and a case-control study was conducted to determine risks for infection. Typing of Aspergillus flavus with the use of restriction endonuclease analysis and restriction fragment length polymorphism using random amplified polymorphic DNA reactions to generate DNA probes revealed different patterns between isolates from two patients and a similar pattern among those from one patient, a health care worker, and an environmental source. Case patients were more likely than controls to have longer periods of hospitalization (median, 83 vs. 24 days; P < 0.01), neutropenia (median, 33 vs. 6 days; P < 0.05), and exposure to broad spectrum antimicrobials (median, 56 vs. 15 days; P = 0.08). No patients restricted to protected areas developed aspergillosis. Risk of exposure of immunocompromised patients to opportunistic organisms stirred up by construction activity may be decreased by admitting these patients to protected areas away from construction activity and by restricting traffic from construction sites to these areas. Although typing of A. flavus isolates did not reveal a single type or source of organism responsible for infection, this method may facilitate epidemiologic investigation of possible nosocomial sources and transmission in similar settings.

Epidemic measles in the postvaccine era: evaluation of epidemiology, clinical presentation and complications during an urban outbreak.

A total of 440 cases of measles were seen at a single childrens hospital during an epidemic in a large urban center. These cases were retrospectively analyzed for demographic characteristics, exposure histories, risk factors for and incidence of complications, outcome and financial consequences. More than 90% of children were <5 years of age and 56% were <15 months of age. Ninety-four percent were of Hispanic or African-American ethnic background. A visit to a medical facility was the only source of infection for 83 of the 115 patients for whom exposure histories were available. Four patients with underlying immunodeficiency were among those nosocomially exposed and one died of pulmonary complications. Of the 440 patients 195 (44.3%) required hospitalization for measles complications. The mean age of hospitalized patients, 1.9 ± 2.4 years, was not different from those not admitted (2.1 ± 2.5 years; P < 0.25). The most frequent indications for admission were respiratory tract complications (pneumonia and/or croup) seen in 161 patients and dehydration in 25 patients. Fourteen required intensive care and 11 required intubation and mechanical ventilation. Three children died, all of pulmonary involvement. Total hospital and medical charges for care of these patients was more than

Bordetella bronchiseptica infection in pediatric lung transplant recipients

1.7 million dollars.

Hand hygiene adherence is influenced by the behavior of role models

Abstract: Bordetella bronchiseptica are small, pleomorphic Gram‐negative coccobacilli which are commensal organisms in the upper respiratory tract of many wild and domestic animals (‘kennel cough’ in dogs). While it is common for health care providers to ask about exposure to ill family/friends, most do not routinely inquire about the health or immunization status of household pets. We report two cases of B. bronchiseptica pneumonia in lung transplant recipients [cystic fibrosis (CF); ages 10 and 15 yr; one male] who contracted B. bronchiseptica from pet dogs. We compared their course and outcome to four children (two CF, one congenital heart disease and one Duchennes muscular dystrophy; four males, age range 6 months to 14 yr) with B. bronchiseptica cultured from the respiratory tract. Two of the four patients also acquired their illnesses from pet dogs and two from unknown sources. One lung transplant recipient expired from progressive respiratory failure. We conclude that B. bronchiseptica can cause serious infections in both immunosuppressed and immunocompetent children. We speculate that a detailed history of exposure to ill pets (particularly dogs), and the immunization status of all pets should be included in the routine evaluation of all pediatric transplant recipients.

Prospective monitoring for invasive aspergillosis using galactomannan and polymerase chain reaction in high risk pediatric patients.

Objective: Proper hand hygiene (HH) reduces nosocomial infections. Therefore, factors that influence HH behavior of healthcare workers are of great interest. We hypothesized that strict HH adherence by supervisor role models would improve the HH behavior of junior staff. Design: Prospective observational study. Setting: Pediatric and cardiac intensive care units of a tertiary care children’s hospital. Subjects: Two critical care fellows and four nurse orientees. Interventions: First, we observed and recorded HH adherence of the fellows and nurse orientees and their respective supervising attending physician or nurse preceptor during daily patient care. Subsequently, we paired the same fellows and nurse orientees with a different supervisor who maintained strict HH adherence, and again noted HH adherence. We used measures of HH opportunities and HH adherence consistent with guidelines set by the Centers for Disease Control and Prevention and Association for Professionals in Infection Control and Epidemiology. Measurements and Main Results: HH adherence by fellows and nurse orientees at baseline was 22% of 200 HH opportunities, and improved to 56% of 234 opportunities as a result of role modeling—an average increase of 34% points (95% confidence interval, 18.7–51; p < 0.01 by linear regression), representing a HH adherence rate greater than 1.5 times that of the baseline. The control senior practitioners’ HH adherence rate was 20% of 180 opportunities compared with the study senior practitioners’ HH adherence of 94% of 187 opportunities—an average difference of 72% points higher compared with the control senior practitioners (95% confidence interval, 56–88.3; p < 0.01 by linear regression). Conclusions: HH adherence of junior practitioners improved under the supervision of adherent role models. These results suggest that HH behavior of senior practitioners plays a crucial influence on other staff. Senior healthcare practitioners should consider the important role they may play in reinforcing or weakening a culture of patient safety and proper HH.

Raoultella ornithinolytica bacteremia in an infant with visceral heterotaxy.

Background The diagnosis of invasive aspergillus remains a challenge in the care of high-risk patients. Outcomes are improved when invasive aspergillus is diagnosed early, prompting the initiation of appropriate antifungal therapy. We evaluated the utility of prospective monitoring for invasive aspergillosis (IA) using biomarkers such as serum galactomannan (GM) and/or blood polymerase chain reaction (PCR) in high-risk pediatric patients. Methods Patients with high-risk leukemia (HRL) or allogenic hematopoietic cell transplant (HCT) recipients were prospectively monitored twice weekly for IA using GM and PCR for Aspergillus species. Results Sixty-eight patients had collected ≥2 specimens. The 1086 specimens were collected; 627 from HRL (58%) and 459 (42%) from HCT recipients. Median specimens/patient was 11.0 (2 to 58), and median follow-up/patient was 98.5 days (14 to 437). Fifty-six percent of samples were obtained from patients receiving mold-active agents; 32% HRL and 89% HCT. There were no proven, 3 probable, and 20 possible episodes of IA. Thirteen specimens (1.2%) from 4 patients (5%) were GM+. None were positive by PCR. Conclusions The prospective use of GM and PCR in this high-risk pediatric population did not identify cases of proven IA. A high false positive rate was not detected. It is speculated that changes in clinical practice, such as early use of empiric and/or prophylactic mold-active agent and frequent imaging studies have impacted the epidemiology of IA. In a population with low incidence of IA, the use of these assays as a screening device on blood may not further enhance current outcomes.

Nosocomial measles infection in a pediatric hospital during a community-wide epidemic

A case of Raoultella ornithinolytica bacteremia in an infant with visceral heterotaxy is reported. Physical examination was remarkable for markedly red skin flushing, not unlike that seen during histamine fish poisoning. R. ornithinolytica is a histamine-producing bacterium recently elucidated as a major cause of histamine fish poisoning. Only 2 other cases of human infection by R. ornithinolytica have been reported.

Paecilomyces variotii in a pediatric patient with lung transplantation

From Jan. 1, 1988, through Dec. 31, 1988, a total of 89 cases of measles were observed at Childrens Hospital of Los Angeles, and 37 patients were admitted to the hospital. Of the 37 patients, six were not initially thought to have measles, which resulted in exposure of 107 patients and 24 personnel. Of the exposed patients, measles developed in four. One nosocomially infected infant died of pneumonia. Another exposed patient was subsequently admitted to another hospital with unrecognized measles, which led to exposure of an additional eight patients. Of seven employees in whom measles developed, two required hospitalization because of pneumonia. Two hundred eleven employee days were lost because of measles exposure or infection. Infection control interventions included prophylaxis of exposed patients, employee education, and measles immunization for susceptible personnel. Of 1103 hospital personnel considered susceptible to measles, 800 received monovalent measles vaccine. No secondary cases of measles occurred in hospital personnel who received appropriate prophylaxis. We conclude that infection control programs aimed at mandating measles immunity in hospital employees at risk should be instituted.

Orally administered clarithromycin for the treatment of systemic Mycobacterium avium complex infection in children with acquired immunodeficiency syndrome

Abstract: Aspergillus has been noted to be the most common species of filamentous fungus isolated from the airways of lung transplantation (Tx) patients. In general, the bronchi are colonized asymptomatically with Aspergillus but this places such a patient population at greater risk of invasive infection. Other filamentous fungal species may also assume importance in this patient population. Here we report the post‐transplant isolation of Paecilomyces variotii from the airways of a pediatric patient with cystic fibrosis (CF) who underwent bilateral living‐donor lobar lung Tx. This is the first report of isolation of P. variotii in the pediatric lung Tx population. The isolation of filamentous fungi, such as Paecilomyces, with variable in vitro susceptibility to currently available antifungal agents further complicates the approach to post‐transplant antifungal therapy in patients with lung Tx.