Lorry G. Rubin

Emergence of Candida parapsilosis as the Predominant Species Causing Candidemia in Children

An increase in the rate of isolation of Candida parapsilosis, relative to other Candida species, in our childrens hospital led us to analyze the clinical and epidemiological variables associated with candidemia. We sought to determine if these variables are different for patients infected with C. parapsilosis. All episodes of candidemia occurring over a 7-year period were analyzed retrospectively. Of 81 episodes in 80 patients, 35 (43%) were in neonates, and 46 (57%) were in nonneonates. C. parapsilosis was isolated in 40 episodes (49%). C. parapsilosis was significantly more likely than non-C. parapsilosis species to be associated with prematurity (P = .001), presence of a central venous catheter (P = .002), and use of total parenteral nutrition (P = .03). C. parapsilosis has emerged as the predominant species in our childrens hospital. The mortality rate associated with candidemia in children is lower than previously reported and may be associated with the high rate of isolation of C. parapsilosis.

Cure of Implantable Venous Port—Associated Bloodstream Infections in Pediatric Hematology-Oncology Patients without Catheter Removal

The efficacy of antibiotic treatment of port-associated bloodstream infection without device removal has not been systematically studied. We analyzed the outcome of 43 consecutive port-associated bloodstream infections in pediatric hematology-oncology patients. Etiologies included Staphylococcus epidermidis (30) and Staphylococcus aureus (6). Antibiotics were given through the port for a median of 11 days. Four ports were removed within 72 hours. In 36 (92%) of the remaining 39 episodes, there was a response to antibiotic therapy (defervescence and negative blood culture). In 78% of episodes in which there was a response (excluding two in which the catheters were removed because of mechanical problems), the infections were cured without port removal. Two of the four relapses were cured with a second course of antibiotics. The cure rate was 92% for S. epidermidis infections and 67% for S. aureus infections. Thus, the majority of port-associated bloodstream infections in pediatric hematology-oncology patients can be cured without device removal.

FEVER IN INFANTS AND YOUNG CHILDREN WITH SICKLE CELL DISEASE |[lpar]|SCD|[rpar]|

Forty-four patients with SCD (39 SS and 5 SC disease), aged ≤ 5 yrs (mean 28 ± 17 mths) were hospitalized for 140 febrile episodes (temperature ≥ 38.4°C.) from Jan. 1978 to July 1983. All received continuous oral penicillin prophylaxis (OPP) from time of diagnosis and polyvalent pneumococcal vaccine (PPV) at 2 yrs of age. At least 2 blood cultures were obtained from all patients during hospitalization. All patients (except those with temperature < 38.9°C and vaso-occlusive syndrome-VOS) were treated with IV ampicillin for a minimum of 48-72 hrs. VOS accounted for 52 episodes (37%) (37 abdominal crises; 12 hand-foot syndrome and 3 aseptic necrosis of bones); fever of unknown cause in 18 episodes (13%) and fever with an infectious source in 70 episodes (50%). There were 28 episodes of pneumonia, 16 otitis media, 13 URI, 5 pharyngitis, 4 UTI, 1 osteomyelitis. The 6 episodes of bacteremia were associated with temperature ≥ 39.8°C. The blood-stream isolates were Streptococcus pneumoniea (2), Haemophilus influenzae, type b (1), Group B salmonella sp (1), Klebsiella sp (1), and Staphlococcus aureus (1). The 2 patients with pneumococcal bacteremia (age 16 and 22 mths) were non-compliant with OPP and had not received PPV because of their age. All patients responded to treatment and recovered from the febrile episode. The low incidence of pneumococcal bacteremia (2 cases per 147 patient-years) may be attributable to OPP and/or PPV.

Pulmonary Infections Caused by Haemophilus influenzae

Haemophilus influenzae is a gram-negative coccobacillus frequently present as part of the normal flora of the upper respiratory tract, but it may cause a wide variety of infections in children and adults. Under natural conditions, humans are the only known hosts of H. influenzae. Of fundamental importance to the understanding of infections caused by H. influenzae is the recognition that isolates may be nontypable (unencapsulated) or may elaborate one of six polysaccharide capsules designated types a through f. Encapsulated strains expressing type b capsular polysaccharide (a polymer of ribosylribitol phosphate) cause infections primarily in children younger than 6 years old and are responsible for most cases of systemic infection with H. influenzae. The most common systemic infection is meningitis, but epiglottitis, bacteremic cellulitis, septic arthritis, and pneumonia are also frequently seen. Nontypable H. influenzae are commonly resident flora in the pharynx of both children and adults. Although they are not usually the cause of infection with bacteremia, they are important etiologic agents of otitis media, sinusitis, bronchitis, pneumonia, conjunctivitis, and puerperal infection. Both encapsulated and unencapsulated H. influenzae may cause pulmonary infection.