Russell W. Steele

Compliance issues related to the selection of antibiotic suspensions for children.

Objective. To evaluate the palatability, cost and other compliance issues as variables in the selection of antibiotic suspensions for children. Methods. Eighty-six physicians and health care personnel randomly sampled amoxicillin (used as a standard for comparison) and 11 other antibiotics, evaluating them in categories of appearance, smell, texture, taste and aftertaste. Overall scoring was then adjusted for cost, duration of therapy and dosing intervals. Results. Overall taste (palatability) ranking of antibiotics, highest to lowest, was as follows: loracarbef, cefdinir, cefixime, azithromycin, ciprofloxacin, trimethoprim-sulfamethoxazole, clarithromycin, trimethoprim, amoxicillin/clavulanate, cefpodoxime and cefuroxime. Overall rating of antibiotics was greatly influenced by other compliance variables, in order of their impact: cost; duration of therapy (5 vs. 10 days); and dosing intervals. Cost was not judged to be a major factor by most participants unless antibiotic expense was >

Comparative severity of pediatric osteomyelitis attributable to methicillin-resistant versus methicillin-sensitive Staphylococcus aureus.

50.00 for treatment of otitis media in our hypothetical 2-year-old, 13-kg child. Taking all variables into consideration, final ranking from highest to lowest was azithromycin, cefdinir, loracarbef, cefixime, amoxicillin, trimethoprim-sulfamethoxazole, cefpodoxime, trimethoprim, clarithromycin, ciprofloxacin, cefuroxime and amoxicillin/clavulanate. Conclusions. Variables related to compliance for families filling antibiotic prescriptions and children taking these products are important in the selection of antimicrobial therapy. Because final assessment is likely to vary considerably among health care personnel, decisions must be made on an individual basis.

Fatal Cerebral Herniation After Lumbar Puncture in a Patient With a Normal Computed Tomography Scan

Background: Staphylococcus aureus remains the most common etiology of hematogenous osteomyelitis in children. Recently emerged virulent strains of methicillin-resistant S. aureus (MRSA) strains now predominate. It remains uncertain whether these pathogens cause a measurably more severe illness than methicillin-sensitive strains. Methods: We reviewed records of 97 pediatric patients with hematogenous osteomyelitis of varying etiologies to determine whether there were significant differences among the groups in terms of predetermined measures of disease severity. These measures included degree and duration of elevated temperature, acute-phase reactants, length of hospitalization, the number of surgical procedures required, and long-term sequelae. Results: Differences in the clinical course of illness were observed. Patients with MRSA had a significant increase in degree and duration of elevated temperature (P = 0.0001 for both), acute-phase reactant measures (white blood cell count, P = 0.0001; C-reactive protein, P = 0.0058; erythrocyte sedimentation rate, P = 0.0046), initial length of hospital stay (P = 0.0001), and surgical interventions (all procedures, P = 0.0001; therapeutic procedures, only P = 0.0002) as compared with patients with osteomyelitis caused by other bacterial pathogens and culture-negative osteomyelitis. A similar general pattern was observed when the analysis was restricted to culture-positive staphylococcal cases only. Conclusions: Our results support the hypothesis that MRSA produces more severe bone infection and is likely to require more aggressive surgical and medical management. Level of Evidence: Level II (retrospective study investigating the effect of a patient characteristic on the outcome of disease).

Medical management of orbital cellulitis.

Cerebral edema and resulting elevated intracranial pressure (ICP) is a well-known complication of acute pyogenic meningitis.1,,2 A diagnostic lumbar puncture (LP) may then precipitate herniation or coning of the brain, often with fatal outcome.3–8 A computed tomography (CT) scan of the brain is therefore recommended before LP whenever raised ICP is suspected, particularly if the possibility of a mass or space-occupying lesion exists.9–11 We describe a 15-year-old adolescent with bacterial meningitis with a normal CT scan who developed signs of herniation immediately after a subsequent LP. To the best of our knowledge this is the second documented report of herniation found at postmortem examination in a child with a normal CT scan.

A Double-Blind Taste Comparison of Pediatric Antibiotic Suspensions

To determine the appropriate early management of orbital cellulitis and the current bacterial etiology and to evaluate the clinical usefulness of orbital computed tomographic imaging for this infection, a prospective study of orbital cellulitis was conducted during a 2-year period, 1999 to 2000, after the introduction of a conservative medical management plan designed by our pediatric infectious diseases, ophthalmology and otolaryngology services. Basically patients did not have surgical intervention unless progressive involvement of the optic nerve occurred after 24 to 36 h of intravenous antimicrobial therapy. Nine patients had orbital cellulitis and subperiosteal abscesses; only one required surgical drainage because of progressive disease, this case being culture-negative. One had a blood culture positive for Streptococcus pneumoniae; conjunctival cultures showed moderate to heavy growth for S. pneumoniae from this and two other patients, but otherwise bacterial etiology could not be defined. Haemophilus influenzae was not recovered from any of their blood or conjunctival cultures. This experience, during the computed tomography scan and Haemophilus vaccine era, supports an initial medical management approach for most patients with subperiosteal or retrobulbar abscesses resulting in orbital cellulitis.

Adherence Issues Related to the Selection of Antistaphylococcal or Antifungal Antibiotic Suspensions for Children

This study examined the palatability of 22 antimicrobial suspensions by using five independent categories for scoring: appearance, smell, texture, taste, and aftertaste. The likely overall influence on patient compliance was also evaluated. Drugs were compared within their respective classes. The only antibiotics judged to be so unpalatable as to potentiallyjeopardize compliance were dicloxacillin, oxacillin, erythromycin/sulfisoxazole, and cefpodoxime. Among the penicillins, amoxicillin and ampicillin were preferred. Azithromycin was slightly superior to erythromycin and clarithromycin within the macrolide class. Many cephalosporins were ranked quite high, the best being loracarbef, cefadroxyl, cefprozil, and cefixime.

Tigecycline: a single antibiotic for polymicrobial infections.

To evaluate the palatability and cost as variables in the selection of antimicrobial suspensions to treat staphylococcal infections and oral thrush, 31 physicians and health care personnel randomly sampled 7 antistaphylococcal antibiotics and 2 antifungal agents, evaluating them in categories of appearance, smell, texture, taste, and aftertaste. Final scoring was then adjusted for cost. Overall taste (palatability) ranking of antistaphylococcal antibiotics, highest to lowest, was as follows: rifampin, cephalexin, EES, TMP/SMX, clindamycin with FLAVORx, linezolid, and clindamycin without FLAVORx. Fluconazole was superior to nystatin. Cost was considered a major factor if the medication was more than

Advice for Families Traveling to Developing Countries With Young Children

60.00 for treatment of a hypothetical 2-year-old, 13-kg child.

Late pregnancy screening for human immunodeficiency virus.

Tigecycline (Tygacil; Wyeth Pharmaceuticals) is the first in a new class of antibiotics, the glycylcyclines, approved by the U.S. Food and Drug Administration in 2005. It is essentially a derivative of minocycline chemically modified to prevent the 2 common mechanisms of tetracycline resistance: efflux pump activity and ribosomal attachment. Therefore, it has in vitro activity against many tetracycline sensitive and resistant Grampositive as well as Gram-negative pathogens (Table 1). Its activity against most anaerobes, rapidly growing mycobacteria (abscessus, chelonae and fortuitum group, mycoplasma and Chlamydophyla) is excellent, although tigecycline is not active against most strains of Mycobacterium avium complex, Mycobacterium marinum and Mycobacterium kansasii. Although not yet approved for patients less than 18 years of age, its excellent safety and tolerability profile in adults suggests that it may be an important antimicrobial agent for children in selected cases.

Ring-Enhancing Central Nervous System Lesions

Young children are most likely to travel to developing countries with their parents to visit relatives. Preparation for such travel must include careful counseling and optimal use of preventive vaccines and chemoprophylaxis. For infants and very young children, data defining safety and efficacy of these agents are often limited. However, accumulated experience suggests that young travelers may be managed similarly to older children and adults.