Shehla H. Naqvi

Eradication of epidemic methicillin-gentamicin-resistant staphylococcus aureus in an intensive care nursery

A methicillin-resistant strain of Staphylococcus aureus (phage type 47,54,75,83A) became epidemic in our 50 bed level III nursery, with a colonization rate of 70 percent and an infection rate of more than 25 percent. This prevalence and the appearance of gentamicin resistance necessitated epidemic control measures. Standard measures included separate housing for infants in whom colonization had occurred and infants in whom it had not, low nurse to patient ratios, and cohorting of all personnel. Use of all antibiotics was curtailed by the requirement of infectious disease consultation. Gentamicin was available only on order of the Director. The colonization rate fell from 55 percent to 25.4 percent, the first-week colonization rate from 31 percent to 0 percent, and the infection rate from 29.3 percent to 15.9 percent over eight weeks. The mean duration of antibiotic therapy decreased from 12.21 to 9.05 days per treated patient; however, the frequency of gentamicin usage and the proportion of gentamicin resistance were unchanged. Nurse to patient ratios were modified to allow increased admissions, but cohorting was continued for 12 weeks until all infants in whom colonization had occurred were discharged. With the elimination of the reservoir, no further colonization occurred and antibiotic resistance did not reappear. Standard infection control measures can eliminate epidemics of multiple antibiotic-resistant Staph. aureus, and control of antibiotic usage may present re-emergence of resistant strains.

Cefotaxime therapy of neonatal gram-negative bacillary meningitis.

Seven neonates were treated with cefotaxime during eight episodes of Gram-negative bacillary meningitis and sepsis. The causative organisms were Escherichia coli in six cases and Klebsiella pneumoniae and Enterobacter sakazakii in one each. After identification of the pathogen cefotaxime was used alone in six instances. Two patients with brain abscesses received adjunctive therapy with another antibiotic. The sterility of cerebrospinal fluid was documented after a mean of 3.3 days of therapy. Mean cerebrospinal fluid bactericidal titer was 1:64. All patients recovered with good neurologic outcome. Cefotaxime in a dosage of 150 mg/kg/day divided every 6 hours intravenously seems safe and effective therapy for neonatal Gram-negative bacillary meningitis.

Shock in children with gram-negative bacillary sepsis and Haemophilus influenzae type b sepsis.

To study the incidence of shock in children in association with gram-negative bacillary (GNB) sepsis and Haemophilus influenzae type b sepsis, we reviewed all episodes of septicemia with those organisms in a 10-month period. GNB were isolated from 10.95% and H. influenzae b from 13.8% of the patients whose blood cultures yielded bacteria. Shock occurred in 12.5% of patients with sepsis caused by GNB and in 10.3% of those with H. influenzae b sepsis. Shock occurred more frequently in patients with H. influenzae b sepsis with meningitis (20.6%) and more commonly in those who had GNB sepsis without meningeal involvement (11.4%). GNB sepsis was associated with severe shock and caused death of three of the four patients. Only one of the five patients with shock caused by H. influenzae b had severe shock and died. The good outcome of patients with sepsis and shock caused by H. influenzae may be related to the health status before illness and prompt appropriate antibiotic therapy.

Significance of Neutrophils in Cerebrospinal Fluid Samples Processed by Cytocentrifugation

We reviewed medical records of 155 pediatric patients whose cerebrospinal fluid (CSF) sam ples contained an increased proportion of neutrophils when processed by cytocentrifugation, despite normal CSF total white blood cell count. It was determined that these CSF findings occurred more commonly in patients with bacteremia, peripheral leukocytosis, and increased numbers of red blood cells in the CSF. Pulmonary infiltrates in infants and otitis media in children were also significantly associated. Cytocentrifugation allows the identification of neutrophils in the CSF, even in the absence of central nervous system infection. Infants and children with more than 10 per cent neutrophils in CSF require evaluations for focal and bacteremic infections.

Age-specific Presentation of Campylobacter Enteritis in Children

The presentation of Campylobacter enteritis varies with the age of the patient. Abdominal distention is common in infants less than 3 months of age. Fever remains uncommon up to 6 months of age, whereas abdominal pain and fever are common in children more than 1 year of age.

Value of Rapid Diagnosis of Respiratory Syncytial Virus Infection on Management of Small Infants

Respiratory syncytial virus (RSV) is a common cause of infection in infancy and early childhood. A presumptive diagnosis of RSV infection can frequently be made on clinical grounds. Confirmation can be made by viral culture, which may take 3 to 7 days. Immunofluorescent assay (IFA) is a specific and sensitive test that can provide laboratory confirmation of RSV infection the same day. Rapid diagnosis of RSV infection may have implications regarding prevention of nosocomial spread of RSV, early initiation of anti-viral therapy, use of antibiotics, and duration of hospital stay. Data are presented regarding the use of RSV-IFA and its effect on patient management.

Prevention, Diagnosis and Treatment of Neonatal Herpes Simplex Virus Infections: A Review

DOI: http://dx.doi.org/10.5915/17-2_3-12757 Herpes simplex virus (HSV) infections of the neonate are associated with very high mortality and survival frequently carries neurologic sequelae. The infection is generally acquired from infected maternal genital tract. The risks of neonatal HSV infection have become magnified by the recent increase in the incidence of genital herpes. Recognition of the high risk pregnant patient, detection of maternal genital herpes by culture or histopathology, followed by delivery of the child by cesarean section will prevent intrapartum exposure to infection. Treatment of neonatal herpes with adenine arabinoside and acyclovir significantly decreases the morbidity and mortality of the disease.

INITIAL THERAPY FOR OSTEOMYELITIS AND SEPTIC ARTHRITIS WITH CEFOXITIN

Single drug therapy with a broad spectrum antibiotic is a desirable option for patients with bone and joint infections of unknown etiology. We initiated treatment for 23 children, ages 6 months-15 years (mean 6.5 years) with cefoxitin. The infecting organisms proved to be S. aureus-10, Strep. pneumoniae-2, H. influenzae b-2, and S. epidermidis, B. melaninogenicus, Moraxella sp. and Ps. fluorescens-1 each. No agent was identified in 6 cases. Initial clinical response was good in 21 cases (91%). One primary resistant organism (Ps. fluorescens) and one cephalosporin-tolerant S. aureus failed to respond. A third child with infection due to H. influenzae b developed meningitis after 3 days. These 3, and 6 patients with negative cultures, were dropped from the study. All other patients did well and received [xmacr ] 15.7 days IV cefoxitin before switching to oral antimicrobials. Adverse reactions included allergic rash (1), mildeosinophilia (2) and mild elevation of SGOT (1). Cefoxitin was discontinued for reason of the rash; all other reactions resolved when the drug was discontinued at the completion of therapy. Neutropenia (PMN <1000/mm3) was seen in 2 patients but resolved spontaneously. Urinary reducing substances were detected in 5 cases (22%). Cefoxitin appears to be satisfactory initial therapy for osteomyelitis and septic arthritis in pediatric patients; it should not be used for infants <2 years of age where H. influenzae b is suspected, due to the possible development of meningitis.