Paediatric inpatient morbidity patterns and drug usage in a teaching hospital serving an underdeveloped area.

Morbidity patterns and drug usage in hospitalized children in a developing area were prospectively studied. The study group consisted of 347 children (age 0-12 yrs) representing all admissions to a paediatric unit over a six month period. Respiratory tract diseases (30.5%) and infectious diseases (26.1%) were the most common reasons for hospitalization. Tuberculosis was the most common infectious disease seen among the hospitalized children. Antimicrobials (60.8%), iron preparations (45.5%), vitamins (43.2%) and antipyretics (29.9%) were the most frequently prescribed groups of drugs. Ampicillin was the most commonly used antimicrobial. Adverse drug reactions were seen in 1.7% of the children. The overall mortality was 9.2%. The mean length of stay was 7.9 days and the mean number of drugs used was 3.4 per patient. More than 4 drugs were prescribed in 54.4% of children. Approximately two thirds received parenteral therapy.

Seroprevalence of hepatitis A virus in Mumbai, and immunogenicity and safety of hepatitis A vaccine.

OBJECTIVES: Since epidemiologic trends of hepatitis A are changing worldwide, we studied its seroprevalence in Mumbai, which is thought to be a high-endemicity area. The immunogenicity and safety of a hepatitis A vaccine were also studied. METHODS: Six hundred and seventy subjects (456 men; age range 6 mo-60 y) answered a questionnaire on social and medical history. Qualitative analysis of total anti-HAV was performed in all subjects by ELISA. One hundred and seven of 147 anti-HAV negative subjects received hepatitis A vaccine at months 0, 1 and 6. Subjects were followed up (months 1, 2, 6, 7) to look for side-effects and seroconversion. RESULTS: The seroprevalence of HAV was 523/670 (78%); 38% of children < 5 years were anti-HAV negative. Seroprevalence rates of 80% were reached by 15 years. Prevalence was lower in the higher socio-economic group (151/234; 64.5%) compared with the lower socio-economic group (372/436; 85%) (p < 0.001). One month after doses 1, 2 and 3 of the hepatitis A vaccine, seropositivity was 92%, 99% and 100%, respectively. Minor self-limited side-effects occurred in 19.5% of subjects; there were no major side-effects. CONCLUSIONS: The seroprevalence of anti-HAV is high in Mumbai. Seroprevalence is lower in the higher socio-economic groups. The hepatitis A vaccine is safe and immunogenic.

Diagnostic and therapeutic evaluation of bronchoscopy.

The diagnostic and therapeutic efficacy of bronchoscopy was determined in 85 children. The major indications were foreign body removal in younger patients and evaluation of tracheobronchial pathology in older children. Foreign body was commonly isolated in the toddlers and even in the elder age group (19%) as well as in those with suspected ingestion (44%). Groundnut was the predominant foreign body and right bronchus was the most frequent site. Tracheobronchitis (27%), bronchiectasis (13%) endobronchial tuberculosis (9.4%) and mucus plug (3%) were the other frequent findings. Bronchography was performed in 16 patients and it confirmed the diagnosis in 75% of the cases. Minor complications were encountered in 8% of patients. In the present study bronchoscopy yielded definite results in 83% and in many, including those with normal findings it guided further management.

Experience with brain abscesses.

Brain abscesses were studied in 47 patients. Thirty-four (72%) of them were between 5-15 years and 9 were infants. Otogenic source (34%) was the commonest predisposing factor, followed by scalp and face infection (21.3%) and congenital cyanotic heart disease (12.8%). Twenty (42%) patients had multiple abscesses. Supratentorial abscesses were commonest (75.9%). Predominant clinical features were fever (87.2%), raised intracranial tension (78.7%) and altered sensorium (53.2%). A total of 38.3% presented with focal neurological deficit and 34% were admitted in Grade III or IV coma. Diagnosis of abscess and monitoring of its evolution was done principally by CT scanning. Causative organisms were isolated in 54.8% of cases and Staphylococci, Proteus and Pseudomonas were the common pathogens. Therapy was most often a combination of surgical aspiration with or without excision in addition to antimicrobial therapy. The overall mortality in our series was 44.7%. Bad prognostic factors were Grade III/IV of coma at admission, age below 2 years and multiple abscesses.

Acute renal failure in children requiring dialysis therapy.

A prospective study over two and a half years analysed 48 children of acute renal failure requiring dialysis therapy. The mean age was 3 years 9 months and M:F ratio was 1.8:1. Renal causes predominated, accounting for 65%, with prerenal and postrenal causes responsible for 19% and 16%. Acute glomerulonephritis was seen in 13 cases, hypovolemia secondary to gastroenteritis in 9, tubular necrosis in 6, and hemolytic uremic syndrome in 5. A delay in seeking medical attention was present in as many as 48%, and was especially common with female children. All had oligo-anuria, with fluid overload present in 18.7%, hypertension in 23%, hypotension in 16.6%, neuropsychiatric manifestations in 20%, and infections in 47%. Peritoneal dialysis was carried out in 95%, and hemodialysis in 6.2%. Urine output and renal function returned to normal within 1.5 to 16 days (mean 5.9) in the survivors. Of the 28 who survived, 19 were followed up regularly for a mean of 4.25 months and all except one had normal renal function. Factors associated with a poor prognosis included female sex, age < 1 year, neurological manifestations, and hypotension, though these were not statistically significant. Mortality in our series was 41.5%. While etiological factors have shown changing trends, mortality still remains high inspite of dialysis.

Prevalence of bacteriuria in febrile infants.

Urine samples from 129 admitted febrile infants were collected using the suprapubic aspiration technique, and subjected to routine urinalysis, culture, and antibiotic sensitivity testing. Most of the infants suffered from respiratory tract infections (n = 80) and gastroenteritis (n = 25). Sixty nine patients were male and sixty female. In all, 7 patients had positive cultures (5.4%), indicating a high yield (> 5%). Six of these were female and occurred in patients with gastroenteritis (p < 0.05 for both by chi 2 and Z test). Four patients showed pus cells and organisms on smear, and all of them were culture positive. Another three had only pus cells, but were also culture positive. One patient each, who had pus cells only or organisms only on smear had no growth on culture. E. coli was grown in 6 of these cases, and Klebsiella in one. All cultures were sensitive to ciprofloxacin. Variable sensitivity was seen with gentamicin, streptomycin, and furadantin. The organisms were uniformly resistant to ampicillin and chloramphenicol. The procedure of suprapubic aspiration was safe with no complications. Our findings indicate that bacteriuria is not uncommon in febrile infants even with clinical evidence of other illnesses and that female children, especially those with gastroenteritis, are at most risk. Routine urine cultures in such patients would appear justified.

Adverse drug reactions in pediatrics with a study of in-hospital intensive surveillance.

A two-part prospective study of adverse drug reactions (ADRs) in Indian children was carried out at a teaching general hospital. Using an in-hospital intensive surveillance scheme (IISS) for the detection of ADRs, indoor patients of one of the two units in the pediatric ward were monitored daily for 6 months, with the other unit serving as a control group. A total of 347 patients were monitored, 2781 daily orders written and 24,474 doses of 96 different drugs given. Six patients suffered from ADRs (1.73%), and 1 reaction proved fatal (0.29%), while the control group reported only 1 ADR in the same time period. The frequency of ADRs (p < 0.001) and their resultant mortality in Indian children was less than that in a western prototype study. Though IISS showed a marked increase in ADR reporting, it was too cumbersome for routine use in our country. In the second part of the study, 40 cases of ADRs seen over 2 years were analyzed. Antimicrobials, especially sulphonamides, accounted for a high percentage of cases mostly as skin rashes and fairly severe reactions were common. Patients on anti-tuberculous and anti-convulsant drugs required prolonged supervision for late onset reactions.