Serious complications due to acute rhinosinusitis in children up to five years old in Stockholm, Sweden - Still a challenge in the pneumococcal conjugate vaccine era.

OBJECTIVES: The aim of this study was to analyze the rate of admissions, the rate of serious complications (postseptal orbital complications and surgery) and the bacterial etiology of acute rhinosinusitis in hospitalized children under five years old in Stockholm County, eight years after the introduction of the pneumococcal conjugate vaccine (PCV). The secondary aim was to compare this period with the period four years prior to the vaccine's introduction. METHODS: This was a population-based, descriptive observational study with retrospectively collected data from 1 July 2008 to 30 June 2016 in Stockholm County. Hospital admissions of children with a discharge diagnosis of rhinosinusitis and related complications were reviewed and compared to the pre-PCV period of 2003-2007. RESULTS: A total of 215 children were admitted, for a yearly incidence of 18.8 per 100 000 children (22.8 for boys, 14.6 for girls). Computer tomography-verified postseptal orbital complications occurred in 29 cases (13.5%) and surgery was necessary in nine (4.2%). Pathogens other than Streptococcus pneumoniae were found in the cases with postseptal complication or surgery (Streptococcus pyogenes in four, Haemophilus influenzae in three and Staphylococcus aureus in one case). In comparison to the four years pre-PCV, the incidence of admission decreased from 43.81 to 20.31 and 17.45 per 100 000/year for the two four-year periods after vaccine introduction. The incidence of CT-verified postseptal complication increased slightly from 1.51 to 2.34 and 2.74 per 100 000/year. The incidence of surgeries increased marginally but continued to be very low, from 0.22 to 0.54 and 1.03 per 100 000/year. CONCLUSIONS: Complications due to acute rhinosinusitis in children living in Stockholm County continues to be very rare after the introduction of pneumococcal vaccine. Hospitalization has decreased for children under five years old after PCV introduction, but the incidence or postseptal complications and surgery in the same population increased slightly. Predominantly bacteria other than Streptococcus pneumoniae was found. There is a need of larger studies to determine trends, and a need of prospective studies to elucidate the bacterial etiology, of serious complications due to acute rhinosinusitis in children.

Borrelia antibodies in children evaluated for Lyme neuroborreliosis.

BACKGROUND: We wanted to elucidate the value of Borrelia antibodies in serum and cerebrospinal fluid (CSF) for the diagnosis of Lyme neuroborreliosis (LNB). MATERIAL AND METHODS: We analyzed the serological findings, by anti-flagellin assay, in 267 patients with neurological symptoms from the Stockholm area, where Lyme borreliosis is endemic. RESULTS: In the 70 children with LNB, intrathecal Borrelia antibody production was diagnostic and found in 50 (71%). Sixteen (23%) showed an elevated antibody titer in serum only, and 4 (7%) had no serologic findings. Borrelia IgG in serum, with or without concomitant IgM, was a specific (98%), but insensitive (43%) marker of infection. Isolated, false-positive serum IgM titers were common and found in 10 of 67 children (15%) with viral meningitis, as well as in 28 of 111 (25%) with various neurological symptoms and normal CSF. The specificity of an isolated Borrelia IgM titer in serum was 81%, and the positive predictive value for Borrelia infection only 50% in our material. On the other hand, absence of antibodies in blood had a negative predictive value of 94%, which increased to 97% if also CSF findings were included. CONCLUSIONS: Intrathecal antibody production is strongly supportive of an LNB diagnosis. Conversely, isolated, elevated levels of Borrelia IgM in serum occur in up to one-fourth of children with various neurological complaints, and should be interpreted with caution, especially in nonendemic areas.

Extensive transmission of an isoniazid-resistant strain of Mycobacterium tuberculosis in Sweden.

SETTING: City of Stockholm, Sweden. BACKGROUND: The incidence of tuberculosis (TB) in Sweden increased by 40% between 2003 and 2005. The spread of a unique TB strain resistant to isoniazid (INH) contributed to this increase. OBJECTIVE: To describe outbreaks of TB caused by this single strain, elucidate possible causes for its extensive spread and identify shortcomings of the TB control programme in Sweden. RESULTS: We identified a cluster consisting of 102 culture-confirmed TB cases with identical DNA fingerprints and 26 epidemiologically related cases, not confirmed by culture, all diagnosed between 1996 and 2005. Five partly separate outbreaks of this strain were discovered. Epidemiological links were established for 56% of the culture-confirmed cases and for all cases not confirmed by culture. Three patients died while receiving treatment, four became failures and eight defaulted or were lost to follow-up. Only eight patients received directly observed treatment (DOT) up to a period of 3 months, although 40% had poor adherence. CONCLUSIONS: Shortcomings of the national TB programme were revealed. Improved contact tracing and case holding, including DOT, is crucial to reduce TB transmission in Sweden.

Population-based rates of severe respiratory syncytial virus infection in children with and without risk factors, and outcome in a tertiary care setting.

UNLABELLED: The aim of this study was to make a population-based estimate of the risk of hospitalization and complications during virologically confirmed respiratory syncytial virus (RSV) infection in relation to established risk factors, and an estimation of additional risk factors and outcome as seen in a tertiary care referral centre. During a period of 12 y, all children with virologically confirmed RSV infection were included. Recorded complications were: admission to the intensive care unit, mechanical ventilation, death and later hospitalization for wheezing. In total, 1503 cases were identified, 1354 of which originated from the population defined by the catchment area. There was a biannual seasonal variation with late small outbreaks alternating with early large ones. The hospitalization rates for infants without risk factors were 0.8 and 1.4% during the 2 epidemic types. They were 1.6-3.2% for infants born preterm (<33 gestational wk), 2.9-7.0% for children under 2 y old with chronic lung disease of prematurity and 2.8-6.4% for infants with congenital heart disease. The presence of siblings in the family more than doubled the risk of hospitalization. Later hospitalization for wheezing occurred in 8.4 and 4.9% of children without risk factors over and under the age of 2 mo, respectively (p < 0.001). CONCLUSION: This study found lower population rates of hospitalization and complications than have previously been reported. The seasonal variation and the presence of siblings in the home influenced these rates by factors of 2.

The fecal microflora of 1-3-month-old infants during treatment with eight oral antibiotics.

We examined the fecal microflora of 1-3-month-old infants during treatment with phenoxymethylpenicillin, amoxycillin, pivampicillin, cefaclor, cefadroxil, loracarbef, erythromycin or cotrimoxazole. Escherichia coli increased during treatment with penicillins or cephalosporins, but was not affected by erythromycin or cotrimoxazole. Other enterobacteria were acquired or increased during treatment with all agents except cotrimoxazole. Enterococci persisted or increased during phenoxymethylpenicillin, cephalosporin or cotrimoxazole treatment, whereas erythromycin and the other penicillins suppressed them. Bacteroides, bifidobacteria and lactobacilli were suppressed to undetectable levels in most infants during treatment with all agents, except phenoxymethylpenicillin and loracarbef.

Non-tuberculous mycobacterial lymphadenitis in healthy children: another "lifestyle disease"?

UNLABELLED: An increasing incidence of non-tuberculous mycobacterial (NTM) lymphadenitis has been reported in previously healthy children in the western world since about 1985. In this study we investigated the sociodemographic and individual characteristics of these patients. Information about patients was collected prospectively from 1977 to 1996. For comparison, an ad hoc group of hospitalized children with bacterial cervical lymphadenitis was chosen. In addition to individual characteristics, information was collected on the country of birth of the patients and their parents, and the socioeconomic characteristics of the domicile area. We identified 81 children with NTM, 14 with tuberculous and 192 with septic lymphadenitis. Significantly more parents of children with NTM than in either of the other two groups were Swedish-born and lived in privileged socioeconomic areas. CONCLUSION: The increase in NTM lymphadenitis in healthy children has taken place at the same time as the reported increase in atopic disease and asthma in childhood. Both groups of patients seem to come from favourable living conditions. It is speculated that NTM lymphadenitis, like asthma and certain other diseases triggered by the immune system, might be a "lifestyle disease".

Wheezing following lower respiratory tract infections with respiratory syncytial virus and influenza A in infancy.

We examined the incidence of subsequent wheezing in 292 children, hospitalized for influenza A or respiratory syncytial virus (RSV) lower respiratory tract infection, during two consecutive seasons (November-December, 1993 and March-April, 1995). Questionnaires concerning episodes of wheezing and known risk factors for wheezy bronchitis were mailed to parents 1 year after hospitalization. Sixty per cent of parents reported two or more episodes of wheezing following either influenza A or RSV. Hospitalization as a result of wheezing was necessary in 15% of the patients. The severity of the primary infection, as indicated by the need for treatment in the intensive care unit (ICU), was correlated with later wheezing. No additional significant risk factors predicting later wheezing could be identified.

Incidence and estimates of the disease burden of rotavirus in Sweden.

Laboratory and hospitalization data from two children's hospitals with large primary catchment areas and national laboratory and hospitalization data for children under 4 y of age with acute diarrhoea were compiled to estimate the number of hospitalizations and the cost burden associated with rotavirus diarrhoea in Sweden. According to our estimates 1500-1700 rotavirus-associated hospitalizations occur annually in Sweden in children under 4 y of age (3.7 hospitalizations/1000 children/y). This number represents 2.3% of admissions for all diagnoses in children of this age group. The cost of these hospitalizations is 13.5-15 million Swedish crowns (US$1.8-2 million). Serotyping by PCR for two years revealed that serotype 1 (G1) was the most common (49% and 58%, respectively) identified. Serotypes 2-4 were identified in the following proportions G2 (23% and 5%), G3 (21% and 0%) and G4 (7% and 16%). The national laboratory report data for 1993-96 show that as much as 7-13% of rotavirus infections occur in elderly people.

Clinical manifestations and epidemiology of childhood tuberculosis in Stockholm 1976-95.

81 cases of tuberculosis infection (17) and disease (64), seen between 1977 and 1995 at St Göran's Children's hospital, Stockholm, Sweden are reviewed. The incidence of tuberculosis disease increased from 1 to 6/10(5) children/y. The increase was due to immigration from high-prevalence countries, with an incidence of 20/10(5) in a partly segregated suburb. Most of the children were foreign-born. Of the 31 0-4-y-old cases, 19 were born in Sweden, and 7 had received BCG vaccination. For Swedish-born children with Swedish-born parents, the incidence of tuberculosis disease remained stable at < 0.5. 50 patients were symptomatic when first seen (60% pulmonary tuberculosis, 8% military tuberculosis, 25%, cervical adenitis, 15% other extrapulmonary tuberculosis). There was 1 death, and in 2 children complicated tuberculosis courses. Side effects of drug therapy were seen in 5% of the children. In conclusion, tuberculosis remains an important differential diagnosis in children of immigrants from high-prevalence countries for at least 5 y after settlement in Sweden. The practice of delaying BCG vaccination of them until 6 months of age can be disputed.

Nosocomial gastroenteritis in two infant wards over 26 months.

We retrospectively reviewed 209 cases of nosocomial diarrhea in two infant wards at St Göran's Children's Hospital. They occurred from April 1987 to May 1989, when 3105 patients spent 26,355 hospital days. The hospital is a 250-bed tertiary center with university affiliation. Fourteen percent of patients at risk developed nosocomial diarrhea, and the relative attack rate was 1.1 episodes per 100 hospital days. A probable viral etiology was found in 47% of patients. Rotavirus was most frequent and occurred during the community rotavirus seasons. Also small, round, structured viruses were common, and two outbreaks of astrovirus gastroenteritis occurred. Failure to detect a virus was particularly common among infants younger than 4 months. However, a seasonal distribution and peaks concordant with defined clusters in older patients, suggest also that some of these detection-negative cases may have a viral etiology.

Early infant feeding and micro-ecology of the gut.

Newborn infants are rapidly colonized by both aerobic and and anaerobic bacteria, initially with about 50% of each type. Several factors related both to the infant and its environment influence the composition of the intestinal microflora quantitatively as well as qualitatively. Major ecological disturbances are observed in newborn infants treated with antimicrobial agents. One way of minimizing the ecological disturbances, which may be seen in infants treated in neonatal intensive care units, is to provide them with fresh breast milk from their mothers and to use antimicrobial therapy only under strict clinical indications.

Nosocomial calicivirus gastroenteritis in a pediatric hospital.

At St. Göran's Children's Hospital (a tertiary center), we perform electron microscopy of feces in most cases of nosocomial gastroenteritis. From September 1987 through April 1992 we identified 32 episodes of calicivirus infection, 25 of which were nosocomial and, except for one outbreak, sporadic. Systematic study of the nosocomial outbreak of calicivirus gastroenteritis from November 1991 to January 1992, revealed calicivirus in the stools of 8 of 23 children with diarrhea and 0 of 10 without diarrhea. In 3 of 7 sampled after cessation of diarrhea, calicivirus excretion continued for 3 to 6 days. We found no calicivirus in 42 staff members or 9 members of infected patients' families. Nosocomial transmission of calicivirus can occur among infants.

Transient, asymptomatic colonisation of newborn, Ethiopian infants by Salmonella.

We performed faecal cultures from 71 Addis Ababa infants. Salmonella spp. were found in 12 of 61 hospitalised infants. None had diarrhoea. Colonisation was most common (8/21) during the second week of life. There was no correlation to mode of delivery, breast feeding, type of ward or antibiotic treatment in this small sample.

Aluminum Tolerance in Wheat (Triticum aestivum L.) (I. Uptake and Distribution of Aluminum in Root Apices).

We investigated the uptake and distribution of Al in root apices of near-isogenic wheat (Triticum aestivum L.) lines differing in Al tolerance at a single locus (Alt1: aluminum tolerance). Seedlings were grown in nutrient solution that contained 100 [mu]M Al, and the roots were subsequently stained with hematoxylin, a compound that binds Al in vitro to form a colored complex. Root apices of Al-sensitive genotypes stained after short exposures to Al (10 min and 1 h), whereas apices of Al-tolerant seedlings showed less intense staining after equivalent exposures. Differential staining preceded differences observed in either root elongation or total Al concentrations of root apices (terminal 2-3 mm of root). After 4 h of exposure to 100 [mu]M Al in nutrient solution, Al-sensitive genotypes accumulated more total Al in root apices than Al-tolerant genotypes, and the differences became more marked with time. Analysis of freeze-dried root apices by x-ray microanalysis showed that Al entered root apices of Al-sensitive plants and accumulated in the epidermal layer and in the cortical layer immediately below the epidermis. Long-term exposure of sensitive apices to Al (24 h) resulted in a distribution of Al coinciding with the absence of K. Quantitation of Al in the cortical layer showed that sensitive apices accumulated 5- to 10-fold more Al than tolerant apices exposed to Al solutions for equivalent times. These data are consistent with the hypothesis that Alt1 encodes a mechanism that excludes Al from root apices.

Transient colonization of the gut of newborn infants by orally administered bifidobacteria and lactobacilli.

We investigated if orally administered bifidobacteria and/or lactobacilli could be cultured from faeces of infants after antibiotic treatment, when these bacterial species are usually absent. Lyophilized Bifidobacterium longum, strain BB-536, B. breve, strain BB-576, or Lactobacillus acidophilus, strain LAC-343, were used. Doses of 3 x 10(9) cells of one strain, or a mixture of all three strains 3 x 10(9) cells each were fed three times daily at mealtimes to 11 infants aged 0-8 weeks. Treatment was started the first day after antibiotic treatment and was continued for 5 days. The bacterial species were isolated in 9 of 11, 7 of 10 and 2 of 9 specimens obtained on the last day of bifidobacteria or lactobacilli administration, 5 and 15 days thereafter, respectively. No side effects were noted.

Astroviruses as a cause of nosocomial outbreaks of infant diarrhea.

During a 16-month study period at a children's hospital, 32 children developed nosocomial gastroenteritis caused by astroviruses. Twenty-five of these occurred during 2 epidemic outbreaks in medical and surgical infants' wards. From the community, 13 confirmed cases were admitted during the study period. Both community-acquired and nosocomial cases occurred during autumn, winter and early spring. The attack rates during outbreaks ranged between 7 and 62% and were highest among children with underlying gastrointestinal diseases. Diarrhea and vomiting were the most common clinical manifestations. The median duration of symptoms was 4 days and that of virus excretion was 5 days. Hospital infection with astroviruses is common and usually affects children less than 2 years of age. The probable mode of transmission is spread via contaminated hands.

Intestinal bacteria of newborn Ethiopian infants in relation to antibiotic treatment and colonisation by potentially pathogenic gram-negative bacteria.

The aerobic and anaerobic intestinal microflora of 60 newborn infants in Addis Ababa was studied. As opposed to earlier published studies from Stockholm, there were no consistent changes of the microflora attributable to antibiotic treatment. The reason why antimicrobial agents caused quantitatively smaller changes of the intestinal microflora in newborn infants in Addis Ababa than in Stockholm is not known, but may be due to antimicrobial inactivation, or marked, continuous ingestion of bacteria. Colonisation by potentially pathogenic gram-negative bacteria was coupled to a low isolation rate of bifidobacterium, but not of lactobacillus. This is consistent with the hypothesis that bifidobacterium might convey some kind of resistance to colonisation by and overgrowth of gram-negative bacteria in newborn infants. Similar results have previously been obtained in Stockholm. In comparison to 45 healthy infants in Stockholm, the Ethiopian infants had more enterococcus and lactobacillus and less staphylococcus and bacteroides during the first 2 weeks of life. After that time, the only difference was more frequent colonisation by lactobacillus in Addis Ababa.