The resurgence of acute rheumatic fever in the United States.

Several areas in the United States have experienced significant outbreaks of acute rheumatic fever. Reasons for the reappearance of acute rheumatic fever are incompletely understood but may relate to changes in the organism. Fortunately, however, GABHS has remained exquisitely susceptible to penicillin. Given the resurgence in cases of acute rheumatic fever, the practicing physician needs to be vigilant in diagnosing and ensuring adequate treatment of acute streptococcal pharyngitis. In addition, acute rheumatic fever must be considered in a patient who presents with a new onset murmur, a migratory polyarthritis, chorea, or a rash suggestive of erythema marginatum.

Comparison of an acellular pertussis-component diphtheria-tetanus-pertussis (DTP) vaccine with a whole-cell pertussis-component DTP vaccine in 17- to 24-month-old children, with measurement of 69-kilodalton outer membrane protein antibody.

Healthy 17- to 24-month-old children, previously immunized with three doses of whole-cell diphtheria-tetanus-pertussis (DTP) vaccine, were enrolled in a multi-center double-blind, randomized study comparing a DTP vaccine with an acellular pertussis-component (APDT) and a conventional whole-cell pertussis-component DTP vaccine. Thirty-eight children received APDT vaccine, and 37 children received DTP vaccine. APDT vaccine recipients had significantly less local pain and warmth than DTP vaccine recipients. Antibody responses to lymphocytosis-promoting factor were similar in the two groups. The APDT vaccine recipients had a higher IgG antibody response to filamentous hemagglutinin than the DTP vaccinees had. Equivalent agglutinin responses were seen in the two groups. The APDT vaccine recipients had a significantly better antibody re-enzyme-linked immunosorbent assay, than DTP vaccinees had 1 month and 1 year after immunization. This APDT vaccine was immunogenic and caused fewer local reactions than conventional DTP vaccine when administered as a fourth dose to 17- to 24-month-old children.

Escherichia coli O114:nonmotile as a pathogen in an outbreak of severe diarrhea associated with a day care center.

Five infants from a day care center developed severe diarrhea associated with enteropathogenic Escherichia coli O114:nonmotile (EPEC O114:NM) and required hospitalization. Five additional cases of diarrhea associated with EPEC O114:NM subsequently occurred, four in hospital contacts of the patients and one in a household contact. Biochemically, all EPEC O114:NM isolates were sorbitol nonfermenters. All isolates produced low concentrations of cytotoxin with a mean of 10(1.23) CD50/mg of protein. Cytotoxin was not neutralized with antibody to Shiga-like toxin I or II. Heat-labile and heat-stable enterotoxins were not present by gene probe analysis. Stool isolates from 9 of 10 hospitalized infants were positive for EPEC adherence factor by colony blot DNA probe analysis. The severity of the disease, sorbitol nonfermentation, and presence of enteroadherence are unusual features of this organism.

Evaluation of a commercially available cytomegalovirus-specific IgM test for the diagnosis of cytomegalovirus infection in the symptomatic newborn.

A commercially available (Electro-Nucleonics, Inc.) indirect fluorescent antibody test was evaluated for the detection of cytomegalovirus-specific IgM antibody in serum of newborn infants. The serum IgM fraction from 13 symptomatic newborns with cytomegalovirus infection and 30 control infants was tested. Seven of 13 infected infants and none of 30 control infants had a positive IgM test. This cytomegalovirus-specific IgM test is rapid and specific but lacks sensitivity.

Safety and efficacy of once daily ceftriaxone for the treatment of bacterial meningitis.

Fifty-seven patients with bacterial meningitis were treated with once daily ceftriaxone. After an initial loading dose of 100 mg/kg, the patients received 80 mg/kg as a single daily dose. Etiologic agents included: Haemophilus influenzae type b, 37 (11 beta-lactamase-positive); Neisseria meningitidis, 11; Streptococcus pneumoniae, 6; Streptococcus pyogenes, 1; Haemophilus influenzae type f, 1; and Group B Streptococcus, 1. All patients showed clinical improvement and all were bacteriologically cured. Satisfactory cerebrospinal fluid bactericidal activity and drug concentrations were seen 24 hours after a dose even in those patients in whom repeat spinal taps were carried out following the last dose of therapy. The drug was well-tolerated and the major adverse effect seen was diarrhea in 20.4% of the patients. The diarrhea was mild and self-limited and did not necessitate discontinuation of the drug although it was frequently associated with alterations in the stool microbiologic flora. Based on this preliminary experience, ceftriaxone, when given in a single daily dose, appears safe and effective in the treatment of bacterial meningitis in nonneonatal infants and children.

Clinical efficacy and safety of cefmenoxime in children.

Cefmenoxime, an investigational semisynthetic cephalosporin, was evaluated in 18 pediatric patients with a variety of infections. There were seven patients with urinary tract infections, two with wound infections, two with osteomyelitis, two with abscess infections, one with cervical adenitis, one with hidradenitis, one with pneumonia and sepsis, one with periorbital cellulitis, and one with ventriculitis. A total of 16 (88%) patients had a satisfactory clinical response demonstrated by improvement in clinical signs and symptoms. A total of 12 (67%) patients demonstrated eradication of their infecting organisms. Of the pathogens isolated in these patients, 16 isolates were susceptible to cefmenoxime. One patient developed a generalized urticarial rash that resolved within 24 h after cessation of cefmenoxime therapy. Mean peak level in serum after intravenous infusion was 55 micrograms/ml.

Once-daily ceftriaxone therapy for serious bacterial infections in children.

Ceftriaxone administered as a single daily dose of 50 mg/kg was evaluated in the treatment of 35 children with a variety of nonmeningitic bacterial infections. In two of the patients, the drug was discontinued before the response to the drug could be evaluated. All of the remaining patients had a satisfactory response. In 22 of the patients, plasma was available for the determination of ceftriaxone levels 1 h after a dose and immediately before the next dose. All but one of these patients had trough ceftriaxone levels which exceeded the MIC of the infecting organism, although marginally so for Staphylococcus aureus. Ceftriaxone appears to be safe and effective in the treatment of a variety of bacterial pathogens in children when administered at a single daily dose of 50 mg/kg. This drug may be especially useful in those patients in whom outpatient antibiotic therapy is contemplated or in whom maintenance of intravenous access is difficult.

Evaluation of a latex particle agglutination kit in pneumococcal disease.

Latex particle agglutination for Streptococcus pneumoniae was evaluated in 76 patients. Fifteen of these patients had invasive disease due to S. pneumoniae including 12 with meningitis, 2 with occult bacteremia and 1 with suppurative arthritis. Five of the patients with meningitis also had bacteremia. Pneumococcal antigen was detected in the cerebrospinal fluid of 9 of the 12 patients with meningitis (sensitivity 75%). However, antigen was detected in the serum of only two of the six patients with bacteremia (sensitivity 33%) and was detected in the urine of none of five patients with bacteremia (sensitivity 0%). Consequently latex particle agglutination appears to be useful when cerebrospinal fluid is examined in patients with pneumococcal meningitis but does not appear to be sufficiently sensitive to warrant its use with serum or urine in patients with invasive disease due to S. pneumoniae. The specificity of the system used here appeared satisfactory, since pneumococcal antigen was not detected in any of the body fluids from the 61 patients without evidence of invasive pneumococcal disease (specificity 100%).

Twice daily ceftriaxone therapy for serious bacterial infections in children.

The clinical efficacy and safety of ceftriaxone, a long half-life cephalosporin were evaluated in 48 children with a variety of serious bacterial infections. Clinical cure was achieved in 92% (44 of 48) of patients. Peak serum bactericidal titres for Haemophilus influenzae type b, Streptococcus pneumoniae, Str. pyogenes and Escherichia coli were greater than or equal to 1:1024. Mean peak and trough ceftriaxone levels were 173 and 42 mg/l, respectively. Mild and transient diarrhoea was observed in 10% of patients. Laboratory side effects encountered were eosinophilia, thrombocytosis and neutropenia in another 8%. Ceftriaxone is a useful antibiotic for common childhood infections. Its prolonged half-life allows twice daily administration which reduces problems related to intravenous therapy as well as the cost and personnel time.

Comparison of ceftriaxone and traditional therapy of bacterial meningitis.

Forty-five children (aged 1 day to 15 years) with bacterial meningitis were randomized to receive either traditional therapy (ampicillin and chloramphenicol or gentamicin, pending sensitivity) or ceftriaxone (100 mg/kg per day in two doses for a minimum of 10 days). The etiological agents involved were similar for the two groups and included Haemophilus influenzae type b, Neisseria meningitidis, Streptococcus pneumoniae, and group B streptococcus. Repeat spinal taps were carried out 24 to 48 h after admission. Organisms were seen on the Gram stain of one patient treated with ceftriaxone, but five patients in the traditional therapy group had organisms present on Gram stain of uncentrifuged spinal fluid or positive cultures of the spinal fluid (or both). Ceftriaxone entered the cerebrospinal fluid well, and the average cerebrospinal fluid bactericidal activity for ceftriaxone 1 h after a dose was at least 60 times greater than for ampicillin or chloramphenicol. In those patients who received treatment for a long enough period of time to permit evaluation, there was one death in each group, both due to S. pneumoniae. The length of fever and complications were similar for the patients in both groups. Ceftriaxone was well tolerated; diarrhea, seen in 5 of the 22 patients who received the drug, was the most commonly encountered adverse effect. It was mild, and in no case was it necessary to discontinue the drug. Ceftriaxone appears in this preliminary study to be a safe and acceptable single agent for the treatment of bacterial meningitis in children.

An approach to the child with pharyngitis.

In the child with pharyngitis, the physician's major task is to distinguish streptococcal from nonbacterial pharyngitis. Clinical and laboratory information is useful, but the diagnosis of streptococcal disease may be imprecise. Even the recovery of group A streptococcus from a throat culture must be interpreted with caution. Most physicians who treat a large number of children with pharyngitis will depend to a large extent on clinical judgment. When judgment is reinforced by a leukocyte count and differential and/or a throat culture, accuracy is enhanced considerably. Under the best of circumstances, some patients without streptococcal disease will be treated. Once the decision to treat is made, there is never a reason to use any drug other than penicillin for 10 days. In my experience, an injection of benzathine penicillin G, usually in combination with procaine penicillin G, is the safest, most effective, and most practical form of therapy, and compliance in 100 per cent of patients is ensured.

Expanded spectrum of organisms causing osteomyelitis after puncture wounds of the foot.

Although there is a general awareness developing about the role of Pseudomonas aeruginosa in producing osteomyelitis following puncture wounds of the foot, it is not generally appreciated that other organisms may gain access to the bones of the foot following penetrating injuries. This paper addresses two additional cases of osteomyelitis produced by organisms other than Pseudomonas, and characterized by the same indolent course. It is emphasized that puncture wound osteomyelitis generally requires surgical intervention, not only for proper diagnosis, but for evacuation of the infective process.

Latex agglutination test for rapid detection of bacterial antigens in body fluids.

A modified latex agglutination (LA) test performed on glass slides was evaluated for the detection of Streptococcus pneumoniae (Pn), Hemophilus influenzae type b (Hib), and K1 antigens in serum, cerebrospinal fluid (CSF), nasopharyngeal secretions, and other body fluids in patients suspected of having infection. Forty-eight, 61, and 31 specimens were tested for the presence of Pn, Hib, and K1 antigens, respectively, by countercurrent immunoelectrophoresis (CIE) and LA. Of the specimens positive by CIE or LA, 16 of 28 specimens (57 percent) were positive for Pn antigen by CIE while all 16 (100 percent) were positive by LA. LA was unique in detecting type 7 and 14 Pn antigens which are not detected by CIE. Twenty-seven of 37 specimens (73 percent) were positive for Hib by CIE, while all (100 percent) were positive by LA. LA test (11 of 11) was superior (p < 0.002) to CIE (4 of 11) in detecting Hib antigens on patients with nonmeningitic Hib diseases (cellulitis, epiglottitis and pneumonia). Sensitivity of CIE and LA were identical in detecting K1 (5 of 5) antigen. LA is a simple, sensitive and specific test for the detection of Pn, Hib, and K1 antigens in various body fluids.

Diagnosis of pneumonia by counterimmunoelectrophoresis of respiratory secretions.

Several recent studies in adults have indicated that counterimmunoelectrophoresis (CIE) of sputum can distinguish persons with pneumococcal pneumonia vs those in whom merely colonization of pneumococcus occurs--CIE being positive in the former and negative in the latter. Counterimmunoelectrophoretic determinations were done on nasopharyngeal (NP) secretions in 20 children with bacterial pneumonia as evidenced by physical and radiological findings, leukocytosis, response to a penicillin, and in some cases, evidence of bloodstream invasion. Thirty-five children with other types of respiratory illness served as controls. Ten of 16 children from the pneumonia group had pneumococcal antigen in their NP secretions. Four of the six patients without pneumonia had evidence of disease associated with type 14 pneumococcus, which is not generally detected by CIE. The four additional patients with pneumonia had Haemophilus influenzae type b, and H influenzae type b antigen was present in the NP secretions. In the control group, one patient had pneumococcal antigen, and one patient had H influenzae type b antigen in the NP secretions, although 17/35 were positive for pneumococcus by culture. Counterimmunoelectrophoretic determinations of NP secretins are reliable in distinguishing patients with pneumococcal pneumonia vs those who are merely carriers (P less than .001).