Community-acquired methicillin-resistant Staphylococcus aureus infections in south Texas children.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA) infections have increased dramatically from 1990 to 2000. OBJECTIVES: The objectives of this retrospective study were to report the frequency of CAMRSA isolates, to describe the spectrum of disease observed in children infected with CAMRSA and to compare the antibiotic susceptibility patterns of community-acquired and nosocomial methicillin-resistant S. aureus (MRSA) infections. METHODS: All cases of S. aureus including MRSA infections were identified by a computer-assisted search of the Vitek system culture results from 1990 to 2000 and review of the minutes of Infection Control Committee meetings. RESULTS: MRSA was isolated from 147 children (77 boys; 2 weeks to 17 years) from October 1, 1990, to December 31, 2000. Seven cases of CAMRSA were identified from 1990 to 1996, and 53 cases were identified from 1997 to 2000 with 35 cases occurring in 2000. Of the 128 children whose medical records were reviewed, 60 (47%) had CAMRSA infections. In 53 (88%) of these 60 children no risk factor for MRSA was identified. Soft tissue infections accounted for 48 (91%) of the 53 cases of the CAMRSA in children without known risk factors. CAMRSA isolates from children without known risk factors were more susceptible to trimethoprim-sulfamethoxazole (98% vs. 82%; P < 0.005) and clindamycin (92% vs. 57%; P < 0.001) and less susceptible to tetracycline (54% vs. 95%; P < 0.001) than were nosocomial MRSA isolates. CONCLUSIONS: The emergence of CAMRSA as a cause of common infections may require a change in the initial selection of antibiotics to assure appropriate coverage in critically ill children.

Nocardiosis in South Texas children.

Primary cutaneous nocardiosis can present as cellulitis or abscess with or without lymphadenitis. In South Texas children with suspected Staphylococcus aureus or Streptococcus pyogenes skin and soft tissue infections who do not improve as expected with appropriate antibiotics, physicians should consider Nocardia brasiliensis in the differential diagnosis, especially if there are multiple lesions in a lymphocutaneous distribution.

Murine typhus in South Texas children.

BACKGROUND: Murine typhus is a zoonotic infection caused by Rickettsia typhi. This illness used to be endemic in the southeastern and gulf coast of the United States and is now only rarely reported in South Texas and Southern California. Murine typhus causes a febrile illness with headache and rash that has been well-described in adults. OBJECTIVE: To define the epidemiologic and clinical characteristics, laboratory findings, hospital course and response to therapy of children discharged from our hospital with a diagnosis of murine typhus. METHODS: Retrospective chart review of all children discharged from Driscoll Children's Hospital, Corpus Christi, TX, from January 1, 1990, to June 30, 1998, with a diagnosis of murine typhus. Patients. Thirty children (17 females) ages 2 to 17 years (mean, 10 +/- 4 years). RESULTS: Eighty percent of the children were admitted between May and November, and 67% had a history of contact with or exposure to a potential animal reservoir. Children were admitted after a mean of 7 +/- 4 days. The most common clinical features were fever 100%, rash 80% and headache 77%. Laboratory abnormalities included elevated erythrocyte sedimentation rate (75%), elevated serum transaminases (67%), hyponatremia (66%) and increased immature leukocytes without leukocytosis (63%). Only one child had leukocytosis and 40% had leukopenia. Defervescence occurred a mean of 35 +/- 19 h after initiation of appropriate antibiotics. Hospitalization lasted for a mean of 7 +/- 3 days. There were no readmissions and no patients died as a result of the infection. CONCLUSIONS: Despite being rarely reported in this country now, murine typhus continues to be an important cause of fever and hospitalization for children in South Texas. Children with murine typhus develop an illness similar to that reported in adults with fever, rash and headache. Children respond quickly to therapy with doxycycline or tetracycline and recover completely from their illness.

The role of inflammatory mediators and anti-inflammatory drugs in otitis media.

Despite multiple studies, the role of anti-inflammatory drugs in the treatment of AOM and OME is unclear. Although the AHCPR was against the use of steroids in OME, other studies suggest a possible role with potential cost savings and a decrease in the need for surgery in some patients. But the risk-benefit ratio of steroid treatment is unclear. There is some evidence that NSAIDs may decrease otalgia associated with AOM, but no proof that NSAIDs reduce or prevent inflammatory changes in the middle ear associated with AOM and OME.

Intrathoracic Mycobacterium avium complex infection in immunocompetent children: case report and review.

Mycobacterium avium complex (MAC) infection is a rarely recognized cause of intrathoracic infection in immunocompetent children. The incidence of this disease is unknown but is likely underestimated among children in whom MAC infection is not usually considered. An increase in the number of cases of MAC infection in adults has been noted since the late 1970s. The number of these cases in children with AIDS has also increased. There are currently no guidelines for the treatment of these children. We describe a previously healthy 14-month-old boy with a mediastinal mass for whom tuberculosis was initially diagnosed; subsequently, biopsy-proven infection with MAC was demonstrated. He received no specific therapy after surgical excision of his intrathoracic mass and has done well since. We reviewed eight additional cases of intrathoracic nontuberculous mycobacteria infection in children that were reported from 1979 to 1994 and found excellent outcomes for seven immunocompetent children who received diverse methods of treatment.

Pseudomonas aeruginosa bacteremia in immunocompromised children: analysis of factors associated with a poor outcome.

We identified 98 children and adolescents with cancer who were treated for Pseudomonas aeruginosa bacteremia over a 27-year period. The most common underlying disease was leukemia (lymphoblastic in 63 cases and myeloblastic in 17); in addition, 12 episodes were associated with solid tumors and 6 with other diagnoses. There were 29.5 episodes of P. aeruginosa bacteremia/1,000 cases of acute lymphoblastic leukemia, with a mortality of 27%, and 29.8 episodes/1,000 cases of acute myeloblastic leukemia, with a mortality of 24%; patients with solid tumors had an incidence of 5.0/1,000 cases and a mortality of 58% (P = .01 for mortality in leukemia vs. mortality in solid tumors, logistic regression analysis). Mortality was lower among children who developed bacteremia during remission therapy or induction therapy than among children who were being treated for relapse (P = .001). The majority (78%) of the 76 evaluated cases developed during periods when the absolute neutrophil count (ANC) was < 0.1 x 10(9)/L; mortality was higher among patients with such counts than among those with higher ANCs (36% vs. 14%, P = .04). Logistic regression analysis showed that perineal skin lesions were associated with higher mortality than were lesions at other sites of skin involvement (54% vs. 23%, P = .04).

Pseudomonas aeruginosa cellulitis and ecthyma gangrenosum in immunocompromised children.

Pseudomonas aeruginosa skin infections are generally considered to be secondary manifestations of disseminated disease. A retrospective analysis of all cases of P. aeruginosa skin infections seen at St. Jude Children's Research Hospital since 1962 revealed 16 episodes of the infection (ecthyma gangrenosum, 8 episodes, 7 patients; cellulitis, 8 episodes, 7 patients) in which blood cultures were uniformly negative for P. aeruginosa. All cases were identified while the patients were receiving ambulatory care. Five episodes developed while the patients' neutrophil counts were greater than 1 x 10(9) cells/liter. Eight patients had acute lymphoblastic leukemia, 2 had acute myeloid leukemia, 2 had aplastic anemia, 1 had transient agranulocytosis and 1 had cyclic neutropenia. There were no solid tumor patients. Although patients received different antibiotic combinations, all had resolutions of their lesions without fatal complications. Patients diagnosed as having cellulitis required a mean of 9.2 days of treatment with intravenous antibiotics, as compared with 17.8 days for those with ecthyma gangrenosum (P less than 0.05 by the Wilcoxon test). These observations show that P. aeruginosa skin infections can develop in the absence of bacteremia in immunocompromised children.