Varicella screening and vaccination for healthcare workers at KK Women's and Children's Hospital.

INTRODUCTION: Varicella is a highly contagious disease with significant morbidity and mortality, especially in adults. It can lead to nosocomial transmission with dire consequences, especially in a healthcare facility where children and pregnant women form the majority of patients. At KK Women's and Children's Hospital, we embarked on a programme in 2 phases, between 1997 and 1999, to screen healthcare workers (HCWs) for varicella immunity and to offer varicella vaccination to those who tested negative for antibody. MATERIALS AND METHODS: HCWs were initially screened via a questionnaire; those with no previous history of chickenpox underwent a blood test for varicella zoster antibody. Varicella vaccine was offered to those who tested negative for antibody and they were monitored for adverse reactions. RESULTS: Of the HCWs surveyed, 14.7% and 26.9% in phases 1 and 2, respectively, had no previous history of chickenpox. Of these, 55.3% in phase 1 and 26.1% in phase 2 tested negative for antibodies. Thus, the overall seronegativity of all HCWs surveyed was between 6.5% and 7.6%. Among those who tested negative for antibodies, 42.9% in phase 1 and 74% in phase 2 were vaccinated. Hence, the overall vaccination rate in HCWs was 3.2% and 4.8% in phases 1 and 2, respectively. Adverse reactions were observed in 2 (22.2%) HCWs in phase 1 and in 9 (9.3%) in phase 2, consisting mostly of maculopapular rashes or vesicles around the injection site. CONCLUSIONS: Our study shows that 26% to 55% of HCWs with no history of chickenpox and who tested negative for antibody against varicella required vaccination. Hence, in healthcare facilities, varicella screening and vaccination should be offered to all HCWs.

Chronic monoarthritis of the knee in systemic lupus erythematosus.

We describe a middle-aged lady with systemic lupus erythematosus who presented with chronic left knee monoarthritis without constitutional symptoms. The histology of synovial tissue taken at arthroscopy showed acute inflammation and Erysipelothrix rhusiopathiae, identified with some difficulty, was isolated from the enrichment broth only. Blood cultures were negative. Her history revealed significant exposure to pond fish. She responded well to intravenous penicillin and remains well 12 months later.

Aseptic meningitis in children--the Singapore experience.

OBJECTIVE: To study the incidence, aetiology, clinical characteristics and management of paediatric aseptic meningitis in a paediatric hospital in Singapore. MATERIALS AND METHODS: Patients with cerebrospinal fluid (CSF) pleocytosis, a negative Gram stain and bacterial culture were reviewed retrospectively from 1 January to 31 December 2000. Eighty-seven patients who fulfilled the criteria for aseptic meningitis and without neurological deficits were studied. In addition, reverse transcriptase polymerase chain reaction (RT-PCR) using pan enterovirus primers was subsequently performed on 73 of these CSF specimens which were available for storage. RESULTS: The incidence of aseptic meningitis was approximately 37 cases per 10,000 admissions. Non-polio enteroviruses were isolated from 29 of 64 (45.3%) CSF and 38 of 52 (73.1%) stool samples. RT-PCR was positive in 43 (58.9%) of the archived CSF specimens. The aetiologies of the remaining cases were mostly unidentified. Their ages ranged from 5 days to 12 years (median, 2 months). All patients except 1 had fever. Vomiting or poor feeding occurred in 44.7%, cough or running nose in 35.3%, irritability was observed in 35.3%, seizures in 7.1%, a rash in 10.6% and diarrhoea in 5.9%. All patients recovered without sequelae. The median CSF white cell count was 212 cells/mm3 (range, 7 to 12,000). The median glucose concentration was 2.7 mmol/L (range, 1.6 to 4.4). The median CSF/blood glucose ratio was 0.52 (range, 0.23 to 0.73). Median length of stay was 7 days (range, 4 to 17). Eighty-four patients (96.6%) received antibiotics for a median of 5.5 days (range, 2 to 14). CONCLUSION: Enteroviruses were the most common aetiologic agent identified. A method of early diagnosis using RT-PCR for enteroviruses is necessary to reduce the current duration of antibiotic usage and to decrease the length of hospital stay.

Serotype distribution and antimicrobial resistance of Streptococcus pneumoniae isolates from pediatric patients in Singapore.

One hundred eighty Streptococcus pneumoniae strains isolated from children at a pediatric hospital in Singapore from 1997 to 1999 were serotyped and their antimicrobial susceptibility patterns were determined. Sixty-three percent of the isolates were resistant to penicillin. Significantly large numbers of the strains investigated were resistant to trimethoprim-sulfamethoxazole (87.8%), tetracycline (71.7%), erythromycin (67.8%), and chloramphenicol (40%). Penicillin and multidrug resistance was mostly associated with the frequently isolated S. pneumoniae isolates of serotypes (serotypes 19F, 23F, 6B, and 14). Isolates of serotype 19F, the serotype most commonly encountered in Singapore (41.1%), had the highest prevalence of penicillin (78.4%) and multidrug resistance (94.6%). Most of the invasive S. pneumoniae isolates (8 of 17; 47. 1%) were of serotype 14.

Increasing antimicrobial resistance in clinical isolates of Streptococcus pneumoniae.

The presence of antibiotic-resistant Streptococcus pneumoniae has become a major clinical problem in several parts of the world. However, there is a lack of data from Southeast Asia. We therefore initiated a study to determine the serogroups/serotypes and antimicrobial susceptibilities of clinical strains of S. pneumoniae isolated in our laboratory. In 1995, we isolated 144 strains of S. pneumoniae. Thirty-six (25.0%) strains were resistant to penicillin of which 19 (13.2%) were highly resistant (minimal inhibitory concentration > 1.0 microgram/ml). Thirty-eight (26.4%) strains were resistant to erythromycin, 75 (52.1%) were resistant to tetracycline, 48 (33.3%) were resistant to sulfamethoxazole-trimethoprim and 29 (20.1%) were resistant to chloramphenicol. Twenty of the penicillin-resistant strains also had diminished susceptibility to ceftriaxone. Strains resistant to penicillin belonged to serogroups/serotypes 6 (n = 1), 9 (n = 1), 23 (n = 4), 14 (n = 6) and 19 (n = 20). Children under 5 years of age were more likely than older children and adults to have isolates resistant to penicillin (52.9% versus 16.2%, P = 0.00002). Penicillin-resistant strains were more likely than penicillin-susceptible strains to be multidrug-resistant (86.1% versus 7.4%, P < 0.000005). We concluded that there is a high prevalence of penicillin-resistant pneumococci in our isolates especially among very young children. Most penicillin-resistant strains belong to serogroup 19 and are also resistant to multiple drugs.

Serotypes and antimicrobial resistance in Haemophilus influenzae in a hospital practice.

We studied the clinical spectrum, serotypes and antimicrobial resistance of Haemophilus influenzae received by our laboratory. The majority of cases involved the elderly (more than 60 years old) and children under the age of 5 years. Most infections involved the respiratory tract and were caused by non-serotypable strains. Invasive infections (meningitis, septic arthritis and bacteraemia) were infrequent and were caused by both type b and non-serotypable strains. The estimated incidence of invasive Haemophilus influenzae type b disease in children under the age of 5 years is at most 5 per 100 000 a year. Resistance to ampicillin (40.5%) and trimethoprim-sulfa (37.7%) was high and would affect the choice of antimicrobials used for treating Haemophilus influenzae infections.

Infections of the eye.

Infections of the eye range from the mild to the severe. They may affect the lid, conjunctiva, cornea, lacrimal apparatus, vitreous, orbit or retina. Common presentations, diagnostic methods and treatment are briefly described. The doctor should not only manage outpatients appropriately, but know when to seek the advice of the ophthalmologist when indicated. Common conditions which can be managed by the general practitioner include blepharitis, styes, chalazia and conjunctivitis. With increased use of contact lenses, infection of the cornea has become more common. Sight-threatening conditions like endophthalmitis and orbital cellulitis should be recognised and treated early.

Two cases of lower respiratory tract infection due to Chlamydia pneumonia in Singapore.

Chlamydia pneumoniae, previously known as Chlamydia psittaci strain TWAR, causes both upper and lower respiratory tract infection. We report the first two cases of culture-positive Chlamydia pneumoniae lower respiratory infection in Singapore. Both patients had underlying fibrosing alveolitis and presented with a history of prolonged productive cough and fever. Chlamydia pneumoniae was isolated from the bronchoalveolar lavage fluid in the absence of other pathogens. The patients responded clinically to three weeks of oral doxycycline therapy. Infection due to Chlamydia pneumoniae should be considered when a patient with community-acquired pneumonia fails to respond to the usual standard antimicrobial therapy.

Acquired immunodeficiency syndrome and Cryptosporidium infection.

A child suffering from the acquired immunodeficiency syndrome (AIDS) with intestinal cryptosporidiosis is reported. The child presented with profuse diarrhoea up to 15 episodes a day over a period of one week. Management was with intravenous rehydration and oral spiramycin. Diagnosis of intestinal cryptosporidiosis requires examination of multiple stool specimens by several concentration and staining procedures which aid in the visualisation of the oocysts. In the absence of an effective treatment for cryptosporidiosis, the cornerstone of management is mainly supportive therapy.

Corynebacterium diphtheriae endocarditis in an adult with congenital heart disease: a case report.

A rare case of septicaemia and endocarditis due to Corynebacterium diphtheriae is presented. The patient had underlying congenital heart disease and died despite high-dose penicillin therapy. The implications for diagnosis and identification and some public health issues brought to the fore by the case are discussed.

Enterococci highly resistant to penicillin: characterizing isolates from Singapore hospitals.

Enterococci are increasing in importance as nosocomial pathogens and causes of severe sepsis in immunocompromised patients. From September to November 1989, a survey of 898 enterococcal isolates showed that 52 had acquired high-level resistance to penicillin and ampicillin (MIC greater than 100 mg/l). These were all Enterococcus faecium, did not produce beta-lactamase and showed high-level resistance to gentamicin and streptomycin as well. The majority were urinary isolates, but a few caused bacteraemia in severely ill patients. The potential spread of these highly-resistant enterococci would limit the therapeutic options for systemic infections.