Comparison of three methods for culturing throat swabs from cystic fibrosis patients

In patients with cystic fibrosis who do not produce sputum, deep throat swabs are cultured for potential respiratory pathogens. Usually these swabs are directly streaked onto selective agar media. In a study of 50 pediatric cystic fibrosis patients, we compared this traditional method using rayon swabs with two methods having quantitative modifications: calcium alginate swabs eluted in Ringer's lactate and rayon swabs eluted in normal saline. The eluates were then processed quantitatively (three-step dilution series). The yield of potential pathogens was significantly higher with the two quantitative methods. Overall, the combination of alginate with Ringer's lactate was superior to the combination of rayon with saline, although only some of these differences achieved statistical significance.

Orointestinal yeast colonization of paediatric oncologic patients during antifungal prophylaxis: results of quantitative culture and Candida serology and comparison of three polyenes

The orointestinal yeast colonization of 46 children with newly diagnosed malignancies was studied prospectively and longitudinally with quantitative cultures during remission induction chemotherapy. The initial colonization rate was 24%; only 28% of the patients remained free of yeasts during their entire treatment although all of them continuously received oral polyenes as antifungal prophylaxis. A randomized comparison of natamycin (suspension, lozenges), nystatin (suspension) and amphotericin B (suspension, lozenges) failed due to serious problems with patient compliance. Natamycin was best accepted by the patients and natamycin lozenges were the most efficacious drug in the oral cavity. The effectivity of the suspensions of nystatin and amphotericin B was similar; both were equally efficacious in the oral cavity and the gut. Assessment of faecal polyene concentrations by HPLC showed the highest results for amphotericin B (mean 6808 microgram(-1)). Regularly performed Candida serology (indirect haemagglutination, indirect immunofluorescence and immunodiffusion precipitation) revealed significant titre increases in 63% of the patients. In six cases, the synopsis of clinical picture, culture and serology strongly suggested systemic yeast invasion.

Orointestinal yeast colonization of paediatric bone marrow transplant recipients: surveillance by quantitative culture and serology

We quantitatively studied the orointestinal yeast colonization of 15 consecutive paediatric patients who underwent 16 bone marrow transplantations (BMT). Cultures were performed initially, longitudinally weekly during the period of aplasia (in-patient treatment) and, if possible, also during out-patient follow-up. With one exception, all patients received fluconazole as antifungal prophylaxis. Patients remained free of yeasts during the complete observation period only in six out of 16 cases (38%). Non-albicans species of Candida were isolated in six out of 16 cases (38%), mainly C. glabrata (five out of 16; 31%). All of these patients had undergone allogeneic BMT. In one case, there was indirect evidence of systemic invasion by C. glabrata. Even combined prophylaxis with fluconazole and and amphotericin B suspension could not reliably prevent yeast colonization but this combination at present appears to be the optimal regime. Regular concomitant Candida serology (determination of specific antibodies by three methods) proved to be a valuable additional surveillance method.

Acute mastoiditis--relevant once again

During recent years, a significantly increased incidence of acute mastoiditis was observed at the University Children's Hospital, Tübingen, Germany (1975-1979: 1.4 patients/year; 1987-1992: 4.2 patients/year; p < 0.05). We therefore reviewed the records of all patients with acute mastoiditis (n = 58) that had been treated at the Children's Hospital between 1975 and 1992 and at the Clinic of Otorhinolaryngology between 1978 and 1992. The male to female ratio was 1.8:1 and 60.4% of the patients were younger than 24 months. Retroauricular swelling was more often observed (n = 49) than protrusion of the pinna (n = 45) and retroauricular redness (n = 38). Streptococcus pneumoniae was the most frequently isolated pathogen. Several factors predisposing for the development of acute mastoiditis were identified. These included withholding antimicrobials for treatment of the preceding episode of otitis media; use of suboptimal agents for therapy of otitis media (penicillin and, possibly, erythromycin ethylsuccinate); and insufficient duration of treatment.

Selection of Candida glabrata in pediatric bone marrow transplant recipients receiving fluconazole

We observed an alarmingly high rate (5/16 patients; 31.3%) of orointestinal colonization with Candida glabrata--often in high numbers--in pediatric bone marrow transplant recipients receiving fluconazole as antifungal prophylaxis. This selection is probably due to the intrinsically low susceptibility of C. glabrata to fluconazole.

Catheter-related Rahnella aquatilis bacteremia in a pediatric bone marrow transplant recipient

Rahnella aquatilis, a rarely encountered member of the family Enterobacteriaceae, was twice isolated from the blood of a pediatric bone marrow transplant recipient. This is the first report of a pediatric case of R. aquatilis bacteremia, and it was probably related to inappropriate handling of a Hickman catheter.

[Cryptosporidium enteritis]

Cryptosporidium has been found to be a common cause of gastroenteritis during the last years. The natural course of the disease in immunocompromised patients is often met by serious complications. A general therapy recommendation has not been reported so far. We report of a two-year-old boy, who was immunocompromised by a multidrug cytostatic chemotherapy. The patient suffered from a long lasting most severe gastroenteritis, caused by cryptosporidium. There was a good clinical response to spiramycin, a treatment suggested in the literature.

Bacteriological and serological study of pertussis in Abeokuta, Nigeria

Charcoal horse blood agar is the medium of choice for isolation of Bordetella pertussis from patients with early whooping cough. Since sterile animal blood often is not available in developing countries, a field study in Nigeria was undertaken to evaluate donated human blood as supplement to charcoal agar. Out of 209 children with suspected early pertussis, 33 were culture-positive (isolation rate 16%). Out of 188 children studied serologically by enzyme immunoassay, 36 (19%) were seropositive. The satisfactory isolation rate of 16% shows that culturing for B. pertussis on charcoal human blood agar can be tried in countries, where there is no regular supply of bacteriological media with animal blood.

[Environmental chemoprevention of Haemophilus influenzae type B meningitis. Consequences of 2 indirectly related case pairs]

BACKGROUND

Within a few months we twice observed the following situation: In each of two different communities, a young child fell ill with meningitis caused by Haemophilus influenzae type B (HIB). One week later, a second case occurred in the same community. Both patients had had no direct contact with each other. But each had an asymptomatic older sibling. These siblings attended the same kindergarten and had close contact with each other. The isolated HIB strains were identical (capsular type b, biotype I, outer membrane protein subtype 1 and lipopolysaccharide serotype 1) and were beta-lactamase-negative.

CONCLUSION

Since it must be assumed that the causative HIB strains circulated in the respective kindergartens and were transmitted to the patients by their healthy siblings, a rifampicin chemoprophylaxis was instituted which included all kindergarten children and their younger siblings. Since the current guidelines on chemoprophylaxis in HIB meningitis do not deal with a situation like the one encountered by us, a revision of the present guidelines was proposed and has been implemented in the meantime.

Comparison of erythromycin estolate and erythromycin ethylsuccinate for treatment of pertussis. The Erythromycin Study Group

In an open randomized multicenter study 190 culture-positive pediatric ambulatory pertussis patients were treated for 14 days with either erythromycin estolate (EST) (n = 93; 40 mg/kg/day divided in 2 doses) or erythromycin ethylsuccinate (ETH) (n = 97; 60 mg/kg/day divided in 3 doses). On day 14 Bordetella pertussis was recovered from cultures of 2 patients (2.2%) treated with EST and 1 patient (1.0%) treated with ETH. Despite the fact that 151 patients (79.4%) had reached the early paroxysmal stage at initiation of antimicrobial therapy, clinical improvement was seen in the majority (reduced frequency and severity of coughing: EST, 77.4 and 67.7%; ETH, 74.2 and 63.9%, respectively). Drug-related side effects were noted in 11 patients (11.8%) treated with EST and 16 patients (16.5%) treated with ETH (P greater than 0.05) and consisted mainly of minor gastrointestinal complaints. Erythromycin estolate in a lower dose administered only twice a day was equivalent to erythromycin ethylsuccinate in all aspects and proved to be adequate antimicrobial treatment for pertussis patients.

[Chemoprophylaxis in indirectly related cases of Haemophilus influenzae meningitis]

In January 1991, in a community near the South German town of Tübingen, an infant and a toddler developed a Haemophilus influenzae type B (HIB) meningitis within a period of one week. The patients had no direct contact with each other, but each of them had a healthy sibling that was older. These siblings attended the same kindergarten and the same group. Five months later we noted the same situation in another community. Two infants fell ill with HIB meningitis at short intervals from each other, and again both patients had no common contacts, but they did have healthy siblings attending the same kindergarten and group. Hence, it must be assumed that the HIB strain circulated among the healthy kindergarten children and was transmitted by these to the patients. In order to prevent that after the two pairs of patients we had observed, further patients would follow among the kindergarten children or their younger siblings, chemoprophylaxis with rifampicin was initiated in all kindergarten children, their younger siblings and the adult Kindergarten staff. The problems arising from these unusual case constellations in respect of mass prophylaxis with rifampicin in cases of Haemophilus influenzae type B meningitis that are merely indirectly linked to each other, are discussed.

Costal BCG osteomyelitis presenting as a tumor

We present the case of an 11-month-old male infant who had been BCG vaccinated as a neonate. At the age of nine months, he developed a localized tumor above his right mamilla. The tumor destroyed the fourth rib and infiltrated the surrounding soft tissue. X-ray and CT scan suggested a malignant neoplasm. Histology, however, showed the typical picture of tuberculosis and Mycobacterium bovis (BCG strain) was isolated from the lesion. Thus, the tumor was caused by an unusual presentation of a costal BCG osteomyelitis which was associated with negative findings in the bone scan.

In vitro susceptibilities of Bordetella pertussis and Bordetella parapertussis to seven fluoroquinolones

The in vitro susceptibilities of Bordetella pertussis and Bordetella parapertussis to seven fluoroquinolones were assessed by the agar dilution method. Ciprofloxacin and temafloxacin were the most active compounds (MIC for 90% of isolates tested [MIC90], 0.06 microgram/ml), while enoxacin and pefloxacin were the least active (MIC90, 0.5 microgram/ml). Fleroxacin, lomefloxacin, and ofloxacin showed intermediate activities (MIC90s, 0.125 to 0.25 microgram/ml). These results suggest a possible role for the fluoroquinolones in the treatment of pertussis, at least in adult patients.

In vitro susceptibilities of Bordetella pertussis and Bordetella parapertussis to six new oral cephalosporins

Of six new oral cephalosporins, cefixime and cefpodoxime were the most active (MIC for 90% of isolates tested [MIC90], 16 micrograms/ml) against Bordetella pertussis, followed by cefetamet, cefprozil, and loracarbef (LY163892) (MIC90, 64 micrograms/ml) and ceftibuten (MIC90, 128 micrograms/ml). Against Bordetella parapertussis, loracarbef was more active (MIC90, 32 micrograms/ml) than the other compounds tested (MIC90s, 64 to greater than 128 micrograms/ml). The new oral cephalosporins are unlikely to play a role in pertussis treatment.

[Pertussis: diagnosis, clinical aspects and therapy]

Isolation of the causative agent remains the "gold standard" for the early diagnosis of pertussis. For this purpose, the nasopharynx is swabbed with a calcium alginate swab. Cephalexin-containing charcoal horse blood medium is used for the transport of the swabs to the bacteriology laboratory. As an alternative, the isolation of bordetellae can be performed at the paediatrician's office by direct inoculation of charcoal horse blood agar plates. Long-lasting cough of unknown aetiology is the main field for pertussis serology (ELISA). Even today, severe courses of whooping cough requiring hospitalization are not rare, especially in infants. Erythromycin (given in high doses for 14 days) is the antibiotic of choice for pertussis. As an alternative to the macrolides, cotrimoxazole may be administered or amoxycillin. Salbutamol and the corticosteroids have been shown to be useful for the symptomatic treatment of severe pertussis in infants.

[Comparison of cefsulodin and cephalexin as selective agents in agar for Bordetella pertussis]

Cefsulodin (12 mg/l) was evaluated as an alternative to cephalexin (40 mg/l) as selective agent in agar for isolation of Bordetella pertussis from clinical specimens. Charcoal horse blood agar with cefsulodin and with cephalexin supported growth of Bordetella pertussis strains (n = 50) equally well. The nasopharyngeal flora of healthy adults (n = 49) was suppressed significantly better by cephalexin, but colony numbers of flora on the agar with cefsulodin in general were low.

Comparison of three kinds of blood and two incubation atmospheres for cultivation of Bordetella pertussis on charcoal agar

We compared the growth of Bordetella pertussis strains (n = 32) on antibiotic-free and cephalexin (40 micrograms/ml)-containing charcoal agar supplemented with 10% defibrinated horse blood, defibrinated sheep blood, or anticoagulant-containing human blood. Plates were incubated either in air or in an atmosphere with 5 to 10% CO2. As assessed by mean colony numbers and rapidity of growth, normal air was preferable to CO2 enrichment for incubation. Growth on horse blood agar was more abundant and more rapid than on sheep blood agar, but the difference in general was not statistically significant. Human blood was clearly inferior to both horse and sheep blood.

Activity of new macrolides against Bordetella pertussis and Bordetella parapertussis

MICs and MBCs of four new macrolides (azithromycin, clarithromycin, dirithromycin and roxithromycin) and two older macrolides (erythromycin and josamycin) for Bordetella pertussis and Bordetella parapertussis were determined. The activity of the new macrolides was as good as that of erythromycin, while josamycin was slightly less active. Bordetella parapertussis was more resistant than Bordetella pertussis.

Comparison of erythromycin ethylsuccinate and co-trimoxazole for treatment of pertussis

Fifty-five ambulatory children with early culture-proven pertussis were treated for two weeks either with erythromycin ethylsuccinate (n = 28) (50-80 mg/kg/day in three doses during meals) or with co-trimoxazole (n = 27) (6-10 mg trimethoprim/kg/day in two doses after meals). After completion of treatment, all patients in the erythromycin group were culture-negative, while in the co-trimoxazole group one child was still culture-positive. In this case vomiting may have played a role. Both agents appear to be able to eradicate Bordetella pertussis from the nasopharynx of patients with early whooping cough.

[Systemic salmonella infections in chemotherapy in 2 children with acute lymphoblastic leukemia]

A 15 year old patient with acute lymphoblastic leukemia, previously diagnosed as being a salmonella carrier, developed S. typhimurium sepsis after allogeneic bone marrow transplantation, in spite of pretreatment with chloramphenicol. Clinical improvement and termination of salmonella excretion were achieved by treatment with multiple antibiotics. Another patient with acute lymphoblastic leukemia, a 3 year old boy not previously identified as a salmonella carrier, also developed sepsis and osteomyelitis, together with pathological fractures during chemotherapy. Chloramphenicol, administered after isolation of S. typhimurium from blood cultures, led to resolution of the bony defects, complete recovery, and cessation of salmonella excretion. Selective cultures for salmonellae seem indicated in patients with malignant diseases, prior to chemotherapy.

Comparison of four charcoal media for the isolation of Bordetella pertussis

Charcoal-horse blood agar with 40 micrograms of cephalexin per ml, charcoal-horse blood agar with 3 micrograms of lincomycin per ml, charcoal agar with 3 micrograms of lincomycin per ml, and Legionella (buffered charcoal-yeast extract) agar with 3 micrograms of lincomycin per ml were compared for isolation of Bordetella pertussis. Charcoal-horse blood agar with 40 micrograms of cephalexin per ml gave the best results, with a B. pertussis recovery rate of 100%. Growth was most rapid and the mean number of colonies was highest on this agar, and growth of pharyngeal flora was completely suppressed.