Risk factors for osteomyelitis

An approach that is useful in classifying the risk factors for the development of acute osteomyelitis is the same as one commonly employed to discuss the mechanisms responsible for pathogenesis: hematogenous dissemination, direct inoculation, and contiguous spread from an adjacent area of soft tissue infection. Acute hematogenous osteomyelitis is predominantly a disease of children. Factors that favor the development of acute bone infection are those that predispose to bacteremia. These include indwelling intravascular catheters, distant foci of infection, and intravenous drug abuse. The distant sites of focal infection that are most commonly associated with acute osteomyelitis include the skin as well as urinary and respiratory tracts. Two patient groups with an usual susceptibility to acute skeletal infections are those with sickle cell anemia and chronic granulomatous disease. The second major mechanism for the development of acute osteomyelitis is by direct inoculation. Injuries due to penetrating bites and puncture wounds of the food may serve to infect bone directly. Diagnostic procedures (lumbar puncture, fetal monitoring electrodes, suprapubic aspiration, and heel sticks) may result inadvertently in the inoculation of a neighboring osseous structure. Surgical procedures such as internal fixation of long bone fractures and skeletal traction may cause an infection of the bone. Osteomyelitis may develop as a consequence of contiguous spread of infection from adjacent soft tissue, particularly if vascular insufficiency complicates the clinical picture. Infection of the mandible, maxilla, and frontal or mastoid bones may result from persistent or neglected infection of the teeth, paranasal sinuses, or middle ear cavity, respectively. The major risk factor for chronic infection of bone is inadequate or delayed management of acute osteomyelitis or completely unrecognized bone infection.

Isolated uvulitis due to Haemophilus influenzae type b

Infections of the uvula are infrequently recognized and have been previously described only in association with group A streptococcal pharyngitis or Haemophilus influenzae type b epiglottitis. Three cases of H influenzae type b bacteremic uvulitis are described. In suspected cases of H influenzae type b uvulitis, a lateral neck radiograph should be performed and parenteral antibiotics initiated.

Maxillary sinus radiographs in children with nonrespiratory complaints

An attempt was made to determine the frequency of abnormal maxillary sinus radiographs in a group of unselected children having diagnostic skull radiographs performed for indications unrelated to respiratory infection. An occipitomental, or Water's, view was obtained in every case in order to evaluate the maxillary sinuses. Prior to performance of the radiographs, a history of recent respiratory symptoms was obtained and a physical examination of the ears, nose, and throat was performed. An abnormal maxillary sinus radiograph was defined as one that revealed an air-fluid level, partial or complete opacification, or mucous membrane thickening of 4 mm or greater. Fifty-nine (53%) of 112 presumably "normal" children had evidence of recent respiratory inflammation by history or at physical examination. In 50 subjects less than 1 year of age, abnormal maxillary sinus radiographs were common, irrespective of respiratory symptoms and signs. In contrast, eight of 14 children (57%) aged 1 to 16 years with both symptoms and signs of respiratory inflammation had abnormal maxillary radiographs, compared with only two of 31 children (7%) with neither symptoms nor signs (P less than .005). Crying alone was not associated with abnormal radiographs in the older age group. In children more than 1 year of age, abnormal maxillary sinus radiographs are infrequent and are generally related to inflammation of the upper respiratory tract.

Treatment of acute maxillary sinusitis in childhood: a comparative study of amoxicillin and cefaclor

Maxillary sinus aspiration and quantitative culture of the aspirate were performed in 50 patients, ranging in age from 1 to 16 years, with clinical and radiographic evidence of acute sinusitis. Of 79 sinuses aspirated, at least one was found to be infected in 35 (70%) children. Streptococcus pneumoniae, Branhamella catarrhalis, and Haemophilus influenzae were the most common organisms recovered. All H. influenzae were nontypeable. Twenty percent of the H. influenzae and 27% of the B. catarrhalis organisms were beta-lactamase positive and amoxicillin resistant. The subjects received either amoxicillin or cefaclor at a dose of 40 mg/kg/day in three doses for 10 days. The clinical cure rate with amoxicillin was 81%, compared to 78% with cefaclor. Radiographic improvement was similar in both treatment groups. Antibiotic therapy failed in four patients; three had been given amoxicillin, and one cefaclor. In three of these, a beta-lactamase-positive antibiotic-resistant bacterial species was recovered from the maxillary sinus aspirate; the fourth aspirate was sterile.

Epidural abscess and vertebral osteomyelitis following serial lumbar punctures

Lumbar epidural abscess and vertebral osteomyelitis were diagnosed in a 3-month-old infant, born prematurely, who had had repeated lumbar punctures for the treatment of posthemorrhagic hydrocephalus. Staphylococcus aureus was the causative organism. Successful treatment was achieved with 6 weeks of intravenous antibiotics without surgical drainage. Infectious complications of lumbar punctures are rare, but may occur when multiple punctures are attempted in small premature infants whose subarachnoid space contains large amounts of blood. Infection can be introduced directly by a contaminated spinal needle, or trauma to the tissues with bleeding can create a favorable site for bacterial adherence and multiplication. Posthemorrhagic ventricular dilation often resolves spontaneously and serial lumbar punctures should be used to treat this condition only when CSF flow is easy to establish and maintain.

Bacteriology of the maxillary sinuses in patients with cystic fibrosis

The maxillary sinuses of 20 patients (median age, 15 years) with cystic fibrosis were examined with ultrasound, radiography, and transantral sinus aspiration (14 bilateral and six unilateral for a total of 34 aspirates). The sinus aspirations were performed with careful sterile techniques, and the material that was recovered was cultured quantitatively for both aerobic and anaerobic bacteria. Nineteen (95%) of the 20 patients had at least one positive (greater than or equal to 10(4) colony-forming units/ml) culture of sinus aspirate. The organisms most commonly recovered from the sinus aspirates were Pseudomonas aeruginosa (13), Haemophilus influenzae (10), streptococci (five), and anaerobes (five). There was no association between the bacterial species recovered from the sinus and the predominant bacterial species in the nasopharyngeal, throat, or sputum culture. Although most patients had been chronically receiving therapeutic oral doses of antimicrobial agents, bacteria sensitive to the antimicrobial agents that the patient had been taking (excluding P. aeruginosa) were recovered from the sinuses of nine of these 10 patients.

Gram stain interpretation of blood cultures

Bacteremia without an obvious focus of infection occurs relatively frequently in highly febrile children between the ages of six and 24 months. Management depends on the clinical situation and probable identity of the bacteria. A year-long study to determine the accuracy of differentiating gram-positive cocci morphologically on the Gram-stained smear of a blood culture demonstrated that streptococci and staphylococci can be distinguished when Gram staining is the procedure used by the laboratory. From such a preliminary report, the bacteremia can be evaluated in the context of the clinical situation and appropriate action can be taken.

Broviac catheter-related bacteremia in oncology patients

In 27 pediatric oncology patients (median age, 2 years) undergoing chemotherapy for malignant tumours, Silastic Broviac catheters were placed to provide vascular access. The catheters were in place for a total of 174 patient-months. There were 14 episodes of Broviac catheter-related bacteremia or fungemia that occurred in six patients: one patient had six bacteremic episodes, one patient had four episodes, and four patients each had one bacteremic episode. Cultures of blood drawn from Broviac catheter were positive in all instances, and in 12 of 14 samples drawn from the peripheral vein. The most common initial symptoms were fever and chills. The species causing the infections were Enterobacter cloacae (three cases), Staphylococcus epidermidis (three cases), Staphylococcus aureus (three cases), Klebsiella pneumoniae (two cases), Escherichia coli (two cases), Pseudomonas dentrificans, Pseudomonas aeruginosa, and Candida tropicalis. Antimicrobials administered through the catheter cured the infection in ten of the 11 cases in which they were used.

Periorbital cellulitis and paranasal sinusitis: a reappraisal

The terms periorbital (preseptal) and orbital cellulitis are often used interchangeably, obscuring important differences in their pathogenesis, bacterial etiology, clinical presentation and appropriate therapy. A review of 56 cases of periorbital cellulitis indicated that the patients could be divided into three groups: Group 1, cases secondary to paranasal sinusitis, more correctly termed inflammatory edema because the periorbital swelling is due to venous obstruction (a specific bacterial etiology is rarely documented in these patients because aspiration and culture of the sinuses are usually not performed and the infection is not associated with bacterial invasion of either the soft tissue or the blood stream); Group 2, cases associated with disruption of local skin integrity which are usually due to Staphylococcus aureus or Group A streptococci; and Group 3, cases associated with bacteremia usually occurring in infants and young children without other apparent foci of infection and caused by Haemophilus influenzae type b or Streptococcus pneumoniae. Actual infection of the orbital contents (orbital cellulitis or abscess), marked by proptosis and ophthalmoplegia, is rare and is due either to advanced purulent sinusitis or to penetrating orbital trauma.

Bacteriology of the maxillary sinus of rhesus monkeys

Quantitative cultures of transantral aspirates of the maxillary sinuses of rhesus monkeys were performed to determine whether the sinuses have a normal bacterial flora. Of 13 sinus aspirate cultures 11 (85%) were sterile. The two positive sinus aspirate cultures had extremely low colony counts of the same bacteria present on the nasal mucosa prior to the sinus puncture. The maxillary sinuses of rhesus monkeys are sterile.

Acute maxillary sinusitis in children

We sought to correlate the clinical, radiographic, and bacteriologic findings in maxillary sinusitis in 30 children who had both upper-respiratory-tract symptoms and abnormal maxillary radiographs. Cough, nasal discharge, and fetid breath were the most common signs, but fever was present inconsistently. Facial pain or swelling and headache were prominent symptoms in older children. Bacterial colony counts of greater than or equal to 10(4) colony-forming units per milliliter were found in 34 of 47 sinus aspirates obtained from 23 children. The most common species recovered were Streptococcus pneumoniae, Haemophilus influenzae, and Branhamella catarrhalis. No anaerobic bacteria were isolated. Viruses were isolated from only two sinus aspirates. There was a poor correlation between the predominant species of bacteria recovered from either the nasopharyngeal or throat culture and the bacteria isolated from the sinus aspirate. This study demonstrates that children with both upper-respiratory-tract symptoms and abnormal sinus radiographs are likely to harbor bacteria in their sinuses, suggesting that such children have bacterial sinusitis.

Fever in Haemophilus influenzae type B meningitis

Ninety-nine cases of Haemophilus influenzae type B (HIB) meningitis were analyzed to assess the causes of secondary and persistent fever and outcome of treatment. Secondary fever developed in 47 patients, 11 had persistent fever and 4 patients died. Secondary fevers were associated with intercurrent illness in 30 per cent, drug fever in 15 per cent, and neurologic complications in 13 per cent. Serious neurologic or other complications were no more common in patients with than in those without secondary fever. However, patients with persistent fever demonstrated a higher rate of neurologic complications. Neither persistent nor secondary fever are markers of bacteriologic relapse or inadequate therapy.

Pitfalls on the diagnosis of acute osteomyelitis by bone scan

Two patients with acute osteomyelitis had technetium 99m methylene diphosphonate bone images that were misinterpreted. A review of six prospective evaluations of technetium scanning in the diagnosis of acute osteomyelitis shows that bone image interpretation may be misleading in five to seven per cent of pediatric patients. Definitive diagnostic procedures and management should not be delayed until a positive bone scan is obtained, if the clinical findings are persuasive.

Efficacy of rifampin in eliminating pharyngeal carriage of Haemophilus influenzae type b

Household contacts less than 6 years of age of children with Haemophilus influenzae type b meningitis are at increased risk of developing systemic H influenzae type b disease. Positive oropharyngeal cultures for H influenzae type b were found in 17/97 patients (18%) and 7/62 staff members (11%) at a chronic area facility at which two patients had developed ampicillin-resistant H influenzae type b meningitis. H influenzae type b colonization was eliminated in 8/9 carriers treated with a single daily oral dose of rifampin, 20 mg/kg/day (maximum 600 mg) for four days; colonization persisted in 9/10 control subjects (Fisher's exact test P < .001; corrected chi 2 P < .005). After treatment of additional H influenzae type b-positive individuals and the remaining control subjects, rifampin was found to have eradicated H influenzae type b in a total of 24/25 carriers (96%). All isolates of H influenzae type b were sensitive to rifampin at either 0.5 or 1.0 microgram/ml. Rifampin is effective in eliminating the H influenzae type b carrier state and may be useful in preventing associated H influenzae type b disease in close contacts of children with H influenzae type be meningitis.

Bacteremia in childhood

Review of the bacteriology records of a University Hospital pediatric service for a 30-month period revealed 42 patients with Hemophilus influenzae type b bacteremia and 30 patients with Streptococcus pneumoniae bacteremia, all under age 10. Eighty-eight percent of the Hemophilus bacteremias and 7% of the pneumococcal bacteremias occurred in children less than 2 years of age. Hemophilus bacteremia was seen mot frequently in the first year of life, in contrast to pneumococcal bacteremia which was seen evenly throughout the first and second years of life. In all but one of the Hemophilus infections, a definite source of the bacteremia was apparent; these included CNS infection (58%), cellulitis (14%), and pneumonia (12%). In contrast, no obvious source was apparent in 37% of the pneumococcal bacteremias. When a focus for pneumococcal bacteremia was identified, otitis media and pneumonia were the most frequent diagnoses. Most of the occult pneumococcemias were transient; the results of repeat blood cultures before a treatment decision were helpful in determining the necessity for and duration of antibiotic therapy in those patients with no obvious source of infection.

Gonorrheal disease among children in a university hospital

In the current veneral disease epidemic the pediatrician may observe every clinical expression of gonococcal infection. Review of outpatient records at the University of Maryland Pediatric Clinic (Baltimore, Md.) showed frequent utilization of this health-care facility by girls with genitourinary complaints and a high rate of recovery of Neisseria gonorrhoeae from those patients from whom specimens were obtained for culture. The adolescent girl is the most likely pediatric patient to have genitourinary complaints that indicate a diagnosis of gonorrhea. Overall, 16.3% of girls and 37.2% of boys who had speciments cultured for N. gonorrhoeae had positive results. Although the older teenager (15--18 years of age) was most likely to have a positive culture, high rates comparable to those reported in venereal disease clinics were found for all age groups. Half of the cases of gonorrhea in girls aged 15 to 18 years took the clinical form of pelvic inflammatory disease. Most gonococcal infections in prepubertal children were in girls 2 to 5 years of age and resulted from presumed sexual abuse. Vulvovaginitis was the initial symptom in all cases. Prepubertal boys infected with N. gonorrhoeae all had urethritis; three of seven admitted to voluntary sexual activity.

Gonococcal conjunctivitis in a four-month-old infant

Classic neonatal gonococcal ophthalmia usually manifests during the first week of life with a purulent ocular discharge accompanied by periorbital edema and erythema. This case report describes a 4-month-old child with chronic but minimal ocular discharge and intermittent mild conjunctival infection who proved to be infected with Neisseria gonorrhoeae. This experience emphasizes the need for the physician to evaluate for gonococcal infection any child with conjunctivitis.

Roentgenographic follow-up of acute pneumonia in children

The need for follow-up roentgenograms documenting complete clearing of pulmonary infiltrates in the pediatric patient with acute pneumonia was studied prospectively. Seventy of 129 children enrolled in the study had a repeat roentgenogram within three to four weeks after initial diagnosis. Twenty percent of this group had residual pulmonary infiltrates. Of the two thirds of those who returned for a second follow-up roetgenogram, the infiltratrates had cleared completely within three months. Routine repeat chest roentgenograms may not be necessary unless there is clinical evidence of persistent respiratory difficulty or failure to thrive.

Haemophilus influenzae type b pneumonia

Thirteen patients with Haemophilus influenzae type b pneumonia are reported to emphasise the clinical, radiographic, and therapeutic aspects of this illness. All but one patient was under 2 1/2 years of age. The presenting complaint was a variable duration of upper respiratory infection and fever in most cases. One-third of patients had radiographic evidence of pleural involvement; one-third showed a patchy bronchopneumonia on roentgenogram; and the remainder had segmental or lobar infiltrates. Clinical response to antibiotic therapy was prompt in patients without pleural involvement.

Gonorrhea: diagnosis by gram stain in the female adolescent

The Gram-stained smear of secretions in female children and adolescents was evaluated as a diagnostic aid in acute gonorrhea. A positive smear was defined as the presence of at least eight or more pairs of Gram-negative, kidney-bean-shaped diplococci in each of at least two polymorphonuclear leukocytes. When the Gram-stained smear was compared with culture results in female patients it detected two thirds of infections and had a very high specificity. When the smear was positive, the culture was positive in 96% of the cases. The Gram-stained smear of cervical secretions is recommended as a guide to the early diagnosis of gonorrhea and its prompt therapy in the pediatric age group.

Group B beta-hemolytic streptococcal colonization. Acquisition, persistence, and effect of umbilical cord treatment with triple dye

Following an outbreak of group B beta-hemolytic streptococcal neonatal infection (GBS), a prevalence survey of GBS colonization was performed on 238 infants. No important differences were noted in the prevalence of colonization when the infants were grouped according to age. Follow-up of 24 colonized babies for three months disclosed that most had persistence of GBS at the rectum and pharynx. Local umbilical cord care with triple dye (TD) or hexachlorophene skin cleanser was compared with untreated controls with respect to rates of GBS colonization. At birth the colonization rates of the three groups were similar. The rate of acquisition of colonization with GBS was 1.0% in the TD group, 6.3% in the hexachlorophene group, and 8.3% in the control group. Triple dye was much more effective than no specific cord care or hexachlorophene in preventing acquisition of GBS colonization.

Cervical adenitis in infancy. Report of four cases due to staphylococci

Four cases of cervical adenitis occurring in infants under four months of age are presented. Coagulase positive staphylococci were recovered in pure culture from the involved lymph node in each instance. Staphylococcal aureus as a cause of lymphadenitis should be suspected in patients who present with acute lymph node swelling and no obvious focus of infection. Antibiotic management of this clinical problem should include therapy specific for the staphylococcus.

Frequency of detection of Hemophilus influenzae type b capsular polysaccharide in infants and children with pneumonia

Countercurrent immunoelectrophoresis was used to detect H. influenzae type b antigen in sera of 65 consecutive infants and children with clinical and radiographic evidence of pneumonia. Antigenemia was observed in only one patient who also had H. influenzae type b bacteremia. Blood cultures from four other children were positive for H. aphrophilus (one), Streptococcus pneumoniae (two), and an alpha-hemolytic Streptococcus (one). The frequency of pharyngeal colonization with H. influenzae type b was similar in children with or without pneumonia. If H. influenzae type b was the cause of pneumonitis in the children studied, it occurred without bacteremia or antigenemia.

BL-P1654, ticarcillin, and carbenicillin: in vitro comparison alone and in combination with gentamicin against Pseudomonas aeruginosa

Minimum inhibitory concentrations of carbenicillin, ticarcillin, and BL-P1654 were determined for 89 clinical isolates of Pseudomonas aeruginosa. Ticarcillin was generally twice as active and BL-P1654 eight to 16 times as active as carbenicillin. Usually carbenicillin and ticarcillin killed at the same concentration or twice the concentration needed to inhibit, whereas 400 mug of BL-P1654 per ml was not bactericidal for the majority of isolates tested. The inhibitory effect of all three drugs varied markedly with the size of bacterial inoculum. When therapeutically achievable concentrations were used, adding gentamicin enhanced the inhibitory and bactericidal activity of all three penicillin derivatives for the majority of isolates. However, inhibition of isolates highly resistant to gentamicin was not improved by combining the semisynthetic penicillins with gentamicin.