The need for intubation in serious upper respiratory tract infection in pediatric patients (a retrospective study)

Serious bacterial infections occurred in ten children (1.4%) of 710 patients with croup admitted to the Soroka Medical Center during the years 1983-1989. Sixty-four patients (9% of all croup patients) were admitted to the pediatric intensive care unit (PICU), and 13 of them (20%) required intubation. Bacterial infections were noted in nine of the 13 intubated patients, in none of the other 51 PICU patients who did not require intubation and in one of the 646 patients (0.2%) who were not admitted to the PICU (p less than 0.0001). There was no difference in age, ethnic origin, or body temperature on arrival between the two PICU groups. Causative microorganisms were isolated from blood samples (three cases) and tracheal pus (eight cases). All intubated PICU patients were seriously ill: eight had bacterial tracheitis and one supraglottitis. Patients with bacterial tracheitis required frequent suctioning of the trachea for copious purulent secretions. The single patient with bacterial infection who was not admitted to the PICU had transient bacteremia. We conclude that the need for intubation in croup patients was an indicator for the presence of a serious bacterial infection.

Infections due to gram-positive organisms in children: possible role for teicoplanin

The disruptive effect on, and potentially hazardous exposure to nosocomial infection, together with the relative cost of hospitalization, of children favours the need for ambulatory care. An increasing proportion of infections in children are due to beta-lactam resistant Gram-positive organisms. Teicoplanin is proposed as a suitable candidate for treating paediatric patients with serious Gram-positive infections in hospital or ambulatory care. The experience acquired in children is still limited. However, over 200 paediatric patients have been treated with once or twice daily im or iv teicoplanin in daily doses of 3-10 mg/kg. The main clinical diagnoses were skin and soft tissue infections, skeletal infections and septicaemia. The drug was safe and clinical efficacy was greater than 90%. Comparative studies with defined uniform protocols are now required to assess the potential of this drug.

A program of outpatient parenteral antibiotic therapy for serious pediatric bacterial infections

A program set up in the Soroka University Medical Center, Beer Sheva, Israel, offers outpatient parenteral antibiotic therapy (OPAT) for children with serious bacterial infections. The following criteria must be met before a child is placed in this program: OPAT must be a suitable form of treatment for the infection, an appropriate drug must be available, the parents must be cooperative and well-informed, and 24-hour-a-day telephone communication and transportation between the home and hospital must be available. With use of ceftriaxone administered im, the OPAT program has shown positive results: a cure rate of 98.5% and an estimated savings of 1,334 hospital days for 140 patients over a 17-month period.

The use of prophylactic furazolidone to control a nosocomial epidemic of multiply resistant Salmonella typhimurium in pediatric wards

The nosocomial spread of enteric pathogens is often difficult to control in overcrowded pediatric wards. During 1983 and 1984, despite cohorting of patients and enforced hand washing, more than 200 cases of nosocomial multiply resistant Salmonella typhimurium phage type R-9 were observed on two adjacent pediatric wards. Most cases occurred during the summer months. After 19 new cases were detected early in the summer of 1985, oral administration of furazolidone throughout their entire hospital stay (2.5 mg/kg twice daily) was recommended for all subsequently hospitalized infants. Among the 114 (65%) infants who were appropriately treated, only one additional case (1%) was detected. In contrast 11 (19%) cases occurred among the 59 infants who were inappropriately treated: 5 of 35 (14%) of those who were not treated and 6 of 24 (25%) in whom treatment with furazolidone was delayed greater than 24 hours (P less than 0.001 between the appropriately and inappropriately treated groups). In pediatric wards where infection control measures cannot be optimally applied, prophylactic furazolidone administration may be helpful in preventing the spread of enteric pathogens.

Parenteral fluoroquinolones in children with life-threatening infections

The new fluoroquinolones have not been tested in children despite their wide spectrum of in vitro activity and efficacy, because of an observed damage to cartilage in young animals. However, in some cases they may be life-saving. We present three pediatric patients with life threatening infections in whom the fluoroquinolones were used when other antibiotics failed: A seven-year-old boy with meningitis due to multiresistant Acinetobacter calcoaceticus, a three-year-old boy with Job's syndrome with line sepsis due to Staphylococcus epidermidis and a four month-old boy with agammaglobulinemia with mixed infection due to Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter spp. All three children were cured of their infections.

Risk factors for infantile hypothermia in early neonatal life

Hypothermia in infancy is not uncommon among the low socioeconomic population in various parts of the world. It is prevalent in Israel and is associated with severe morbidity and mortality. We tried to identify neonates at risk among the population of the Negev district of Israel. Ninety-one infant hospitalized with infantile hypothermia (IH) during the years 1974 to 1981 were identified. The neonates belonged to two distinct ethnic groups, Bedouins and Jews, and were compared with 120 healthy controls of similar background. Our data show that premature infants and babies with low birth weight born during the cold season to young (inexperienced) mothers of lower socioeconomic strata and who sustained perinatal morbidity are at risk for IH. It is suggested that parents of infants at risk should be approached while the baby is till in the nursery, be advised about the possibility of hypothermia, and institute the appropriate preventive measures.

Medical management of chronic suppurative otitis media without cholesteatoma in children

To determine whether systemic administration of antibiotics may eliminate or reduce the need for tympanomastoid surgery in chronic suppurative otitis media without cholesteatoma, we undertook a randomized, prospective study comparing three regimens: (1) daily suction and débridement, with intravenous administration of mezlocillin until 3 days after the discharge stopped, (2) daily suction and débridement, with intravenous use of ceftazidime until 3 days after the discharge stopped, and (3) daily suction and débridement without antibiotics. No topical antimicrobial agents were used during the study. Fifty-one patients were included, and 48 children completed the study. The duration of discharge from the ear before treatment was 2 to 123 months (median 20 months). In 26 patients (51%), the disease was bilateral. Aerobic cultures, obtained with the Alden-Senturia middle ear aspirator, yielded Pseudomonas aeruginosa in 98%, enteric gram-negative bacilli in 33%, staphylococci in 25%, and Haemophilus influenzae in 12%. The first 33 patients were randomly assigned to one of the three regimens. In the 21 patients treated with suction and antibiotics (either mezlocillin or ceftazidime), the discharge stopped completely, versus in only 1 (8%) of 12 patients in the suction-only regimen (p less than 0.01). Therefore the following 18 patients were randomly assigned to one of only two groups, which included the two suction-and-antibiotic regimens. In all patients treated initially with antibiotics, discharge stopped after 4 to 18 days (mean 12.0 days), but 25% needed treatment for greater than 14 days. Amoxicillin prophylaxis was administered to 27 (56%) of the patients after completion of therapy. All patients were followed for 6 months. Drainage recurred in 12 (25%) patients during the first 3 months after the study. The recurrence rate was not affected by the antibiotic regimen, the patient's age, the duration of drainage before initiation of antibiotic therapy, or prophylaxis. We conclude that intravenous wide-spectrum antibiotic therapy in conjunction with daily suction and débridement is efficacious for the treatment of chronic suppurative otitis media without cholesteatoma.

Epidemiology of invasive Haemophilus influenzae type b infections in Bedouins and Jews in southern Israel

We report the epidemiology of invasive Haemophilus influenzae type b disease requiring hospital intervention in Southern Israel, an area that contains two ethnic populations, Bedouins and Jews. The study is based on 107 blood or cerebrospinal fluid culture-positive cases during the years 1984 to 1988. The annual incidence rate among children younger than 5 years of age was 51/100,000 (48/100,000 for Jews and 58/100,000 for Bedouins). Thirty-nine percent of patients had meningitis, 32% had pneumonia and 31% had otitis media. Epiglottitis was present in only one case (less than 1%). The median age was 8 months. Twenty-six percent of the cases were 6 months old or younger, 75% were 1 year old or younger and 87% were 18 months old or younger. Ninety-five percent of all meningitis cases occurred during the first 18 months of life. A projected number of 2938 hospitalization days and 9.8 deaths/year for a population in which 100,000 births occur yearly was calculated. The major impact of invasive H. influenzae type b infections and the very young age involved justify initiation of H. influenzae vaccine studies in our region.

Rotavirus diarrhea in Jewish and Bedouin children in the Negev region of Israel: epidemiology, clinical aspects and possible role of malnutrition in severity of illness

We conducted a 1-year prospective study in the Negev region of southern Israel to determine the epidemiologic and clinical patterns of rotavirus diarrhea. A total of 605 patients were studied, 392 Bedouins and 213 Jews, 441 of whom had diarrhea (449 episodes) and 164 did not. Rotavirus was the most common organism detected in children with diarrhea (63 of 444; 14%) but was rarely found in controls (3 of 163; 2%) (P less than 0.001). In 22% (12 of 54) of the rotavirus-positive patients, at least one other organism was also detected. The rate of rotavirus detection decreased as age increased, from 18% in the first year to 8% in the third year of life. Hospitalization with rotavirus diarrhea occurred more frequently in the summer. However, during winter, when diarrhea was less prevalent in the community, the proportion of cases associated with rotavirus was higher. Compared with controls, malnourished children were more likely to be hospitalized. However, rotavirus was detected in similar proportions among well-nourished and malnourished cases with diarrhea. The most prevalent rotavirus serotype was type 1 (in 69%), followed by types 4 and 2 (18 and 13%, respectively). We estimated that during the study period, approximately 2% of all Bedouin infants vs. only 0.2% of Jewish infants were hospitalized with rotavirus disease in their first year of life. Clinical signs and symptoms and stool appearance were not useful in predicting rotavirus detection. Malnutrition seems to be an important indicator of disease severity, which may explain why the toll of rotavirus-associated morbidity and mortality is particularly high among children in developing countries.

Epidemiology and laboratory diagnosis of infection with viral and bacterial pathogens in infants hospitalized for suspected sepsis

A prospective study was conducted to determine the frequency and distribution of bacterial and viral pathogens in infants hospitalized with suspected sepsis and to evaluate the potential of virus detection for improving patient management. A causative organism was detected in 157 (67%) of 233 previously healthy infants less than 3 months of age, who had been hospitalized for suspected sepsis: 19 (8%) had bacterial infections, 135 (58%) had viral infections, and 3 (1%) had mixed viral-bacterial infections. Viral infections occurred in a seasonal pattern: enteroviruses were responsible for most of the hospitalizations during summer and fall (65/110; 63%) and respiratory syncytial and influenza A viruses were responsible for most of the infections during winter (44/81; 55%). In contrast, bacterial infections were not seasonally distributed. Virus was detected in 33% of the 138 infected infants within 24 hours, and in 64% within 3 days. We conclude that viral infections are prevalent among infants hospitalized for suspected sepsis, and most can be detected early enough to influence patient management.

Comparison of amoxicillin and clavulanic acid (augmentin) for the treatment of nonbullous impetigo

We undertook a prospective double-blind controlled study to compare the efficacy of a drug that usually has no antistaphylococcal activity (amoxicillin trihydrate) with the efficacy of the same drug with an addition of a beta-lactamase inhibitor (amoxicillin plus clavulanic acid [Augmentin]) in the treatment of nonbullous impetigo. Fifty-one culture-positive patients, aged 6 months to 9 years, were included, 26 in the amoxicillin group and 25 in the Augmentin group. The study groups were clinically and bacteriologically comparable at the start of the study. Staphylococcus aureus was isolated from all patients and beta-hemolytic streptococcus from 14 (29%). All staphylococci were sensitive to Augmentin but resistant to amoxicillin. Forty-nine patients completed the study. The clinical response was significantly better among the Augmentin recipients (marked improvement in 71% and 95% of patients after 2 and 5 days, respectively; no new lesions during the treatment course) than among the amoxicillin recipients (marked improvement in 44% and 68% of patients after 2 and 5 days, respectively; new lesions appeared in 20% of patients). Recurrence within 3 weeks occurred in 12 (26%) of 49 patients, and no difference was observed between the two groups. We conclude that S aureus is common in nonbullous impetigo, and that at least in some cases it plays an important role in the course of the disease that can be altered by specific therapy.

Association of penicillin-tolerant streptococci with epidemics of streptococcal pharyngitis in closed communities

The association of penicillin-tolerant streptococci with reported epidemics of streptococcal pharyngitis in Israel was studied. The streptococcal strains had been isolated during 11 epidemics of community-acquired pharyngitis and 6 food-borne epidemics of pharyngitis occurring in the last 15 years. Strains were stocked lyophilized. Isolates were defined as tolerant if the MBC/MIC ratio for penicillin was greater than or equal to 32. All 122 group A streptococcal strains isolated during the epidemics of community-acquired infection showed tolerance to penicillin. In contrast, none of the 52 strains from food-borne epidemics (24 group A, 18 group C and 8 group G) was tolerant.

Bacterial meningitis with initial normal cerebrospinal fluid findings

Seven pediatric patients with bacterial meningitis but with initial normal cerebrospinal fluid (CSF) findings are presented. They represent 6.5% of all cases with bacterial meningitis seen at our medical center during a 5-year period. In all cases, the duration of symptoms before the initial lumbar puncture was short (6-24 h). The case-fatality rate was 3/7 (43%) compared with 10/100 (10%) among children with abnormal initial CSF, despite early initiation of antibiotics. Bacterial meningitis with an initial normal CSF finding is not rare and may be associated with poor outcome.

Virus-specific IgA in serum, saliva, and tears of children with measles

Measles-specific IgA antibody titres were determined by radioimmunoassay (RIA) for serial serum, saliva and tear samples obtained from 21 children with measles infection, from onset of rash until up to 14 months later. Serum IgA titres rose rapidly after onset of illness and remained detectable throughout the follow-up period. Virus-specific salivary IgA titres peaked at 4 to 7 days after onset of rash and decreased thereafter. Measles-specific lacrimal fluid IgA antibodies remained elevated for long periods of time; however, secretory component-bearing measles-specific antibodies in tears became for the most part undetectable by 1 month after onset of rash. These data raise anew the question of whether some form of viral latency is associated with the presence of virus-specific IgA antibody, or whether such antibody is simply a reflection of immune memory.

Intraamniotic Haemophilus influenzae infection

Haemophilus influenzae was identified in the amniotic fluid of a patient who had a genetic amniocentesis and later aborted.

Association of clinical presentation, laboratory findings, and virus serotypes with the presence of meningitis in hospitalized infants with enterovirus infection

One hundred eight hospitalized infants with enteroviral infections were studied to determine the association of clinical presentation, laboratory findings, and virus serotypes with the presence of meningitis. Of 108 infants, 55 (51%) had meningitis. Clinical manifestations on admission did not distinguish between infants with and those without meningitis. Echoviruses 30 and 11 and coxsackie virus B were frequently associated with meningitis (34/38; 90%) whereas echoviruses 18, 24, and 25 were not (5/35; 4%). The virus isolation rate was directly proportional to the number of leukocytes in cerebrospinal fluid: 5 of 58 (9%) when up to 9 cells/mm3 were found, 10 of 21 (48%) when 10 to 99/mm3 cells were found, and 25 of 29 (86%) when greater than equal to 100 cells/mm3 were found. Meningitis is often unsuspected in children hospitalized with enterovirus infection. The frequency of meningitis among hospitalized infants is serotype dependent and is most frequently, but not exclusively, found with pleocytosis of the cerebrospinal fluid.

Acute ascites accompanying hepatitis A infection in a child

A seven-year-old child developed ascites when recovering from hepatitis A infection. Accumulation of intraperitoneal fluid was confirmed by ultrasonic study. The clinical course was otherwise uneventful and the ascites disappeared after a few days with no treatment, and did not recur for five years. Ascites may exceptionally accompany hepatitis A infection. Its appearance, however, does not indicate an unfavorable outcome.

Differences in the epidemiology of childhood community-acquired bacterial meningitis between two ethnic populations cohabiting in one geographic area

A comparison of the epidemiology of community-acquired bacterial meningitis between Jewish and Bedouin populations cohabiting one geographical area is reported here. During the years 1981 to 1985, 100 children younger than 13 years old with community-acquired bacterial meningitis were hospitalized. Seventy-one patients were younger than 12 months. The principal bacteria isolated were Haemophilus influenzae 42%; Streptococcus pneumoniae 29% and Neisseria meningitidis 20%. The case fatality rate was 12%. The chance of acquiring meningitis during the first 5 years of life was twice as common among Bedouins than among Jews (328/100,000 vs. 173/100,000, respectively; P less than 0.0001). The most common cause of meningitis during the first year of life was S. pneumoniae among Bedouins and H. influenzae among Jews. Meningitis caused by H. influenzae and S. pneumoniae was usually associated with respiratory morbidity during fall and winter among Jews, but with diarrheal morbidity during summer and fall among Bedouins. Since the most prevalent type of morbidity among Jews results from respiratory infections and among Bedouins from diarrhea, our findings suggest that community-acquired bacterial meningitis is associated with the type of morbidity most prevalent in the community at any given season rather than with a specific type of infection.

Ambulatory care of febrile infants younger than 2 months of age classified as being at low risk for having serious bacterial infections

We prospectively examined whether febrile infants younger than 2 months of age who were defined as being at low risk for having bacterial infection could be observed as outpatients without the usual complete evaluation for sepsis and without antibiotic treatment. A total of 237 previously healthy febrile infants were seen at the Pediatric Emergency Room over 17 1/2 months. One hundred forty-eight infants (63%) fulfilled the criteria for being at low risk: no physical findings consisting of soft tissue or skeletal infections, no purulent otitis media, normal urinalysis, less than 25 white blood cells per high-power field on microsopic stool examination, peripheral leukocyte count 5000 to 15,000/mm3 with less than 1500 band cells/mm3. One infant appeared too ill to be included, and had sepsis and meningitis. None of the 148 infants at low risk had bacterial infections, versus 21 of 88 (24%) of those at high risk (P less than 0.0001); eight of 88 (9%) had bacteremia. Of the 148 infants classified as being at low risk for having bacterial infection, 62 (42%) were discharged to home, and 72 (49%) were initially observed for less than or equal to 24 hours and then discharged. Seventeen infants (11%) were hospitalized: in six, low risk became high risk; six had indications other than fever; and five because the study physicians could not be found. The 137 nontreated infants were closely observed as outpatients. The duration of fever was less than 48 hours in 42%, and less than 96 hours in 91%. All infants were observed for at least 10 days after the last examination. The fever resolved spontaneously in all infants but two, with otitis media, who were treated as outpatients. Our data suggest that management of fever in selected young infants as outpatients is feasible if meticulous follow-up is provided.

Methaemoglobinaemia in young infants with diarrhoea

Seventeen infants under 2 months of age are described who presented with methaemoglobinaemia and acute diarrhoea during a period of 2 years. No infants beyond this age presented with such characteristics. In none of them was one of the known mechanisms of methaemoglobin formation found. All infants recovered with conventional therapy. Methaemoglobin associated with diarrhoea relapsed in three infants before they were 2 months old. Twenty-six similar cases have been reported in the literature. The mechanism of methaemoglobinaemia in these infants is unclear.

Outpatient treatment of serious community-acquired pediatric infections using once daily intramuscular ceftriaxone

Pediatric patients with serious infections are usually hospitalized for parenteral antibiotic treatment. We studied prospectively 74 pediatric patients with community-acquired serious infections and used once daily intramuscular ceftriaxone. Seventeen patients (23%) were initially hospitalized and 57 (77%) patients were treated entirely as outpatients. An initial intramuscular dose of 75 mg/kg was followed by daily doses of 50 mg/kg (maximum, 1.5 g). Infections treated included periorbital/buccal cellulitis, other cellulitis, urinary tract infections, pneumonia, osteomyelitis, mastoiditis, suppurative arthritis and orbital cellulitis. Organisms were recovered from cultures of 37 (50%) patients and 6 (8%) patients were bacteremic. Bacteria included Gram-positive (mostly Staphylococcus aureus) and Gram-negative (mostly enteric bacilli and Haemophilus influenzae organisms). No serious side effects were observed. Of 74 patients 72 (97%) were cured and improvement was usually observed within 24 hours. Two patients did not improve: one with chronic Pseudomonas mastoiditis; and one with lung abscess. Based on previous experience it is estimated that 376 hospitalization days were saved. All 72 successfully treated patients and their parents resumed normal activity within 72 hours of starting therapy. Our data suggest that ceftriaxone can be used for outpatient treatment of some infectious diseases.

Postanginal sepsis following infectious mononucleosis

During a five-year period, three patients were seen with postanginal sepsis occurring within ten days of the onset of infectious mononucleosis. Postanginal sepsis was not diagnosed in other hospitalized patients during this period. These cases demonstrate that postanginal sepsis can be a complication of infectious mononucleosis.

Cellular immunity and T-lymphocyte subsets in young children with acute measles

The changes occurring in the T-cell subsets during acute symptomatic measles were examined in ten malnourished and 18 well nourished hospitalized children younger than 5 years of age (median age 14 months). A significant decrease in total lymphocyte count was observed, which was due mainly to a decrease in helper/inducer T lymphocytes, whereas the suppressor/cytotoxic T-lymphocyte subset remained unchanged. Consequently, helper/suppressor ratio decreased significantly during the acute phase of the disease. A reduced response to mitogens (PHA, Con A, PWM) was also observed. Malnourished infants showed a trend toward a deeper depression in both helper and suppressor T cells during the acute phase than well nourished children, whereas the helper/suppressor ratio remained similar in the two groups.

A combination of four cell types for rapid detection of enteroviruses in clinical specimens

Isolation in cell culture is currently the most sensitive and reliable way to demonstrate enterovirus (EV) in clinical specimens. During July-October 1982 and 1983, we studied the impact of adding two new cell lines, Buffalo green monkey kidney (BGM) and human rhabdomyosarcoma (RD), to the more traditional cell combination used for EV isolation, human embryonic lung (HEL) and primary cynomolgus monkey kidney (CMK) cells; 2,558 specimens were studied: 632 fecal, 677 respiratory, 537 CSF, and 712 blood. An EV was isolated from 417 (16%); of these, 77 (18%) were positive only in BGM or RD; 35% (146/417) of the specimens were positive in BGM, RD, or both, at least one day earlier than in the traditional cells. BGM cells were helpful in isolation of group B coxsackieviruses (CB): 99% of 121 positive specimens were detected in BGM vs 73% in CMK and 23% in HEL; 72% of the CB isolates were detected by day 2 in BGM vs 48% in CMK and 0% in HEL. RD cells were helpful in the isolation of echoviruses: 59% of the 189 positive specimens were detected in RD vs 67% in HEL and 58% in CMK. RD was the only positive cell type in 28/189 (15%) positive specimens; 31% of the echovirus isolates were detected by day 2 in RD, vs 20% in HEL and 19% in CMK. Using the cell types described, we provided the clinician with results in 42% of the EV-positive specimens by day 2 after inoculation and in 61% by day 4.

Nobecutane spray as a temporary dressing of skin graft donor sites

Various methods have been used for managing split-thickness skin graft donor sites. Open and closed techniques have been suggested by various authors with the purpose of achieving smooth and rapid healing of the wound. There is growing evidence to suggest that the site and quality of the healing is improved when the wound is protected from dehydration and further mechanical trauma. A recent method is the spraying of Nobecutane Spray on the donor site. Nobecutane sprayed on a wound forms a plastic film which serves as a dressing material. It contains specially modified acrylic resin in an organic solvent (ethyl acetate) and TMTD (tetramethylthiuram disulphide) which is strongly bactericidal and fungicidal. We employed this method on 50 patients and found it to be effective in achieving rapid and painless healing. The dressing is transparent, permits easy follow-up of healing in the donor site, protects the wound against infection, and does not inconvenience the patient. The treatment is simple, economical, and does not require special skills. The dressing peels off spontaneously after epidermal regeneration of the wound is completed. No complications or allergic reaction were observed with this treatment.

Identification of infants unlikely to have serious bacterial infection although hospitalized for suspected sepsis

During a 2-year period, 233 infants younger than 3 months were prospectively studied to determine whether physical examination, white blood cell and band count, and urinalysis could identify infants unlikely to have serious bacterial infections. Only previously healthy infants (born at term, no perinatal complications, no previous or underlying diseases, no previous antibiotic therapy) were studied. One hundred forty-four (62%) of the 233 infants were considered unlikely to have serious bacterial infections, because they did not have physical findings consistent with ear, soft tissue, or skeletal infection, had between 5000 and 15,000 white blood cells/mm3, had less than 1500 bands/mm3, and urinalysis yielded normal findings. Eighty-nine (38%) infants did not meet one or more of these criteria and were classified as being at high risk for serious bacterial infection. Only one (0.7%) of the 144 infants in the low-risk group had a serious infection, compared with 22 (25%) of the 89 infants in the high risk group (P less than 0.0001). None of the infants in the low-risk group had bacteremia, compared with nine (10%) of the 89 infants in the high-risk group (P less than 0.0005). Neither traditional risk factors, such as age, sex, and temperature, nor other signs, symptoms, or laboratory findings were adequate predictors of serious bacterial infection. We conclude that previously healthy infants younger than 3 months with an acute illness are unlikely to have serious bacterial infection if they have no findings consistent with ear, soft tissue, or skeletal infections and have normal white blood cell and band form counts and normal urine findings.

Respiratory syncytial virus infection of human mononuclear leukocytes in vitro and in vivo

Recurrent infections with respiratory syncytial virus (RSV) have been well documented despite serological evidence of prior exposure of the host and the absence of clear evidence of antigenic variation of the virus. Therefore, human mononuclear leukocytes, as well as purified lymphocytes and monocytes-macrophages, were exposed to RSV in vitro and examined for expression of viral antigens by using indirect immunofluorescence with monoclonal antibodies to RSV. RSV infected both human monocytes-macrophages and lymphocytes in vitro. RSV infection resulted in both a decrease in the number of T helper phenotype cells and an increase in T suppressor phenotype cells. RSV proteins were disproportionately expressed by atypical or lymphoblastoid cells, many of which were of the T suppressor phenotype. Circulating mononuclear leukocytes obtained from symptomatic children infected with RSV frequently expressed viral antigens. Viral antigens appeared to be detected more frequently in cells from the younger subjects. The findings suggest that initial or early RSV infections in children include infection of circulating immunocompetent cells. It remains to be determined whether the described RSV-induced alterations in lymphocyte subpopulations contribute to recovery from and/or recurrence of RSV infections.

Imipenem/cilastatin for the treatment of infections in hospitalized children

Imipenem is the first of a new class of beta-lactam antimicrobial agents with potent in vitro activity against most bacterial pathogens that cause infections in children. We studied, prospectively, the clinical efficacy and toxicity of imipenem/cilastatin in 40 children with proved or suspected bacterial infection. A dose of 100 mg/kg/day of imipenem was given to children younger than 3 years of age, while children older than 3 years of age received 60 mg/kg/day. Twenty-nine organisms were isolated from 26 patients. Infections treated included cellulitis, osteomyelitis, septic arthritis, lymphadenitis, renal infections, wound infections, and pneumonia. Bacteria isolated included Staphylococcus aureus, Streptococcus pyogenes, Haemophilus influenzae, and Pseudomonas aeruginosa. All patients responded favorably to treatment, with defervescence and improvement of symptoms. All of the infecting bacteria were susceptible to imipenem. Imipenem/cilastatin was well tolerated, with no serious side effects, and appeared to be an effective and safe antimicrobial agent in the treatment of the population studied.

Atypical bacterial infections explained by a concomitant virus infection

Because both viral and bacterial infections are common during early childhood, dual infections are not unexpected. However, the clinical manifestation of such combined infections may be, difficult to interpret, and they are often misdiagnosed as "atypical bacterial infection." Five patients with concomitant viral-bacterial infections are described. In all five cases, virus detection enabled the physicians to better understand an otherwise puzzling clinical presentation. In view of the recent progress in rapid viral diagnoses and the potential of antiviral drugs, the possibility of dual infection should be investigated more often.

Viremia in hospitalized children with enterovirus infections

In a prospective study during the summer and fall of 1982, enterovirus was isolated from 48 hospitalized children; in 29 (60%) enterovirus was isolated from CSF or blood, and in 19 (40%) only a presumptive diagnosis was established. Blood was positive in 21 (44%) and was the only positive specimen in two children. A presumptive diagnosis was provided within 4 days of admission in 38 (80%) and within 48 hours in 19 (40%) of the children from whom enterovirus was isolated. Viremia was most often detected in febrile infants younger than 3 months of age with a clinical picture simulating bacterial sepsis. The presence of viremia was inversely related to the presence of CSF pleocytosis and to virus isolation from CSF. The diagnosis of diseases caused by enterovirus is more accurate when blood culture is added to CSF stool and throat cultures.

Pneumococcal osteomyelitis. An unusual cluster of cases

Between 1979 and 1981, 22 children with osteomyelitis and/or septic arthritis were hospitalized at Soroka University Hospital. Streptococcus pneumoniae was cultured in five of the children, four of whom were under 2 years of age. In four other children under 2 years of age, Haemophilus influenzae was cultured. Staphylococcus aureus was identified less frequently in the younger age group. In deciding on initial antibiotic therapy, the possibility of such a bacteriological spectrum should be considered.

Infant feeding practices among Bedouins in transition from seminomadic to settlement conditions in the Negev area of Israel

Infant feeding practices among 353 Bedouin families in transition from seminomadic to settlement conditions in the Negev area of Israel were compared with those of 302 Jewish families from the same area. Over 99% of the Bedouin infants were initially breast-fed, in contrast to 79% of the Jewish infants; none of the Jewish infants continued to be breast-fed by the end of the first year of life, while 63% of the Bedouins were. Rice was the first solid food to be introduced to Bedouin infants, while fruits and vegetables were the first solids introduced to the Jewish infants. Rice was not an important constituent of the Jewish infants' diet. By the age of 6 months, 93% of the Jewish infants were eating fruits and vegetables, 78% meat, 49% bread and 55% eggs, in contrast to 20, 13, 8 and 18% among the Bedouins, respectively. Introduction of meat lagged significantly among the Bedouin infants, taking place after the 8th month of life for greater than 50%. Bedouin infant-feeding practices resembled those prevalent among rural populations in developing countries. It is likely that with increasing modernization this pattern will gradually disappear and will be replaced by that prevalent among Western populations.

Infections in hypothermic infants younger than 3 months old

Hypothermia in infants is associated with considerable morbidity and mortality. Infection is thought to occur frequently and to carry a poor prognosis in infants with hypothermia. The medical records of 51 infants less than 3 months of age hospitalized from 1976 through 1981 with rectal temperatures of 34 degrees C or less were reviewed. Infections were diagnosed in 27 of the 51 infants. Infections were associated significantly with the presence of bradycardia, anemia, abnormal leukocyte counts, abnormal serum glucose levels, and uremia, especially if two or more of these variables were present. Morbidity and mortality were higher among infected than among noninfected infants. No rapid reliable indicators for the presence or absence of infection in an individual infant with hypothermia were found despite the differences noted between the two groups. Until new techniques for the detection of bacterial infections became available, we suggest that antibiotics be given to all infants younger than 3 months of age with hypothermia on admission to the hospital.

Influenza A virus infection imitating bacterial sepsis in early infancy

Clinical and laboratory data of 12 previously healthy infants under 3 months of age hospitalized for suspected sepsis and subsequently diagnosed as suffering from influenza A viral infection were obtained prospectively during two epidemics of influenza A/Bangkok/H3N2 epidemics. The onset of the illness was generally acute, and the infants presented with high fever, lethargy often alternating with irritability, anorexia and signs of upper respiratory tract infection. History of contact with at least one person with signs and symptoms consistent with viral disease was present in all infants. White blood cell counts were within normal limits. Only one child had pneumonia and all had normal cerebrospinal fluid findings. Viral diagnosis was made by immunofluorescent testing of nasopharyngeal specimens within several hours of admission in 7 of the 9 infants tested and was isolated within 5 days from admission in 6 of 10 infants. Increasing awareness of the possible viral etiology of acute fever along with a greater availability of rapid viral diagnosis should result in better management of these young infants.

Necrotizing enterocolitis beyond the neonatal period

Necrotizing enterocolitis (NEC) is usually considered to be a neonatal disease, and is rarely described beyond the newborn period. During the last 15 years, 19 infants from the Negev region, Israel, with NEC were beyond the neonatal age group (range = 34-616 days, median = 90 days). Of this group only 16% were born prematurely, and only 16% had perinatal or neonatal pathology. Diarrhea and dehydration preceding NEC were common as was malnutrition. Bacteremia was detected in 42%. The mortality rate was 90%. Malnutrition, supposedly contributed to the formation of NEC and to the high mortality rate among these infants.

The isolation of enteroviruses from blood: a comparison of four processing methods

Blood from 28 children hospitalized with symptomatic enterovirus infections was processed by four different methods in an effort to define optimum conditions for detecting viremia. Enteroviremia was demonstrated in 11/28 children. Virus was isolated by method 1 (serum) in 7/11 children and by method 2 (mononuclear leukocytes) in 9/11, but in only 3/10 and 3/11 children by methods 3 and 4 (granulocytes and plasma-mixed leukocytes, respectively). In four children, the only blood isolate was from mononuclear leukocytes, and in two, serum was the only positive blood preparation. This suggests that viremia can be often detected in hospitalized children with enterovirus disease and shows that the methods used for processing blood may significantly influence the isolation rate.