Septicemia in a pediatric unit. A 20-year study

Pseudomonas septicaemia in apparently healthy children

Among 27 cases of Pseudomonas septicaemia in the Department of Paediatrics of Queen Mary Hospital from 1981 to 1988, we have identified 10 children without known predisposing causes before presentation and report their clinical features. Six were infants, of whom 4 developed shock on admission and died. Ecthyma gangrenosum was present in 4 patients. Pseudomonas aeruginosa was isolated in 8 patients. All isolates, except Ps. cepacia, were sensitive to gentamicin. One patient had cyclical neutropenia. Another had an appendicular abscess. Salmonella was cultured from the stool in one patient. Although Pseudomonas septicaemia is normally considered to be associated with underlying immunodeficiency, in 22% it occurred in previously healthy children. Mortality is high especially in infants who develop septicaemic shock. It is advisable to cover for Pseudomonas septicaemia with aminoglycosides or ceftazidime in sick septic infants.

Septicemia and endocarditis, 1965-1980, in a Swedish university hospital for infectious diseases

A 16-year (1965-1980) retrospective clinical study of septicemia and endocarditis was performed at a hospital for infectious diseases. 634 patients (74.5%) had septicemia, 138 (16.2%) endocarditis and 79 (9.3%) suspected endocarditis. The mean age was 55 years, 472 were males and 379 females. Predisposing underlying conditions were recognized in 89.2%. Gram-positive cocci (62.3%) dominated over gram-negative rods (29.5%). The most common causative organisms of septicemia were Staphylococcus aureus (22.4%) and Escherichia coli (20.2%), and of endocarditis, S. aureus (47.1%) and alpha haemolytic streptococci (21.0%). The overall fatality rate was 17.7% and was highest in infections caused by gram-negative rods and S. aureus. In septicemia the rate was 15.3% and in endocarditis 37.0%. Unfavourable prognostic factors were high age, endocarditis and underlying conditions such as haematological diseases and various other factors.

Febrile infants: predictors of bacteremia

One hundred and seventy-five infants less than 8 weeks of age, presenting to the pediatric emergency room of the Bronx Municipal Hospital Center with rectal temperature greater than or equal to 38 degrees C (100.4 degrees F), were studied. House officers recorded their impressions of the infants on a number of variables prior to performing a lumbar puncture and obtaining laboratory data. All infants were admitted for parenteral antibiotic therapy pending culture results. Culture-positive bacterial infections occurred in 6.3% (n = 11); the incidence of bacteremia was 3.4% (n = 6). Of special concern were the 134 infants who had no visible source for their fever during the first examination. A major goal was to determine whether there were any early predictors of bacteremia in this group. The individual variables of white blood cell count greater than or equal to 15,000/mm3, band count greater than or equal to 500/mm3, temperature, impression of irritability, tone, cry, and activity level were not related to the presence of bacteremia. An erythrocyte sedimentation rate greater than or equal to 30 and the examiner's impression of sepsis were significantly associated with bacteremia but did not correctly identify all cases. However, the combination of impression of sepsis, white blood count greater than or equal to 15,000/mm3, and erythrocyte sedimentation rate greater than or equal to 30 identified all infants with bacteremia and excluded 82% of the infants who were eventually shown not to have bacteremia.

A prospective study on septicemia. II. Clinical manifestations and complications, results of antimicrobial treatment and report of a follow-up study

In a prospective study at a hospital for infectious diseases 151 patients, 110 with proved and 41 with probable septicemia, were analysed. Clinical, laboratory, therapeutic data and prognostic experiences, partly from a follow-up study, are described. Secondary manifestations, mostly from skin, mucous membranes, nervous system and lungs, were present in 72%. They were more often caused by gram-positive cocci than by gram-negative baccilli and in some cases not revealed until autopsy. Lesions in the nervous system were most often caused by strepto- or penumococci or Haemophilus influenzae. In 2 splenectomized patients with extensive hemorrhages, pneumococci were isolated. Subacute courses were rare even in alpha-streptococcal infection and its "classical signs" were never observed. Shock and thrombocytopenia suggesting disseminated intravascular coagulation occurred together in 11%, and in one-third in the lethal cases. Gram-positive bacteria were often involved. Leukocytosis was absent in 53 patients; 20 were alcohol or narcotic drug abusers, and 7 died. ECG changes were registered in 33%. Initial antibiotic treatment was applied according to a fixed schedule, with cure in 61% on this first treatment, and especially so in infections with gram-positive cocci. During the initial hospital stay 20% died from uncontrolled infection. All had underlying diseases or factors, often major causes of death. The infection was regarded as hospital-acquired in 40% among the lethal cases. During a one-year follow-up period 3 patients died from a new septicemia and 10 from their underlying disease.

Fever in the first six months of life: risks of underlying serious infection

The age-specific rate of elevated temperature over 37.8 C was evaluated in all infants less than 6 months of age (n = 1341) seen from July 1, 1974 to June 30, 1978 in a family practice clinic. Mild elevations (37.8 C-38.3 C) were common even in the first few months of life, and accounted for 20.7 per cent of infant visits. Temperatures greater than 38.3 C are uncommon in the first months of life but are seen more frequently with each succeeding month. Temperature elevation over 38.3 C was associated with a significantly higher rate of meningitis (p less than .01), otitis media (p less than .001) and lower respiratory infection (p less than .05). Significantly higher laboratory usage was documented in infants less than 3 months and for infants with temperature more than 38.3 C. The high rate of mild temperature elevations in young infants suggests that a selective diagnostic strategy directed at high-risk infants is important. Infants less than three months of age with a fever exceeding 38.3 C are calculated to have 21.5 times the risk of a serious underlying infection as infants older than three months with a similar temperature elevation. Clinical evaluation must remain an important tool in determining which febrile infants should be evaluated by further laboratory and diagnostic tests.

Septicemia I. A prospective study on etiology, underlying factors and sources of infection

In a prospective study, 110 cases of proved and 41 of probable septicemia were analysed. Underlying diseases or factors were common, also in young patients, often narcotic drug or alcohol abusers. In one third, septicemia was probably hospital-acquired. Streptococci, staphylococci and gram-negative enteric rods were most common, followed by pneumococci and haemophilus species. Staphylococci and gram-negative enteric rods dominated in patients hospitalized at or before the onset of disease, and staphylococci in patients with vascular foreign bodies and in drug addicts. Enteric rods were common in elderly patients with urogenital disease, especially after instrumentation. Among streptococci, alpha-streptococci dominated; they did not emanate as often from dental foci as expected. In 2 of 3 asplenic patients with extensive hemorrhages pneumococci were found. Bacteria of low virulence and fungi occurring as opportunists were rare. Mixed infections, present in 4 cases, were severe. Portals of entry could often be proved or assumed. In half of all patients, the same organism was isolated from a primary focus as from blood. The importance of underlying illnesses and factors and of invasive procedures was evident. A tentative etiological diagnosis could often be made, based on case history, underlying factors and the probable portal of entry.