Do normal leucocyte count and C-reactive protein on admission to hospital exclude a life-threatening attack of acute pancreatitis?

BACKGROUND AND AIMS

The early severity assessment of an attack of acute pancreatitis is clinically of utmost importance. The aim of the present work was to study the role of leucocyte count and C-reactive protein (CRP) measurements on admission to hospital in assessing the severity of an attack of acute pancreatitis. In particular, patients with a life-threatening attack of acute pancreatitis but a normal leucocyte count and CRP level were sought.

MATERIAL AND METHODS

A total of 1050 attacks of acute pancreatitis were treated at Turku University Central Hospital during the years 1995-1999. Leucocyte count and C-reactive protein (CRP) value were determined on admission to hospital. There were 58 life-threatening attacks of acute pancreatitis (group A). Fifty-eight consecutive mild attacks served as controls (group B). The number of patients with both values normal, only leucocyte count raised, only CRP level raised and both values raised were calculated in the groups A and B.

RESULTS

Both leucocyte count and CRP level were significantly (P < 0.001 in both comparisons) higher on admission to hospital in patients with a life-threatening disease (group A) than in those with a mild disease (group B). Group A contained no patients with both values in the normal range. In group B, one fifth of the patients had both values normal.

CONCLUSION

It is very unlikely that acute pancreatitis proves to be a life-threatening one when both the leucocyte count and CRP are normal on admission to hospital. In the present 1050 acute pancreatitis there were no patients with life-threatening disease but normal laboratory values on admission.

Frequency and clinical outcome of potentially harmful drug metabolic interactions in patients hospitalized on internal and pulmonary medicine wards: focus on warfarin and cisapride

Drug metabolic interactions present potential risks in patient care, but their frequency and relative importance as a clinical problem remains unclear. To assess the frequency and clinical outcome of potentially harmful drug metabolic interactions in hospitalized patients, the authors performed a survey of the medication data of patients treated on internal and pulmonary medicine wards in a university hospital. The database was searched for concomitantly administered drug pairs that would, according to Hansten and Horn's drug interaction database, carry a high risk for a clinically harmful metabolic drug interaction. Coadministrations involving warfarin or cisapride were subjected to further analysis regarding clinical outcome. A total of 142 patients were exposed to 150 interactions with potentially harmful clinical outcome, resulting in a frequency of 0.9% (95% CI 0.7% to 1.0%). Inhibition of warfarin metabolism by metronidazole produced significant overanticoagulation as evidenced by elevated international normalized ratio values, whereas inducers (rifampicin and phenobarbital) of warfarin metabolism significantly reduced the efficacy of warfarin. One case of minor bleeding and one case of clavicular vein thrombosis were detected as possible consequences of disturbed anticoagulation. The coadministration of cisapride and erythromycin significantly prolonged the corrected QT (QTc) interval and was associated with clinical symptoms of cardiac arrhythmias. Coadministration of cisapride with fluconazole or miconazole was not associated with prolongation of the QTc interval or cardiac sequelae. Evaluations of patient materials are needed to assess the clinical relevance of metabolic drug interactions.

Reminders of drug effects on laboratory test results

Drug effects on laboratory test results are difficult to take into account without an online decision support system. In this study, drug effects on hormone test results were coded using a drug-laboratory effect (DLE) code. The criteria that trigger the reminders were defined. To issue reminders, it was necessary to write a computer program linking the DLE knowledge base with databases containing individual patient medication and laboratory test results. During the first 10 months, 11% of the results from hormone samples were accompanied by one or more DLE reminders. The most common drugs to trigger reminders were glucocorticoids, furosemide, and metoclopramide. Physicians facing the reminders completed a questionnaire on the usefulness of the reminders. All respondents considered them useful. In addition, DLE reminders had caused 74% of respondents to refrain from additional, usually performed examinations. In conclusion, drug effects on laboratory tests should always be considered when interpreting laboratory results. An online reminder system is useful in displaying potential drug effects alongside test results.

A fertile-aged woman with right lower abdominal pain but unelevated leukocyte count and C-reactive protein. Acute appendicitis is very unlikely

BACKGROUND AND AIMS

An uninflamed appendix at appendectomy represents a misdiagnosis. In fertile-aged women, the diagnostic accuracy in acute appendicitis is usually lower than 60%. We studied the role of preoperative leukocyte count and C-reactive protein (CRP) measurements in the diagnosis of acute appendicitis in fertile-aged women with a clinical suspicion of acute appendicitis. In particular, what is the clinical value of unelevated leukocyte count and CRP in excluding acute appendicitis in these patients?

METHODS

We calculated the mean leukocyte count and CRP values in (1) 100 consecutive fertile-aged women operated on for a clinical suspicion of acute appendicitis but with an uninflamed appendix found at appendectomy, and (2) 100 consecutive fertile-aged women operated on for a clinical suspicion of acute appendicitis and acute appendicitis found at appendectomy. The percentages of patients with (1) both values unelevated, (2) only leukocyte count elevated, (3) only CRP value elevated, or (4) both values elevated were calculated within the groups A (uninflamed appendix) and B (acute appendicitis).

RESULTS

The mean leukocyte value was significantly (P<0.001) higher in patients with acute appendicitis (13.7x10(9)/l) than in those with an uninflamed appendix (10.6x10(9)/l). Similarly, the mean CRP value was significantly (P<0.05) higher in patients with acute appendicitis (42 mg/l) than in those with an uninflamed appendix(29 mg/l). Taken together, 24 patients were operated on for a clinical suspicion of acute appendicitis, although preoperative leukocyte count and CRP values were unelevated. An uninflamed appendix was found in all these patients at appendectomy.

CONCLUSION

Although clinical symptoms and signs indicated acute appendicitis, unelevated leukocyte count and CRP values excluded it, with a 100% predictive value in the current study of fertile-aged women. In our patients, 24% (24 of 100) of unnecessary appendectomies could have been avoided by trusting in this finding.

Leucocyte count and C-reactive protein in the diagnosis of acute appendicitis

BACKGROUND

The aim of the present work was to study the preoperative leucocyte counts and C-reactive protein (CRP) values in three groups of patients operated on for a clinical suspicion of acute appendicitis with different findings at appendicectomy: an uninflamed appendix, uncomplicated acute appendicitis or complicated acute appendicitis. In particular, patients with acute appendicitis but a normal leucocyte count and CRP level were sought.

METHODS

In this retrospective study, the mean preoperative leucocyte count and CRP value in 100 consecutive patients with an uninflamed appendix (group A), in 100 consecutive patients with uncomplicated acute appendicitis (group B) and in 100 consecutive patients with complicated acute appendicitis (group C) were calculated. The numbers of patients with (1) both values normal, (2) only leucocyte count raised, (3) only CRP level raised and (4) both values raised were calculated in each of the three groups.

RESULTS

The increase in leucocyte count was an early marker of appendiceal inflammation, whereas the CRP value increased markedly only after appendiceal perforation or abscess formation. Group A (uninflamed appendix) contained 24 patients in whom both values were normal. Neither group B (uncomplicated acute appendicitis) nor group C (complicated acute appendicitis) contained any patient with both values in the normal range.

CONCLUSION

Acute appendicitis is very unlikely when both the leucocyte count and CRP value are normal.

Spectral analysis of heart rate variability as a quantitative measure of parasympatholytic effect--integrated pharmacokinetics and pharmacodynamics of three anticholinergic drugs

The time course and concentration-effect relationship of parasympatholytic effects of three anticholinergic drugs were investigated using spectral analysis of heart rate (HR) variability. Single intravenous (i.v.) doses of atropine (10 microg/kg), glycopyrrolate (5 microg/kg), scopolamine (5 microg/kg), and placebo were given to eight healthy volunteers in a double-blind, randomized cross-over study. Electrocardiogram (ECG) was recorded at baseline and 2.5, 5, 10, 20, and 30 minutes, and 1, 1.5, 2, 3, 4, 5, and 6 hours after drug administration, while the subjects breathed at a fixed 0.25 Hz frequency. The powers of two frequency bands (low frequency [LF] = 0.07-0.15 Hz and high frequency [HF] = 0.15-0.40 Hz) were calculated using stationary time series of R-R intervals (RRI) free from ectopic beats. To perform pharmacokinetic-pharmacodynamic (PK-PD) modeling, venous plasma drug concentrations were measured. Atropine and glycopyrrolate, and, to a lesser extent, scopolamine induced decreases in HF power and increases in LF/HF ratio of HR variability, indicating parasympatholytic activity and corresponding changes in sympathovagal balance. Maximal average decreases in HF power were 99%, 94%, and 82%, respectively, but in two scopolamine subjects, a parasympathomimetic effect was dominant. Interindividual variability was least for the Hayano index of HF power (square root (RRI HF-power)/RRI*100), and profound and consistent decreases were seen after atropine and glycopyrrolate. Pharmacokinetics were best fitted to a two-compartment open model, and effect compartment link modeling using the Hayano index was performed with the atropine and glycopyrrolate data. The best description of the PK-PD relationship for both drugs was achieved using the sigmoidal Emax model. Mean (+/-SD) EC50, sigmoidicity factor (gamma), and equilibration rate constant (k(e0)) estimates were 1.35 (+/-0.27) ng/mL, 6.07 (+/-1.98) and 11.0 (+/-5.28) l/h for atropine and 1.35 (+/-0.49) ng/mL, 4.34 (+/-1.55) and 2.26 (+/-0.81) l/h for glycopyrrolate. Spectral analysis of HR variability appears to be a powerful tool in monitoring parasympatholytic drug activity. A sigmoidal Emax model with an extremely steep concentration-response relationship was revealed for atropine and glycopyrrolate. The effects of scopolamine were more incongruous.

Linking patient medication data with laboratory information system

Dozens of new drugs are taken into clinical use each year. Even if the clinicians were able to learn the most important therapeutic effects of the drugs they prescribe, they would still be unable to remember all of their minor effects. After storing patient related medication data on computerized patient records it is possible to build decision support modules which automatically remind of possible drug influences on laboratory tests and cause alarms or alerts of drug interactions. Medication profiles coded using the Anatomical Therapeutic Chemical-code (ATC-code) constitutes a valuable part of an Electronic Patient Record (EPR). In this paper, we describe the benefits of our system. By building links to commercially available drug and laboratory databases we can automatically inform clinicians on clinically relevant drug influences on laboratory test results.

Development of beta-lactamase-mediated resistance to penicillin in middle-ear isolates of Moraxella catarrhalis in Finnish children, 1978-1993

The frequency of beta-lactamase production was analyzed in a study of 1,452 strains of Moraxella catarrhalis and 2,738 strains of Haemophilus influenzae isolated from middle-ear fluid of children < 6 years of age at Tampere University Hospital in Tampere, Finland, between 1978 and 1993. In addition, 401 isolates of M. catarrhalis from similar samples collected in different parts of Finland in 1988-1990 were tested for beta-lactamase production; minimal inhibitory concentrations of ampicillin, cefaclor, cephalothin, erythromycin, tetracycline, and trimethoprim-sulfamethoxazole for these strains were determined. These data were compared with figures for the annual consumption of beta-lactam antimicrobials in the community in 1978-1993. A bimodal increase in the proportion of strains of M. catarrhalis producing beta-lactamase was detected: from 0 to 60% in 1978-1983 and from 60% to 80% in 1988-1990. Concurrently with the second increase, the consumption of cephalosporins increased substantially in the community. The frequency of beta-lactamase-producing strains of H. influenzae did not increase between 1978 and 1993.

Using computerized individual medication data to detect drug effects on clinical laboratory tests

In clinical practice, thousands of drugs are used daily. Clinicians know the therapeutic effects of drugs but other minor drug effects are often ignored either because of inadequate knowledge of these effects or simply because of the limited memory capacity of a human being. This problem can be solved by using a computerized information system, which includes medication data of individual patients as well as information about non-therapeutic drug-effects. One of these non-therapeutic confusing drug effects is the influence of drugs on laboratory tests; a problem that should be taken into account in clinical practice and diagnostics. Other complicating drug effects include drug interactions and patient related adverse drug reactions. In a computerized information system, it is possible to build decision support modules that automatically give alarms or alerts of important drug effects other than therapeutic effects. If these warnings concern laboratory tests they are checked by a laboratory physician and only those with clinical significance are sent to clinicians. Warnings of drug interactions and adverse drug reactions are immediately evaluated by the physician responsible for the treatment. By means of the computerized information system, it is also possible to get better information of current medication practice which in turn gives better chances to agree on common guidelines and enables better quality assurance.

Coding drug effects on laboratory tests for health care information systems

Drugs interfere with laboratory diagnostics. This interference is not only confusing for clinicians but may lead to wrong diagnoses or treatments as well as unnecessary further tests. However, at the moment the drug-laboratory interferences are usually ignored in patient care because clinicians do not know or remember these properties of drugs. In Turku University Central Hospital we are now able to bring this information automatically available for clinicians by using a computerized system for linking individual patient medication data with laboratory information system. For this purpose, we are building a rule base containing the effects of drugs on laboratory tests. In order that the rule base would give the maximum benefit for all users, even other hospitals, the data included have to be classified and coded properly taking into account the various requirements and needs of all users. In this paper we introduce a coding scheme for classification and coding of drug effects on laboratory tests.

Basic urinalysis and urine culture: Finnish recommendations from the working group on clean midstream specimens

A recommendation for basic urinalysis and urine culture is published as an attempt to improve the clinical value of urinary tests and to create a system that utilizes laboratory work as sensibly as possible. More clinical background information is needed when basic urinalysis and urine culture is performed in stages. Collection and storage of urine specimens are standardized in addition to used equipment and bacterial culture. Cytological supravital stain improves qualitative and quantitative findings of urine sediment cytology. A close cooperation between central hospital district is necessary and stressed for further bacterial cultures in more complicated microbiological findings.

Class specific antibody response to gonococcal infection

An enzyme immunoassay was used to determine IgM, IgG, and IgA antibodies to gonococcal pili in 68 patients with uncomplicated gonorrhoea, 35 women with pelvic inflammatory disease, and in 115 normal controls. A clear difference in response rate in all three antibody classes between patients with gonorrhoea and healthy controls was evident. Among women with gonorrhoea, the magnitude of antibody response was higher than among men with gonorrhoea, especially in the IgM class. No major differences were found in the overall distribution of serological findings between women with uncomplicated gonorrhoea and those with gonococcal pelvic inflammatory disease. Among this last group, however, high IgM antibody levels in acute phase sera were significantly associated with the isolation of Neisseria gonorrhoeae in the upper genital tract.

Microbiological and histopathological findings in acute pelvic inflammatory disease

Upper genital tract infection was investigated in 45 women admitted to hospital for suspected acute pelvic inflammatory disease (PID). Salpingitis was diagnosed by laparoscopy in 30 (67%) women. Histopathological evidence of endometritis was found significantly more often in the 30 women with salpingitis (87%) than in the other 15 women without salpingitis (33%). C. trachomatis or N. gonorrhoeae, or both, were isolated from the upper genital tract in 14 of the 31 women who had both salpingitis and endometritis or endometritis only but in none of the four women who had salpingitis alone and in none of the 10 women who had no evidence of PID. Bacterial vaginosis was associated with histopathological evidence of upper tract infection. Non-chlamydial non-gonococcal organisms were frequently isolated from the upper genital tract. No organisms were isolated from the upper genital tract from 9 of 35 women with laparoscopic or histopathological evidence of PID compared with 7 of 10 women without evidence of PID. C. trachomatis or N. gonorrhoeae in the endometrium was associated with lymphoid follicles comprising transformed lymphocytes, and correlated with the density of plasma cells on biopsy. The microbiological results support the recommendations of broad spectrum antimicrobial therapy for PID.

Prevalence of nonspecific vaginitis and other cervicovaginal infections during the third trimester of pregnancy

Nonspecific vaginitis (NSV) is a clinical syndrome characterized by a decreased concentration of normal acidophilic Döderlein flora in the vagina and increased concentration of nonacidophilic microorganisms, such as Gardnerella vaginalis, anaerobic bacteria, and mycoplasmas. Since several NSV-associated organisms are associated with complications of pregnancy, we studied the prevalence of NSV among 104 consecutive women during the third trimester of pregnancy. Overall, 14 women (14%) had NSV by clinical and/or biochemical criteria, two women had Chlamydia trachomatis isolated from the cervix, and 24 women (23%) had yeast isolated from the vagina. None had Neisseria gonorrhoeae or Trichomonas vaginalis isolated. There was a correlation between an abnormal succinate to lactate ratio (on gas-liquid chromatography) and cytologic atypia detected by cervicovaginal Papanicolaou smears. More extensive studies are needed to correlate NSV with prematurity.

Serum C-reactive protein determination in acute pelvic inflammatory disease

We have studied the role of serum C-reactive protein determination in the diagnosis of acute pelvic inflammatory disease. Acute-phase serum C-reactive protein concentration reflected the extent and the severity of pelvic inflammatory disease more closely than erythrocyte sedimentation rate or white blood cell count determinations. We recommend that both C-reactive protein concentration and erythrocyte sedimentation rate should be routinely used to augment the clinical diagnosis of pelvic inflammatory disease.

Trimethoprim resistance of Escherichia coli in outpatients in Finland after ten years' use of plain trimethoprim

Development of trimethoprim resistance among Escherichia coli collected from urine samples in three areas in Finland was studied in 1978-1984. Three different trends of development of resistance were found: in the Turku area resistance has increased evenly during 1978-1982 from 5.4% to 10.1%, but thereafter a plateau seems to have been reached; in the Helsinki area resistance increased rapidly from 2.9% in 1980 to 11.1% in 1984, possibly due to the spread of a trimethoprim resistance transposon Tn7, which occurred significantly more often among E. coli strains in this area than in the Turku area; in the Rovaniemi area resistance has been at a plateau level, between 3.1 and 5.7%, during the whole study. No clear correlation between the consumption of trimethoprim and the level of resistance was found. The frequency of trimethoprim resistance in E. coli isolated from patients less than 65 years was 5.2% and in those isolated from patients greater than or equal to 65 years 14.7%.

Chlamydial endometritis

Endometrial biopsies were obtained from 32 women with suspected pelvic inflammatory disease, of whom 23 (72%) had histopathological evidence of endometritis. Chlamydia trachomatis was isolated from the endometria of nine (39%) women (chlamydia group) but not from the other 14 (non-chlamydia group). Severe plasma cell endometritis and lymphoid follicles with transformed lymphocytes were significantly more common in the chlamydia group than in the non-chlamydia group. This suggests that C trachomatis is an invasive endometrial pathogen which often causes severe inflammation. The association was independent of predisposing factors such as use of intrauterine contraceptive devices.

Detection of herpes simplex virus in women with acute pelvic inflammatory disease

Four women are described with acute salpingitis confirmed by laparoscopy who had herpes simplex virus (HSV) isolated from the cervix or the upper genital tract (endometrium, fallopian tube, or cul-de-sac) or both. None of the patients had overt genital herpes, but one had typical HSV cervitis on a cervicovaginal smear stained with Papanicolaou's stain, one had a significant change in level of antibodies to HSV, and one had an endometrial biopsy specimen positive for HSV antigen. There are at least three potential explanations for these findings: chronic viral shedding, viral reactivation caused by acute pelvic inflammatory disease (PID), or that the PID was actually caused by HSV. Further prospective studies are needed to document the role of HSV in causing PID.

Neonatal septicaemia

A total of 410 proved cases of neonatal septicaemia from seven Finnish hospitals seen between 1976 and 1980 were reviewed. The annual incidence of neonatal septicaemia was 3 per 1000 births, and overall mortality was 23%. Onset was early in most patients. Symptoms of septicaemia occurred within the first 24 hours of life in 44% and within the first week of life in 90%. In the very early onset disease (within 24 hours) mortality was 30%, compared with 17% in all other cases. Group B streptococcus was the leading cause in very early onset disease (52%) but mortality from infection with this organism was similar to that in other very early onset cases. It is concluded that very early onset neonatal septicaemia, probably of intrauterine origin and caused by group B streptococcus in one half of the cases, constitutes the major form of neonatal septicaemia in Finland and should receive the highest priority in preventive measures.

Prevention of otitis media in children by pneumococcal vaccination

A total of 3,340 infants, 95 per cent of them 7 to 9 months old, were randomly vaccinated in a double-blind fashion with either the 14-valent pneumococcal (Pn) polysaccharide vaccine or a saline placebo in three urban areas in Finland. The second dose of the vaccine was given 5 months later. Age and sex distribution, recruitment of infants, and their otitis-related treatment and follow-up were similar in the study areas. Side effects after vaccination were mild and fewer than among older children. Antibody responses to vaccine polysaccharides varied from type to type, but were generally poor, especially to types most prevalent in otitis media. After the first dose of vaccine, the occurrence of otitis visits among the Pn-vaccinated, as compared with controls, showed inter-area differences, but ranged from not more than a 30 per cent reduction at its best to an increase in some areas and in some clinical categories. The respective figures for children with acute otitis media were similar between the vaccination groups and the study areas. The effect of the vaccine on acute otitis media caused by specific Pn types/groups represented in the vaccine was variable but generally poor. Group 6 attacks especially seemed to behave problematically. The second dose of the vaccine did not give additional benefit serologically or clinically. The efficacy of currently available pneumococcal vaccine against otitis media seemed poor in infants.

Branhamella catarrhalis in acute otitis media

A total of 5217 middle ear fluid (MEF) samples obtained from 1203 children with otitis media, aged 3 months to 6 years, were studied for the presence of Branhamella catarrhalis (Br) between Oct. 1977 and Sept. 1981. Br grew in 10.2% of 3497 MEFs of acute otitis media (AOM), with almost the same frequency in the very first and subsequent attacks. During the first 4 years of life the percentage did not vary much; among older children it seemed to decrease. The overall prevalence of Br in AOM did not change during the study period. Br alone grew in 72.4% of acute MEFs with Br; with other bacteria the respective figure was 82.9% (p less than 0.001). Acute attacks with bilateral Br were found in 22.8% of attacks with Br. In 1720 non-acute MEFs obtained at postacute control visits, Br was isolated in only 7.0%. The proportion of beta-lactamase-producing strains among the 2419 otitis-Br strains tested in two laboratories of the two study regions showed an increase from 27.1% and 21.1% in 1980 to 57.6% and 38.6% in 1983, respectively (p less than 0.001).

Endometritis and acute salpingitis associated with Chlamydia trachomatis and herpes simplex virus type two

A patient who had endometritis confirmed by endometrial biopsy and acute salpingitis confirmed by laparoscopy is reported. Chlamydia trachomatis and herpes simplex virus type two were isolated from the endometrial cavity and the fallopian tube. The histopathologic findings of the endometritis were similar to those frequently seen in chronic chlamydial eye disease or chlamydial cervicitis.

Haemophilus influenzae causes purulent salpingitis

We describe two patients with laparoscopically diagnosed, severe acute salpingitis who had nontypable Haemophilus influenzae isolated directly from the fallopian tubes. Nontypable H. influenzae should be recognized as an important genital pathogen.

Aminoglycoside resistance among blood culture isolates

A total of 633 blood culture isolates were collected from 1981 to 1982 from seven major Finnish hospitals, including all university central hospitals. Susceptibility of the strains to gentamicin, tobramycin, amikacin, and netilmicin was determined by the Sensititre microtiter procedure. Resistance against any of these agents occurred in 1.3 to 6.5% of all strains studied. In the Turku University Central Hospital, an increased number of tobramycin- and gentamicin-resistant Staphylococcus epidermidis were found; the frequency of strains resistant to tobramycin was 57% and to gentamicin was 29% versus frequencies of 16 and 18%, respectively, which were observed in the other hospitals. An explanation for this might be a change in the use of aminoglycosides in the Turku University Central Hospital; within 3 years, 1979 to 1981, the consumption of tobramycin and amikacin had increased 330 and 290%, respectively, whereas the use of gentamicin had decreased to 24% of that in the beginning of the period. Resistance against tobramycin was mediated by enzymes APH(2")-AAC(6') and ANT(4').

Clostridium difficile in young children. Association with antibiotic usage

Clostridium difficile was isolated from the stools of 11/52 (21%) of children aged 0 to 2 years hospitalized with diarrhoea, and from 17/52 (33%) of a control group of hospitalized children with no diarrhoea; this difference was not significant. Direct demonstration of C. difficile toxin from the stools was positive in 1 case with diarrhoea and in 5 control cases. The children with positive stool culture for C. difficile had had significantly more treatments with antibiotics or chemotherapeutics than those with negative C. difficile culture (3.3 +/- 2.7 vs. 1.6 +/- 1.8, p less than 0.001), but there was no significant difference in the incidence of diarrhoea in the past. During a 4-6-month follow-up, C. difficile disappeared from the stools of 24 out of 28 initially culture-positive children; 3 of the 4 children with persistent C. difficile had received antibiotics during the follow-up period. We conclude that the presence of C. difficile is common in the stools of young children up to the age of 2 years, and that C. difficile is more frequently found in children who have received antimicrobial therapy. Most cases of C. difficile carriage state are symptomless at this age.

Pseudomembranous colitis with recurring diarrhoea and prolonged persistence of Clostridium difficile in a 10-year-old girl

A 10-year-old girl developed, after treatment with amyxocillin, a clinically and sigmoidoscopically apparent pseudomembranous colitis with positive Clostridium difficile stool culture. Treatment with vancomycin resulted in rapid clinical cure, but there was a relapse of diarrhoea and reappearance of C. difficile, with no pseudomembranous colitis, within one month. Clinical symptoms subsided spontaneously but C. difficile persisted for 2 more months in the stools. This case reflects three different aspects of C. difficile infection in one child: pseudomembranous colitis, ordinary diarrhoea, and symptomless carrier state.

Bacteraemia in surgical patients with intravenous devices: a European multicentre incidence study. The European Working Party on Control of Hospital Infections

A survey of the incidence of bacteraemia and the use of intravenous (IV) devices among 10,616 surgical patients was performed in 42 hospitals in eight countries. It was found that 63 per cent of the patients surveyed had an IV device inserted at some time during their hospital stay, with national variations between 40 and 99 per cent. The incidence of device-related thrombophlebitis was 10.3 per cent, with national variations between 7.8 and 28.4. Among the surgical patients not given IV therapy, 1.5/1000 had a bacteraemia, 0.5/1000 of them hospital-acquired. The corresponding figures for patients with a peripheral but no central IV device were 6.9 and 3.7, and for patients with a central venous catheter (CVC) 59.0 and 44.8, respectively. Even though there was a strong correlation between the incidence of bacteraemia and certain diagnoses there was also an independent correlation between it and CVCs or peripheral IV lines. No correlation was demonstrated between the number of catheter days per site for patients with a peripheral IV device, and hospital-acquired bacteraemia. This may be due to the low mean number of catheter days per site that was observed. There was a large and not easily explained national variation in the incidence of bacteraemia in patients with CVCs of between 16 and 108/1000.

Pathogenicity of 42-44 Mdal plasmid positive and negative Yersinia pseudotuberculosis I and Yersinia enterocolitica 0:8 and 0:9 studied in the guinea pig eye model (Serény test)

When virulence plasmid (42-44 Mdal) positive and negative Yersinia pseudotuberculosis I and Yersinia enterocolitica 0:8 and 0:9 were tested in the guinea pig eye model the following order of pathogenicity was observed: Plasmid-positive Y. pseudotuberculosis I (death of the animal) greater than plasmid-negative Y. pseudotuberculosis I approximately equal to plasmid-positive Y. enterocolitica 0:8 (severe conjunctivitis) greater than plasmid-positive Y. enterocolitica 0:9 (mild conjunctivitis) greater than plasmid-negative Y. enterocolitica 0:8 and 0:9 (no effect).

Haemophilus influenzae in acute otitis media

We studied the occurrence of Haemophilus influenzae (Hi) in 2625 middle ear fluid (MEF) specimens obtained from 523 children with otitis media, aged 3 months to 6 years, between October 1977 and May 1979. In clinically acute cases 12.3% of the MEFs grew Hi; 6.3% (13/206) of the strains were of type b and 4.9% (10/206) were beta-lactamase producing. In the very first acute case of a child 8.0% (21/263) of the MEFs grew Hi, but in acute recurrences it was cultured in 17.0% (184/1082) (p less than 0.001). In non-acute persistent MEFs obtained during control visits Hi was found in no less than 21.7% (198/913); as many as 12.6% (25/198) of them were beta-lactamase producing. Both of these figures, but not the proportion of type b strains (8.6%), were significantly (p less than 0.001 and p less than 0.01, respectively) greater than in clinically acute MEFs. Hi was grown in 13.1% of the acute MEFs taken from children less than 4 years old, but in only 8.6% of the older children (p less than 0.05). The annual survey of all the 1816 Hi strains isolated from the MEFs of acute or subacute cases of otitis media in one laboratory in 1976-81 showed the proportion of beta-lactamase producing strains of all Hi strains to be gradually increasing from 8.0% (17/212) in 1976 to 15.2% (16/105) in 1981 (p less than 0.05).

Bacteriological quality control in a human milk bank

The best nutrient for newborn babies is breast milk and preferably provided via breast feeding. Pooled human milk must be used when the babies' own mother's milk is not available. Very often pooled milk is pasteurised. Recent studies, however, suggest avoidance of any sterilisation procedures in view of the decreased nutritional value and loss of anti-infective benefits associated with heating of human milk. In this study a quality control system of banked human milk based on the recent literature is presented. The purpose of systematic bacteriological monitoring is to separate those milk samples contaminated with pathogenic bacteria from the bulk of the collected milk which has only light contamination with likely nonpathogenic skin bacteria. According to our new standards of classification, over 60 per cent of the collected milk proved to be sufficiently free of bacteria to be fed unheated to pre-term infants. Most of the remainder could be fed unheated to full-term infants and less than 10 per cent had to be pasteurised.

Urinary-tract infection and bacteraemia in hospitalized medical patients--a European multicentre prevalence survey on nosocomial infection

A co-ordinated survey of 3899 medical patients in 169 wards, performed simultaneously in eight countries, showed a point-prevalence of urinary-tract infection (UTI) and bacteraemia of 12.6 and 1.6 per cent, respectively. One-half of the infections were acquired after the patients' admission. The bacteriological patterns of hospital- vs community-acquired infections were different, but showed no unexpected features. Antibiotic treatment was recorded in 22.3 per cent of the patients in this study, urinary-tract disinfectants, sulphonamides or penicillins being used in 95 per cent of those treated for UTI. The overall prevalence of urinary-tract drainage was 11.0 per cent with no significant difference between the two sexes. At ward level the rate of catheterized patients varied from below 5 per cent to more than 25 per cent, indicating--besides variations in the ward populations--differences in policies. The association between nosocomial UTI and the presence of an indwelling catheter and/or female sex was confirmed, while high age appeared to be a secondary risk factor among catheterized patients. The prevalence of nosocomial bacteraemia in patients with UTI was five times higher than in those without urinary-tract involvement, and a significant part of the nosocomial cases of both UTI and bacteraemia was clearly device-related. Guidelines for the use of indwelling catheters should be restrictive and provide for prompt removal. When introduced and followed they will effectively reduce nosocomial UTI and bacteraemia.

Plasmids in Yersinia enterocolitica serotypes O:3 and O:9: correlation with epithelial cell adherence in vitro

Human isolates of Yersinia enterocolitica serotypes O:3 (biotype 4) and O:9 (biotype 3) harbored plasmids sized approximately 47 and 44 megadaltons, respectively. No such plasmids were found in "apathogenic" strains of Y. enterocolitica belonging to biotype 1. There was a positive correlation among the presence of plasmid, autoagglutination, and adherence to and toxicity for HEp-2 cell cultures; all of these properties were lost by culturing at 37 degrees C in the absence of calcium. Strains of Y. enterocolitica O:3 and O:9 cured of the plasmids showed increased invasiveness in the HEp-2 cell culture model, but no invasiveness in guinea pig eye. It is suggested that the plasmids of Y. enterocolitica primarily determine epithelial cell adherence, but may also be associated with other pathogenic properties.

Yersiniosis in children

40 cases of bacteriologically proved Yersinia enterocolitica infections in children under 15 years were reviewed. Most children presented with abdominal symptoms, and diarrhoea was present in 80% of them. In half of those with diarrhoea the stools were mucoid and gross blood was often present. Faecal leucocytes were found in 4 out of the 5 children studied. The clinical findings are consistent with the enteroinvasive pathogenic mechanism proposed for Y. enterocolitica. 29 of 30 faecal isolates of Y. enterocolitica were found invasive for human epithelial cells in vitro. Nine strains produced an enterotoxin demonstrable in newborn mouse assay. Toxin production may be an additional pathogenic mechanism in human yersiniosis.

Pneumococcal vaccine and otitis media

After an acute attack of otitis media 827 children aged 3 months to 6 years were assigned randomly to receive either 14-valent pneumococcal polysaccharide vaccine or a control vaccine (Haemophilus influenzae type b capsular polysaccharide). In children older than 6 months serum antibody responses to most of the vaccine polysaccharides were satisfactory. The response to type 6A was poor. Correspondingly, no clinical protection was seen below 6 months of age or against otitis media caused by group 6 pneumococci. Among the children more than 6 months old, the first 6 months after vaccination saw significantly (p < 0.001) fewer attacks caused by the pneumococal types represented in the vaccine (group 6 excepted) in those who received the pneumococcal vaccine than in those who received the control vaccine. Protection against type 19F was statistically significant (p < 0.01). The overall protective efficacy was 58%--somewhat better in children older than 2 years than in those younger. Previous attacks of otitis caused by pneumococci did not influence the protective efficacy of the vaccine.

Evaluation of ELISA in the diagnosis of Yersinia enterocolitica diarrhoea in children

In a series of acute gastroenteritis in children, including 2 bacteriologically confirmed cases of Yersinia enterocolitica infection, paired sera from 286 patients were studied for the presence of Y. enterocolitica 0:3 and 0:9 antibodies, using an enzyme-linked immunosorbent assay (ELISA). In the 2 cases with positive stool culture of Y. enterocolitica 0:3 significant rise was seen in each IgM, IgG and IgA class Y. enterocolitica 0:3 antibodies. There were 6 further cases with elevated anti-Yersinia IgM: these possibly false-positive reactions were distinguished from the confirmed cases of Y. enterocolitica infection by the absence of IgG and IgA antibodies.

Efficacy of pneumococcal vaccination against recurrent otitis media. Preliminary results of a field trial in Finland

For this study, 781 children, and 3 to 83 months, after presenting with acute otitis media, were immunized with either 14-valent pneumococcal or Haemophilus influenzae type b capsular polysaccharide vaccine. The vaccines were tolerated well. Antibody responses to the 14 pneumococcal polysaccharide types, measured by radioimmunoassay, were fair to good and increased with age, with the exception of types 1, 6 and 12 to which the responses were generally poor. During the follow-up of 1-17 months, average 13 months, 45 vaccine type (except type 6) pneumococcal recurrences were met among 456 pneumococcal-vaccinated and 45 among 288 H. influenzae-vaccinated children, at least six months old (P < .05). The corresponding protective efficacy by the pneumococcal vaccine was 37%, for the first six months, 51% (P < .01). No protection by the pneumococcal vaccine was seen against group 6 pneumococci, nor among 19 infants under six months of age. Nonvaccine type pneumococcal ad H. influenzae recurrences did not significantly concentrate in either of the vaccination groups. Thus, it seems that parenteral immunization of children can reduce the recurrence rate of otitis media caused by pneumococci of types (except type 6) present in the vaccine.

Rapid quantitative determining of C-reactive protein using laser-nephelometer

A rapid quantitative immunonephelometric method to determine C-reactive protein is described. Quantitative results are obtained after 1 h incubation. The precision of the method is good and the sensitivity is approximately the same as the sensitivity of the immunodiffusion plates, which are commercially available. A comparison of the nephelometric method with the radial immunodiffusion method gave the correlation coefficient 0.968 and the regression line y = 1.111x -0.005 (n = 85).

Enterotoxigenic and invasive Escherichia coli as causes of childhood diarrhoea in Finland

E. coli was considered as the possible aetiologic agent in 16 cases (5.7%) of 283 hospital admissions for diarrhoea. One invasive strain was isolated from a case with exudative diarrhoea. Four heat-labile (LT) enterotoxin-producing strains were found in relatively mild cases of diarrhoea. Eleven strains belonged to "classic" pathogenic serotypes (EPEC); 9 of these were endemic cases and 2 associated with travel. Of the latter, 1 strain (078) was also found to produce heat-stable (ST) enterotoxin detectable by infant mouse assay. Although EPEC are now found much less frequently than 20 years ago, E. coli as a whole may still be the most common bacterial aetiology of childhood diarrhoea in Finland.

In vitro invasiveness of Yersinia enterocolitica isolated from children with diarrhea

The invasiveness of Yersinia enterocolitica isolated from the feces of children with diarrhea was assayed in cultured human epithelial (HEp-2) cells. Twenty-one of 24 strains were invasive under the test conditions. Infection with Y. enterocolitica was characterized clinically by exudative diarrhea in 11 cases. Polymorphonuclear leukocytes were demonstrated in the feces from all three cases of exudative diarrhea studied. The results suggest a correlation between enteroinvasiveness of Y. enterocolitica, presence of leukocytes in feces, and clinical exudative diarrhea.

Uriglox and quantitative urine microscopy in diagnosis of urinary tract infection

The aim of this study was to find an alternative to the sole use of abundant cultural findings as a basis for the diagnosis of urinary tract infection (UTI). For this purpose, the results obtained from the bacteriological culture of daytime urine specimens from 154 students by the dip slide method were checked against the findings from the quantitative culture, microscopy and Uriglox testing of the first morning urines voided later at home. As a diagnostic criterion, the finding of 10(5) or more bacteria/ml urine in two successive cultures had an error of 19%. For the simultaneous occurrence in the morning urine of abundant bacteria (larger than or equal to 10(5)/ml) and a subnormal glucose concentration (as revealed by the Uriglox test), this error was 1.5%. Only the latter combination showed, therefore, the presence of UTI at the confidence level of larger than or equal to 95%, or was "clinically significant". The specificity indices for the Uriglox test and the quantitative culture were 0.99 and 0.97, respectively. Microscopy of the morning urine showed 10(3) or more bacteria/ml in all the subjects with infection but the number of leucocytes was normal in a fifth of them. The specificity indices for microscopic counts of 10(3) or more organisms/ml and 10 or more leucocytes/mm3 were 0.74 and 0.94, respectively. For higher counts, i.e. 10(5) or more bacteria/ml and 50 or more leucocytes/mm3, the specificity index of positive microscopy was 1.0. This specificity level was, however, attained at the expense of the sensitivity, which for 10(5) or more organisms/ml was 0.67 and for 50 or more leucocytes/mm3 0.53. It is concluded that abundant bacterial contamination of specimens often decisively complicates the diagnostic use of urine culture, and therefore the combined use of quantitative culture, microscopy and the Uriglox test is recommended as the principal tool for the diagnosis of UTI in ordinary hospital and ambulatory health services.