Carriage of multidrug-resistant Streptococcus pneumoniae and impact of chemoprophylaxis during an outbreak of meningitis at a day care center

Three cases of meningitis due to multidrug-resistant serotype 14 Streptococcus pneumoniae occurred at a day care center (DCC) over 5 days. Cultures of nasopharyngeal samples were done at the index DCC, 2 comparison DCCs, and a pediatrics practice. Isolates were serotyped and subtyped by pulsed-field gel electrophoresis (PFGE) with SmaI. Pneumococcal carriage rates ranged from 44%-65% at the 3 DCCs and 29% in the pediatrics practice. Carriage of multidrug-resistant serotype 14 S. pneumoniae was noted in 13%-19% of children at the 3 DCCs. An outbreak strain was identified by PFGE at the index DCC and 1 other DCC; a closely related strain was found in the third DCC. Carriage of the outbreak strain was associated with being age 0-24 months, antibiotic use, upper respiratory tract infections, and otitis media. DCC contacts of the ill children were offered chemoprophylaxis with rifampin and clindamycin, which produced a profound but transient decrease in carriage. No additional cases occurred.

Use of hepatitis A vaccine in a community-wide outbreak of hepatitis A

Hepatitis A outbreaks in communities are often difficult to control. From July 1994 through June 1995, 676 cases of hepatitis A were reported in Shelby County, Tennessee. With the licensure of a hepatitis A vaccine in February 1995, a new tool for outbreak control became available. During August-October 1995, a mass vaccination campaign was conducted. A total of 34,054 children received the first dose of hepatitis A vaccine. From December 1995 through December 1996, the number of hepatitis A cases reported inside the intervention area declined by 64%; outside the intervention area, the number of cases declined by 40%. The precise contribution of the vaccine campaign to the decline in the number of outbreak cases is difficult to quantify because community outbreaks often wane over time. The vaccine campaign may have hastened the decline of the number of outbreak cases. Future interventions should consider an earlier campaign with greater vaccine coverage.

Neonatal tetanus in the United States: a sentinel event in the foreign-born

BACKGROUND

Neonatal tetanus occurred in a 7-day-old infant born to Mexican immigrant parents in Tennessee in February, 1995. This was the first patient with neonatal tetanus reported in the United States since 1989.

METHODS

We interviewed the infant's mother and physicians and reviewed the medical record. We conducted a telephone survey of 103 (17%) of the 609 licensed obstetrician/gynecologists practicing in Tennessee to assess vaccination history-taking practices during prenatal care.

RESULTS

The mother was a 30-year-old gravida 4 para 3 woman who grew up in rural Mexico. After moving to the United States in 1987, she had delivered two children before this delivery. The hospital-based delivery and nursery stay in February, 1995, were uncomplicated. On the sixth day of life the infant became irritable and developed muscle stiffness. The next day he was examined by a pediatrician who diagnosed neonatal tetanus. The infant recovered fully after a 2-month hospitalization. The survey of obstetrical practices revealed that 61 (59%) of 103 respondents asked about the patient's vaccination status during prenatal care. However, of all respondents, only 14 (14%) confirmed that they specifically asked about prior tetanus vaccinations. Tetanus toxoid was available in 47% of offices on the day of the survey.

CONCLUSIONS

Neonatal tetanus can still occur in the United States. This infant's immigrant mother had multiple missed opportunities to be vaccinated against tetanus during her three pregnancies in this country. Health care providers should ask patients about their vaccination status, particularly those patients who are foreign-born or who grew up outside the United States.

Antimicrobial activity of latamoxef (moxalactam) against both Bacteroides fragilis and Escherichia coli in an intraperitoneal abscess model

The antimicrobial activity of latamoxef (moxalactam) was examined against Bacteroides fragilis and Escherichia coli individually and in combination in an intraperitoneal tissue capsule animal model during ten days of therapy given at 40 mg/kg/day. Mean peak serum concentration was 32.8 mg/l. Mean capsular latamoxef concentrations during samplings on days three, seven and ten were 1.8 mg/l for Bact. fragilis, 0.7 mg/l for E. coli, less than 0.5 mg/l for polymicrobial infection and 3.4 mg/l in uninoculated controls. Capsular colony counts for Bact. fragilis and E. coli monomicrobial infections decreased by 2.2 and 4.0 log10 cfu respectively and 1.9 and 3.6 log10 cfu in polymicrobial infections. Latamoxef concentrations necessary to eliminate viable bacteria in both monomicrobial and polymicrobial capsules were not achieved.

Detection of a specific bacterial antigen in urine of rats with Bacteroides fragilis infection

Human intra-abdominal infections frequently yield Bacteroides fragilis and require specific antimicrobial and surgical therapy. Noninvasive immunologic assessment of this organism might allow more optimum therapy. Therefore we raised antisera in goats to Bacteroides fragilis ATCC 23745 and allowed it to react with a solid-phase capsular polysaccharide-protein antigen extracted from the same organism. Preliminary work disclosed that 10 ng/ml antigen could be detected in competition assays in both saline and dialyzed rat urine. Results were manifest by diminution of bound antiglobulin alkaline phosphatase conjugate in an antigen-mediated antibody-inhibition enzyme-linked immunosorbent assay. Rats were then infected intra-abdominally with (1) B. fragilis ATCC 23745; (2) one of eight recent clinical isolates of B. fragilis; or (3) one of nine isolates representative of Enterobacteriaceae. Seventy-two rat urine samples obtained prior to infection disclosed essentially no assay inhibition: 98.3% +/- 10.3 (1 S.D.). Mean values of reagent antibody activity after incubation with urine aliquots from 24 hr samples collected between 24 and 72 hr were (1) strain 23745 (n = 35) 70.9% +/- 2.6 (S.E.); (2) eight isolates of B. fragilis (n = 49) 86.8% +/- 1.9; (3) nine isolates of Enterobacteriaceae (n = 47) 100.9% +/- 1.0; and (4) shams (n = 29) 95.5% +/- 1.55. Ascribing values less than or equal to 77.7% (2 S.D.) as positive, seven of the eight clinical B. fragilis isolates causing infection were detected in at least one 24 hr urine sample (sensitivity = 87% by organism); 12 of 17 infected rats were correctly identified as positive by at least one urine (sensitivity = 70.6% by rat). Specificity, as assessed in the Enterobacteriaceae group, was 89% (by organism) and 94.5% (by rat). Collectively, these results suggest the presence of a potentially specific, soluble antigen excreted in the urine of rats with B. fragilis infection.

Uniform assessments and standards of social and health care services

This paper describes the procedures and methodology used in the development of a model In-Home Care services program for aged and disabled adults in Washington State. This program was designed to replace the existing Title XX chore services program in two geographic regions in which dissimilar chore service usage patterns have been exhibited by similar types of recipients. An analysis of the resultant cost, service utilization, and recipient health status data suggests that in the model program home-based services for the aged and disabled were provided in a more equitable and cost-effective manner than is the case with the existing chore service program in this state.

Protein precipitation by acetone for the analysis of polyethylene glycol in intestinal perfusion fluid

Canine ileal segments were luminally perfused with known amounts of polyethylene glycol (PEG), and samples obtained were freed of protein by a cold acetone (CA) method and assayed for PEG by trichloroacetic acid in the presence of calcium cations. This procedure was compared to the Barium salt (BaS) protein precipitation method of Hyden (Ann R Agric Coll Sweden 22:411-424, 1955). The CA method saved specimen volume and time in handling, whereas its stability, linearity, and reproducibility were equivalent to the more complex BaS method. In vitro studies disclosed no appreciable differences when PEG specimens were bile stained or dissolved in various solvents. A small modification of the CA method improved accuracy in measurement of small PEG concentrations.

Enzyme-linked immunospecific antibody test for detecting antibody to Klebsiella

The enzyme-linked immunospecific antibody test was performed in standard test tubes and microtiter plates to meausre high-titer antibody against Klebsiella capsular polysaccharide. Initial studies were conducted with rabbit sera; other studies were conducted with the serum of a patient infected with type 9 Klebsiella. Both immunized rabbits and an infected patient disclosed high titers of anticapsular antibody. Control sera from other immunized rabbits and other infected humans failed to show this substantial antibody titer against type 9 Klebsiella. Comparisons between counterimmunoelectrophoresis and indirect immunofluorescence disclosed that the sensitivity of the enzyme-linked immunospecific antibody test for anti-Klebsiella antibody ranged between 400 and 10,000 times that of these tests.

Artifactual depression of serum glutamic oxaloacetic transaminase by metronidazole

Eighteen patients developed abnormally low serum glutamic oxaloacetic transaminase values during metronidazole therapy. Metronidazole absorbs at 340 nm, simulating reduced nicotinamide adenine dinucleotide, which is the final colorimetric product of the serum glutamic oxaloacetic transaminase assay.

Clindamycin and gentamicin in surgical infections

The combination of clindamycin phosphate and gentamicin sulfate in treating 53 patients with a variety of serious infections was studied. Initial cultures of specimens from 31 patients yielded both anaerobic and aerobic pathogens. Eleven cultures showed only anaerobic organisms and 11 showed only aerobes. Of patients treated with clindamycin and gentamicin and surgical intervention, 87.8% had bacteriologic cure. Clinical response was poor in only two cases. Two patients developed rash and one had diarrhea, but no reactions suggestive of pseudomembranous colitis were seen.

Demonstration of cryoprecipitable immune complexes in pneumococcal pneumonia

Cold-insoluble protein complexes (cryoprecipitates) can be found in the serum in a variety of infectious diseases. We studied serum cryoprecipitates isolated from three patients with pneumococcal pneumonia by counterimmunoelectrophoresis (CEP) and immunofluorescent technics for the presence of immune complexes. The cryoprecipitates and supernatant serum were tested for pneumococcal capsular polysaccharide (PCP) by CEP at 37 C and 56 C with the appropriate controls. Antibodies against PCP in the cryoprecipitates and the supernatant serum were detected as follows. Streptococcus pneumoniae from each case was fixed onto slides. The slides were incubated with each cryoprecipitate and supernatant serum at 37 C, and further incubated with fluorescein isothiocyanate-conjugated antisera to human IgG, IgM, and IgA. The slides were examined with an immunofluorescent microscope. PCP was demonstrated in all of the cryoprecipitates. IgG antibodies against PCP were detected in all of the cryoprecipitates, while IgM antibodies were detected in Cases 1 and 2, and IgA antibodies in Case 1 only. Complement components of C3 and C4 also were demonstrated in the cryoprecipitates by CEP. These findings suggest that some patients with pneumococcal pneumonia have cryoprecipitable-immune complexes consisting of PCP and its antibodies.

Immune complex glomerulonephritis associated with Klebsiella pneumoniae infection

The kidneys of three patients who died of pneumonia due to Klebsiella pneumoniae were studied at autopsy by light and immunofluoerescent microscopy. One had no clinical evidence of renal disease; two had only microscopic hematuria and mild proteinuria. Light microscopy revealed focal proliferative glomerulonephritis in all three cases. Also in all three, immunofluorescent microscopy revealed a granular deposition of capsular polysaccharide antigens of Klebsiella pneumoniae in association with immunoglobulins and complement components in the mesangium and along the glomerular basement membrane. Furthermore, the glomerular bound immunoglobulins were eluted and demonstrated to contain antibodies specific to a capsular polysaccharide antigen of Klebsiella pneumoniae isolated from each patient. These findings may illustrate that the capsular polysaccharides of Klebsiella pneumoniae are antigenic, and that the immune complex deposition in the kidney during infection with this agent can be associated with renal morphological changes. Whether or not clinical evidence of nephritis occurs may depend on the characteristics of the infection and the host factors.

Therapy for disseminated coccidioidomycosis with transfer factor from a related donor

A 17 year old caucasian woman in whom disseminated coccidioidomycosis developed with culture positive meningitis during her third trimester of pregnancy was treated with amphotericin B and subsequently with transfer factor prepared from her father's peripheral lymphocytes. Clinical response and in vivo and in vitro immunologic data indicated that this transfer factor afforded a significant contribution to her survival whereas previous therapy with transfer factor from an unrelated donor provided only transient immunologic reactivity. This experience suggests that transfer factor prepared from a related donor with positive responses to C. immitis may be more efficacious than that prepared from an unrelated donor.

Skin test and blastogenic responses to Sporotrichun schenckii

In vivo skin testing and in vitro lymphocyte blastogenesis were evaluated in a young adult population as methods for detecting cellular immunity to Sporotrichum schenckii. Similar procedures for Candida albicans and Coccidioides immitis were also investigated. 5 of 143 subjects had positive skin tests and 14 had positive blastogenic responses to S. schenckii. These 14 subjects also exhibited unusually high responses to C. albicans in vitro and 11 of the 14 were female. Data demonstrated a correlation coefficient of 0.89 when comparing the blastogenic assays for S. schenckii and C. albicans, suggesting cross antigenicity. Intact cellular immune mechanisms in combination with exposure to C. albicans may protect the host from systemic infection with S. schenckii. Although a limited number of subjects were studied, as a group, females had more vigorous cellular immune responses to C. albicans than males. The rare occurence of sporothrix infection in females as compared to males may be the result of antigenic stimulation from commonly observed vaginal colonization with C. albicans. The present data indirectly support this hypothesis.

Ion transport during cholera-induced ileal secretion in the dog

To assess the ion transport mechanism by which cholera causes the small bowel to secrete, ion transport rates and electrical potential difference (PD) were determined simultaneously in the normal and choleragen-treated dog ileum in vivo. The results indicate that, during cholera, HCO(3) is actively secreted (i.e., against both an electrical and a concentration gradient); Cl is also actively secreted, against a modest electrochemical gradient. Electrogenic pumping of one or both of these anions is probably responsible for an observed PD change of approximately 13 mv (lumen negative). Na secretion can be accounted for entirely by passive ion movement. K secretion can be partly explained by passive diffusion secondary to the negative intraluminal PD; however, its concentration in the secreted fluid is two to three times higher than expected on the basis of passive forces, suggesting a component of active K secretion. The PD response of the choleragen-treated ileum is normal in response to glucose, but there was no PD response to saline-free mannitol perfusion. This suggests that the normal differential permeability of the ileum to anions and cations may be altered by choleragen, although other explanations of this finding are also possible.