Biomedical subjects
Publications and source records attributed to C W Derrick.
In utero varicella-zoster infections, though infrequent, may have significant consequences for the affected infant depending on the gestational timing of the infection. We present a case of infantile zoster in a 5-month-old boy after maternal varicella infection. Also, we review the three major disorders resulting from in utero infection with respect to severity and management.
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Cephalexin remains an effective and highly useful antibiotic for the treatment of streptococcal and staphylococcal skin infections. Twelve years of experience have not diminished its efficacy, and cure rates of 90% or higher continue to be achieved. Its resistance to degradation by gastric acid and its uniform absorption ensure its bioavailability, and its efficacy in twice-daily dosages enhances medication compliance. The suspension formulation is well accepted by young children, and side effects have generally been mild and infrequent. Cephalexin is comparable to erythromycin, clindamycin, dicloxacillin, cloxacillin, and other cephalosporins in the treatment of streptococcal and staphylococcal infections. Because many of these antibiotics are similar in their efficacy, palatability, and adverse reactions, cost factors may play an important role in choosing one over the other. Penicillin remains the drug of choice for streptococcal skin infections. If the cure rates of the mixed streptococcal-staphylococcal lesions continue to decrease with penicillin, cephalexin and the other alternative antibiotics may assume a more important role in the primary treatment of these infections in the future.
A case of hydroxyzine toxicity following accidental ingestion in a 13-month old female infant has been presented. A plasma hydroxyzine concentration 8.5 hours after the acute ingestion was 102.7 micrograms/ml and toxicity was manifested primarily by generalized seizures and sinus tachycardia. General supportive care and seizure control with physostigmine resulted in complete recovery within 72 hours. This case represents the first documented report of hydroxyzine toxicity following acute ingestion in a child.
The recommended dosage of erythromycin, without regard to the formulation prescribed, for children with streptococcal pharyngitis is 30 to 40 mg/kg/day. We previously reported an acceptable streptococcal eradication rate among patients with pharyngitis treated with erythromycin estolate, 20 mg/kg/day. In this study, an extension of the earlier one, the efficacy of this same dosage of erythromycin estolate was compared with a 40 mg/kg/day dosage of erythromycin ethylsuccinate. Streptococcal eradication rates were nearly identical in the two groups of patients. The efficacy of erythromycin estolate at a dosage lower than that recommended for children is most likely explained on pharmacologic grounds: better absorption and higher levels in serum and tissue than those achieved with other erythromycin formulations. It seems rational to calculate required dosages of erythromycin on the basis of the formulation being administered.
Streptococcal eradication rates of 86% were demonstrated in 97 patients seen on day 14 and in 73 patients seen on both days 14 and 28 after a ten-day course of erythromycin estolate therapy given at a dosage of 20 mg/kg/day, administered in two equal doses. The efficacy of this regimen compares favorably with other results in which this and other erythromycin preparations have been employed at higher doses, usually in the range of 30 to 50 mg/kg/day. Our reported effectiveness at a lower than usual dose of erythromycin is probably explained by the following factors: the known susceptibility of group A streptococci to low concentrations of erythromycin, the uniform absorption of the estolate formulation of erythromycin, and adequate compliance in adhering to the treatment regimen by the majority of our patients. This dosage schedule of erythromycin is simple to administer; and a reduction by half of the total dose usually recommended provides an economical advantage for patients.
A new M-type of group A streptococcus, provisionally designated type 65, is described. The vaccine and other initially isolated strains of this type attracted attention because of the T-agglutination reactions 2/25, not previously encountered among pyoderma streptococci. The investigations characterizing the strains as members of a new type were done with streptococci isolated from patients with pyoderma. However, type 65 was subsequently found to cause both pyoderma and acute pharyngitis. The T-2 agglutination reactions encountered with original members of this type, plus the cross-reactions later seen with type 65 antiserum and M-type 2 streptococci, prompted a comparison of this new type with M-type 2 streptococci, including those with the T-2 agglutination and others with the 8-25-Imp. 19 complex. The two M-antigens were clearly distinguished from one another in reciprocal bactericidal and precipitin tests with absorbed antisera. They were further distinguished in that all type 65 strains were opacity-factor (OF) negative, whereas type 2 streptococci were uniformly OF-positive. Most M-type 65 strains subsequently found in surveillance studies were shown to be members of the 8-25-Imp,19 T-complex. Type 65 is thus a newly described type which shares with M-types 55 and 57 a commom T-agglutination pattern and, like members of these types, fails to produce opacity factor. In our colleciton of strains, from both pyoderma and pharyngitis, shown to be members of the 8-25-Imp. 19 complex, and OF-negative, only type 65 has been identified to date. In contrast to types 55 and 57, the new type 65 does not appear to be of major importance in causing acute glomerulonephritis.
Two hundred and forty-four children were evaluated in a study comparing clindamycin hydrochloride, erythromycin, and phenoxymethyl penicillin for the treatment of streptococcal pyoderma. Similar numbers of patients were followed during (day 7) and after (day 14) therapy in each of the three treatment groups. All patients had skin lesions positive for group A streptococci with or without staphylococci; the percentage rate of pure and mixed cultures was similar for the three groups of patients. Both clindamycin and erythromycin proved somewhat superior to penicillin on the basis of effecting earlier clinical cures and sterilization of skin lesions. Streptococcal eradication rates by day 7 were as follows: clindamycin, 97%; erythromycin, 99%; and penicillin, 91%. By day 14, clinical and bacteriologic cure rates were essentially the same in each group: clindamycin, 99%; erythromycin, 99%; and penicillin, 97%. Persistence or reacquisition of a pyoderma strain in the upper respiratory tract was highest in that group treated with penicillin. There were no adverse reactions associated with clindamycin or the other antibiotic agents evaluated. However, clindamycin holds no advantage over erythromycin for treatment of streptococcal pyoderma, and additional clinical information will be required to determine whether the potential for toxicity in children will compromise the use of this newer antibiotic.
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In an ongoing study of streptococcal skin infection and acute glomerulonephritis (AGN) begun in 1964, C'3 determinations were done in 784 patients. There were 126 patients with acute poststreptococcal nephritis, 172 of their siblings, and 486 patients with uncomplicated impetigo from families without an index case of nephritis.90% of the patients with nephritis were infected with one of the four prevalent streptococcal serotypes associated with nephritis in this population; only 12% of patients with uncomplicated impetigo were infected with similar serotypes.93% of the patients with overt nephritis had diminished complement levels. Low complement was more often observed (8%) in AGN siblings than was transient hypertension and/or hematuria (5%). Considering the relationship of low C'3 alone and low C'3 preceded hematuria in four others. Two (0.4%) of the patients with uncomplicated impetigo had low complement values, both of whom were infected with nephritogenic strains. Transient hematuria and/or hypertension was less frequently observed (2.7%) among patients with uncomplicated impetigo. Serial determinations in patients with low complement revealed a return to normal in a linear fashion within 2-12 wk. The validity of the hypothesis that the asymptomatic patients with low complement levels, with or without hematuria, likely had subclinical nephritis is strengthened by the accompanying epidemiologic data. The finding of low complement before the onset of, or in the absence of, hematuria or other evidence of nephritis supports the concept that an immunologic mechanism may precipitate the renal injury of acute streptococcal nephritis.
All episodes of bacteremia occurring in pediatric practice (birth to age 17) in the major hospitals of one metropolitan area between 1977 and 1981 were analyzed to determine current patterns of bacteremia and associated mortality. The overall mortality for 713 episodes of bacteremia was 13.6%. However, mortality attributed specifically to bacteremia, according to the criteria used in this study, was only 7.6%. Thirty-four of the 54 deaths attributed to bacteremia occurred in the neonatal period. Five deaths were attributed to bacteremia during the second and third years of life, and only three deaths were attributed to bacteremia in patients between 3 and 16 years of age. No deaths were attributed to bacteremia arising from the following sources: otitis media, osteomyelitis, septic arthritis, skin infections, endocarditis, urinary tract infection or infection clearly due to vascular access devices.
In a number of well-designed comparison studies since 1958, erythromycin has proved highly effective in the treatment of both streptococcal pharyngitis and skin infections. Of the two formulations most often prescribed, the estolate salt is better absorbed and achieves higher tissue concentrations than does the ethylsuccinate salt. For these reasons and based on results of the published clinical studies, the appropriate daily dosage for erythromycin estolate is 20 to 30 mg/kg/day and that for erythromycin ethylsuccinate is 40 mg/kg/day. Erythromycin estolate may be given in two, three or four daily doses in the treatment of streptococcal pharyngitis with efficacy rates equal to or better than that achieved with penicillin V. Erythromycin ethylsuccinate is as efficacious as penicillin V when given in three or four daily doses. Treatment of streptococcal pharyngitis should be for 10 days. Recent studies in the treatment of streptococcal skin infections have shown erythromycin to be superior to penicillin. This superiority may be due to increasing numbers of penicillin-resistant staphylococci found in these streptococcal skin lesions. Dosage and frequency of administration of erythromycin in the treatment of streptococcal skin infections is similar to that for the treatment for streptococcal pharyngitis. However, b.i.d. administration has not been well-established in the skin infection studies. Treatment should be given for 7 to 10 days. In conclusion erythromycin is a safe and effective antibiotic for the treatment of streptococcal pharyngitis. Penicillin remains the antibiotic of choice for these infections, but erythromycin is an effective alternate when penicillin allergy is suspected. The appropriate therapy for streptococcal skin infections is less clear.(ABSTRACT TRUNCATED AT 250 WORDS)