Biomedical subjects
E R Wald
Publications and source records attributed to E R Wald.
Microbiology of acute and chronic sinusitis in children.
To determine the bacteriologic cause of acute sinusitis, a sample of sinus secretions must be obtained from one of the paranasal sinuses without contamination by normal respiratory or oral flora that colonize mucosal surfaces. When maxillary sinus aspiration is performed on children who have signs and symptoms of acute sinusitis, bacteria are recovered in high density from 70%. In patients with acute, subacute, or chronic sinusitis who are generally well except for persistent respiratory symptoms, of nasal discharge or cough or both, the usual bacterial isolates are Streptococcus pneumoniae, Haemophilus influenzae, an Moraxella catarrhalis. In contrast, anaerobic organisms and staphylococci should be suspected in patients who have very long-standing symptoms or in those whose symptoms are so severe or complicated that sinus surgery is undertaken.
Antimicrobial therapy of pediatric patients with sinusitis.
The mainstay of medical therapy for acute and subacute sinusitis is the selection of an antimicrobial agent based on an appreciation of the usual bacterial pathogens that include Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis. Amoxicillin is appropriate therapy for patients with uncomplicated sinusitis in geographic areas in which the prevalence of beta-lactamase-producing pathogens is less than 20%. If a patient does not respond to amoxicillin or in areas in which there is a high prevalence of beta-lactamase-producing bacterial species, alternative antimicrobials include amoxicillin-clavulanate, erythromycin-sulfisoxazole, trimethoprim-sulfamethoxazole, cefaclor, cefuroxime axetil, and cefixime. Cefixime, which is less active against S. pneumoniae than most of these antimicrobials, should be reserved for patients who do not improve with amoxicillin. Amoxicillin-potassium clavulanate, cefuroxime axetil, and erythromycin-sulfisoxazole have the most comprehensive antibacterial spectra.
Safety and immunogenicity of acellular diphtheria-tetanus-pertussis and Haemophilus conjugate vaccines given in combination or at separate injection sites.
This prospective, double-blind, randomized trial compared the immunogenicity and reactogenicity of acellular diphtheria-tetanus-pertussis vaccine and Haemophilus influenzae type b conjugate vaccine-diphtheria toxoid conjugate, given at separate injection sites or at a single site, in 79 children 18 months of age who had received three prior immunizing doses of whole-cell diphtheria-tetanus-pertussis vaccine. No significant differences were observed.
Toxoplasmosis in pediatric recipients of heart transplants.
Toxoplasma gondii has long been recognized as a potential cause of severe disease in the congenitally infected infant and the immunocompromised host. This report describes three children with toxoplasmosis after heart transplantation and reviews the cases of 18 adult recipients of cardiac transplants (reported in the English-language literature) who developed toxoplasmosis postoperatively. Onset of disease was within the first 6 1/2 months following transplantation. Severity ranged from asymptomatic seroconversion to myocardial infiltration or disseminated neurological disease and death. Only one patient was known to be seropositive for antibody to T. gondii prior to transplantation. Transmission was most likely via the donor organ. Seronegative patients who receive organs from seropositive donors are at high risk for serious disease; prophylactic strategies need to be developed.
Respiratory syncytial virus infections in pediatric liver transplant recipients.
Respiratory syncytial virus (RSV) is the most important cause of lower respiratory tract infection in infants and young children. The charts of 17 children found to have RSV among 493 children who underwent liver transplantation between February 1985 and February 1991 were reviewed. The median age at diagnosis was 20 months. Median time of diagnosis was 24 days after transplantation. Thirteen patients developed nosocomial infections while convalescing from their transplant. Common symptoms included tachypnea, cough, fever, and congestion. Acute radiographic changes were seen in 12 patients. Two deaths were associated with progressive pulmonary disease and occurred in children with infection early in the postoperative period who were intubated before the onset of symptoms. RSV in children after liver transplantation has a clinical spectrum similar to that in normal children. Early onset of infection (less than 20 days) after transplantation and preexisting lung disease may predict more severe disease.
Adenovirus infection in pediatric liver transplant recipients.
A retrospective review of adenoviral infection in pediatric liver transplant recipients was done at Children's Hospital of Pittsburgh to define its epidemiology and clinical importance. Medical records of patients with adenovirus were reviewed and data collected regarding clinical course, microbiologic studies, biopsy results, immunosuppression, concurrent infections, and outcome. Of 484 liver transplant recipients, 49 had 53 episodes of adenoviral infection. The most common sites of adenoviral infection were the liver, lung, and gastrointestinal tract. Serotypes 1, 2, and 5 were recovered most often; type 5 was commonly associated with hepatitis. Invasive adenoviral infection occurred in 20 children, leading to death in 9. Median time from transplantation until isolation of adenovirus was 25.5 days. This timing suggests either reactivation or donor-associated transmission. Prospective studies using molecular epidemiologic techniques will be helpful in evaluating transmission patterns of adenovirus in this population.
Efficacy of antimicrobial prophylaxis and of tympanostomy tube insertion for prevention of recurrent acute otitis media: results of a randomized clinical trial.
To determine the efficacy of amoxicillin prophylaxis and of tympanostomy tube insertion in preventing recurrences of acute otitis media, we randomized 264 children 7 to 35 months of age who had a history of recurrent otitis media but were free of middle ear effusion to receive either amoxicillin prophylaxis, bilateral tympanostomy tube insertion or placebo. The average rate of new episodes per child year of either acute otitis media or otorrhea was 0.60 in the amoxicillin group, 1.08 in the placebo group and 1.02 in the tympanostomy tube group (amoxicillin vs. placebo, P less than 0.001; tubes vs. placebo, P = 0.25). The average proportion of time with otitis media of any type was 10.0% in the amoxicillin group, 15.0% in the placebo group and 6.6% in the tympanostomy tube group (amoxicillin vs. placebo, P = 0.03; tubes vs. placebo, P less than 0.001). At the 2-year end point, the rate of attrition was 42.2% in the amoxicillin group, 45.5% in the placebo group and 26.7% in the tympanostomy tube group. Adverse drug reactions occurred in 7.0% of the amoxicillin group and persistent tympanic membrane perforations developed in 3.9% of the tympanostomy tube group. The observed degree of efficacy of amoxicillin prophylaxis and of tympanostomy tube insertion must be viewed in light of the fact that study subjects proved not to have been at as high risk for acute otitis media as had been anticipated and in view of the differential attrition rates.(ABSTRACT TRUNCATED AT 250 WORDS)
Duration of rifampin chemoprophylaxis for contacts of patients infected with Haemophilus influenzae type B.
Rifampin is recommended as a prophylactic treatment for intimate contacts of young children who develop invasive infections with Haemophilus influenzae type B (Hib). A 4-day course of rifampin (20 mg/kg of body weight per day, not to exceed 600 mg as a maximum single daily dose) is 95% effective in eradicating pharyngeal colonization with Hib, thus effectively reducing the risk of both associated patients and recurrent illness in index patients less than 2 years old. This study compares rates of eradication of pharyngeal colonization with Hib for 2- and 4-day courses of rifampin therapy. One hundred sixty-three patients with Hib infection were treated at Children's Hospital of Pittsburgh between January 1986 and December 1988; prophylaxis was recommended for 128. Participating families were randomized to receive either 2- or 4-day therapy. Throat swabs were obtained from contacts prior to therapy. Repeat cultures were obtained from colonized contacts 2 days after completing rifampin and again on all contacts 7 to 10 days after completing therapy. Of 68 participating families, 34 received 2-day and 34 received 4-day therapy with rifampin. Twenty-two of 24 colonized contacts in the 2-day group and 17 of 18 in the 4-day group had negative cultures for Hib on follow-up. Two-day therapy with rifampin appears to be as effective as 4-day treatment in the eradication of Hib pharyngeal colonization.
Sinusitis in infants and children.
The major clinical problem in considering a diagnosis of sinusitis is differentiating uncomplicated upper respiratory tract infection from a secondary bacterial infection of the paranasal sinuses that may benefit from antimicrobial therapy. A diagnosis of sinusitis is suggested by presentation with protracted upper respiratory tract symptoms or a cold that is more severe than usual with fever and purulent nasal discharge. Confirmatory tests of sinus disease are transillumination (useful in adolescents if interpretation is confined to the extremes--normal or absent); radiographic findings of opacification, mucous membrane thickening, or an air-fluid level; and sinus aspiration (indicated for severe pain, clinical failures, or complicated disease). When clinical signs and symptoms are accompanied by abnormal radiographic findings, bacteria in high colony count are recovered from the maxillary sinus aspirate in 70% of patients. The common bacterial species recovered from children with acute maxillary sinusitis are Streptococcus pneumoniae, Moraxella (Branhamella) catarrhalis, and Hemophilus influenzae.
Respiratory syncytial virus: a comparison of diagnostic modalities.
This study compared prospectively viral culture for respiratory syncytial virus (RSV) with three rapid RSV antigen detection tests: RSV EIA and TestPack RSV (TP), and Directigen RSV (DIR). Additionally two methods of specimen collection were compared: nasopharyngeal rub (RUB) and nasopharyngeal wash (WASH). True positives were defined as positive RSV viral culture or at least two positive antigen tests. One hundred ninety-eight WASH specimens obtained from children 3 years of age or younger during the 1991 RSV winter epidemic were tested for RSV antigen. Sensitivity and specificity of WASH specimens were 59.5 and 100% (culture), 86.2 and 98.2% (RSV EIA), 91 and 96.3% (TP) and 83.5 and 94.3% (DIR). Concurrently obtained RUB samples from 124 children were tested by TP and/or DIR. Sensitivity of RUB specimens was significantly lower than that of WASH specimens; 64.9% (TP) and 43.6 (DIR). These easy to perform, rapid RSV antigen tests for WASH specimens provide timely diagnosis thereby facilitating management decisions and isolation efforts.
Infective agents in the central nervous system.
Almost all agents can cause infection within the central nervous system. The extent of infection ranges from diffuse involvement of the meninges, brain, or spinal cord to localized involvement presenting as a space-occupying lesion. Epidemiologic considerations, appreciation of the presenting clinical syndrome (acute bacterial meningitis, acute aseptic meningitis, chronic meningitis, or space-occupying lesion), and cerebrospinal fluid analysis facilitate arrival at a diagnosis.
Cautionary note on the use of empiric ceftriaxone for suspected bacteremia.
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Frequency and severity of infections in day care: three-year follow-up.
This study was undertaken to compare prospectively the frequency, nature, and severity of infections in children participating in three types of child care arrangements: home care, group care (two to six children), and day care (seven or more children). Children were enrolled at birth and observed for at least 36 months. The families were telephoned every 2 weeks to record on a standardized form the type and severity of illness during the previous interval. Children remaining in their original child care group for 1, 2, or 3 years were compared with regard to the frequency and severity of illness. Each child care group had the highest number of infections in year 2. Children in day care had more respiratory infections during each year than children in home care, but the magnitude of the differences decreased in year 3. When the child care groups were compared for the proportion of children with more than six illness per year or more than 60 days of respiratory illness per year, significant differences observed in years 1 and 2 for day care children compared with home care children were no longer significant in year 3. We conclude that there is a trend toward stabilized or decreased rates of infection, duration of illness, and risk of hospitalization for children remaining in day care for 3 years.
Acute rheumatic fever in western Pennsylvania: a persistent problem into the 1990s.
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Toxic shock syndrome and staphylococcal infection.
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Purulent nasal discharge.
Purulent nasal discharge is a common presenting symptom associated with infections of the upper respiratory tract. The most likely diagnoses are uncomplicated viral upper respiratory infections and bacterial sinusitis. Allergy may be an underlying problem in children with sinusitis. Less common considerations are adenoiditis, infections caused by B. pertussis, C. diphtheriae or Treponema pallidum or intranasal structural problems.
Anaerobes in otitis media and sinusitis.
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