Viridans streptococci bacteraemia in children with fever and neutropenia: a case-control study of predisposing factors

Viridans streptococci (VS) are an increasing cause of bacteraemia in neutropenic patients with cancer. Case-control studies of predisposing factors for acquisition of this infection in children are not published. Between January 1989 and December 1999, 168 episodes of bacteraemia in 161 children with fever and neutropenia of haemato-oncology origin were analysed. 15 cases (9%) in 15 patients were caused by VS. Each case patient was compared with 6 matched control patients; 2 with other Gram-positive cocci (group 2), 2 with gram-negative bacilli bacteraemia (group 3) and two children with fever and neutropenia without bacteraemia (group 4). The median age of patients was 4.1 years (range: 2-15 years). 87% of children had acute leukaemia or lymphomas. Pneumonia was the predominant clinical focus (70%). Shock was observed in 13% of patients. ARDS was observed in one child who died of this complication. Multivariate analysis of risk factors for the development of VS bacteraemia showed that two factors were independent predictors: high doses of cytosine-arabinoside (ARA-C) as part of the chemotherapy treatment (Odds Ratio (OR): 9.3; Confidence Interval (CI) 1.56-55.5) (P<0.014) and the presence of pneumonia (OR: 1.36: CI 2.27-81.9) (P<0.0043). We propose that further studies are warranted to confirm these results.

Risk factors for nosocomial candidaemia: a case-control study in children

Candida spp. are increasingly important nosocomial pathogens in critically ill children. Data on risk factors of acquisition in children with candidaemia are limited. To determine the incidence, prognosis and risk factors for acquisition of nosocomial candidaemia in children, a prospective case-control study was performed between July 1998 and January 2000. Candidaemia was defined as the presence of at least one positive blood culture containing Candida spp. For each case, two controls were selected and matched for time and site of hospital admission. Logistic regression was used to obtain estimates of risk after simultaneous control for other variables. Candidaemia was diagnosed in 24 children (1.09/1000 admissions). The species most frequently isolated were Candida albicans (50%) and Candida parapsilosis (17%). Mean age was 58.2+/-58 months between cases and 41.8+/-52.2 months in controls (P not significant). The strongest risk factors for acquisition found in the univariate analysis were underlying disease, previous antibiotic treatment, the number of antibiotics administered, presence of a long-duration catheter and total parenteral nutrition (P<0.05). Sex, the site of hospital admission, artificial ventilatory assistance, transitory venous catheters, arterial and peripherally venous accesses, bladder catheter and transfusions were not statistically significant. The risk factors identified by multiple logistic regression analysis were: permanent catheter (OR 31.5; 3.19-310) and total parenteral nutrition (OR 10.5; 2.76-40.0). Nine (37%) children with nosocomial candidaemia and seven (15%) controls died (P=0.05). These findings should facilitate development of rational approaches to preventing infection and assist clinicians in identifying those patients in whom this life-threatening complication is likely to occur.

Comparative analysis of outcome and clinical features in children with pleural empyema caused by penicillin-nonsusceptible and penicillin-susceptible Streptococcus pneumoniae

OBJECTIVE

To describe the clinical characteristics of pleural empyema in children caused by Streptococcus pneumoniae nonsusceptible to penicillin and compare their clinical outcome with pleural empyemas caused by penicillin-susceptible organisms.

METHODS

Records of 109 children with complicated pleural effusions between January 1996 and December 1998 were retrospectively reviewed.

RESULTS

Pathogens were recovered in 45 of these cases. Streptococcus pneumoniae represented 71% of the isolates, with 20 (62%) and 12 (38%) of the strains proving susceptible and nonsusceptible to penicillin, respectively. The average age for children with penicillin-nonsusceptible infections was 18.3 months compared with an average age of 40.9 months for those with penicillin-susceptible infections (P = 0.03). Previous antibiotic treatment was more frequent in children with penicillin-nonsusceptible organisms (P = 0.05). No significant differences were found between the two groups for gender, underlying diseases, duration of fever and tachypnea, need of surgical treatment, bacteremia incidence, mean duration of therapy, or length of hospital stay.

CONCLUSIONS

Pleural empyemas caused by penicillin-nonsusceptible S. pneumoniae appear to be associated with younger age and previous antibiotic treatment. By contrast, the outcome was not influenced by the penicillin susceptibility of the pneumococcus strains.

Atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii in two patients after allogeneic bone marrow transplantation

We report two patients who developed atypical skin lesions caused by Curvularia sp. and Pseudallescheria boydii after allogeneic bone marrow transplantation for severe aplastic anemia. The first patient (female, 18-year-old) had multiple hemorrhagic vesicles on day +30 after her second BMT for graft failure. Pseudallescheria boydii was isolated from a skin biopsy. The patient died of respiratory failure probably as a consequence of systemic fungal infection. The second patient (male, 9-year-old) developed an ecthyma gangrenosum-like lesion on his right palm on day +8. Curvularia sp. was isolated from a skin biopsy. Liposomal amphotericin was given to achieve a total dose of 30 mg/kg and followed by oral itraconazole until steroids were discontinued. The infection resolved completely and the patient has remained disease-free. We conclude that emerging fungal organisms such as those described in this report are increasingly recognized in this setting. Early recognition and biopsy of these cutaneous lesions will allow prompt initiation of therapy to prevent systemic infection.

Oral ciprofloxacin in the management of children with cancer with lower risk febrile neutropenia

BACKGROUND

Recent reports and a previous randomized trial conducted at the authors' institution suggested that a lower risk subset of children with febrile neutropenia under chemotherapy might benefit of an oral antibiotic outpatient approach.

METHODS

The objective of this study was to test the efficacy of oral ciprofloxacin in the treatment of lower risk febrile neutropenia (LRFN) in children treated for malignant diseases. From November 1998 to December 1999, 93 episodes of LRFN in 87 children (median age, 5.5 years; range, 0.9-15.8 years) were included in a prospective randomized controlled single institution trial. Inclusion criteria included fever (> 38 degrees C), severe neutropenia (absolute neutrophil count, < 500/mm(3)), and lower risk features (e.g., absence of severe comorbidity factors, good clinical condition, negative blood cultures, control of local infection, prediction of a period of neutropenia less than 10 days after admission, and compliant parents). After 24 hours of a single intravenous ceftriaxone (100 mg/kg) plus amikacin (15 mg/kg) and completed risk assessment workup, patients were discharged and randomly allocated to two groups. Group A (48 episodes) received ciprofloxacin 20 mg/kg/day orally (p.o.) every 12 hours for 6 days. Group B (45 episodes) received intravenous ceftriaxone plus amikacin for 2 days more followed by cefixime (8 mg/kg/day p.o.) every 24 hours for 4 additional days. Failure was defined as the need of a second hospitalization during the same episode.

RESULTS

Most of the patients (59% in Group A and 52% in Group B) were treated for malignant solid tumors. Fifteen (31%) children in Group A and 15 (33%) in Group B presented with fever of unknown origin (P value was not significant). No significant differences were found in sites of initial infection between both groups. Overall results in this study were excellent. Only one patient with respiratory failure was detected in Group B, who did well with secondary treatment.

CONCLUSIONS

In febrile neutropenic children after anticancer therapy and lower risk features, oral ciprofloxacin for 6 days after 24 hours of intravenous ceftraxione plus amikacin appears to be as efficacious as intravenous ceftriaxone plus amikacin for 2 days more followed by cefixime for 4 additional days. These results contribute to strengthen the concept of LRFN.

Tuberculous meningitis in children: clinical features and outcome in 40 cases

In order to assess the epidemiology, clinical features and outcome of tuberculous meningitis, a retrospective review of patients was conducted between January 1989 and December 1995. Forty cases (representing 10%, of all paediatric patients with tuberculosis) were included. Mean age was 46 months (range 1-165 months). Eighteen (45%) children were classified as stage I (non-specific febrile illness without neurological signs), 16 (40%) as stage II (neurological signs without marked changes in sensorium) and 6 (15%) as stage III (major neurological signs with sensorial changes and/or coma). Twenty-seven (67%) patients had received BCG vaccination and 14 (35%) displayed an induration zone higher than 10 mm after a 2-TU PPD test. Mycobacterium tuberculosis was recovered from 24 (61%) patients. Hydrocephalus was demonstrated by cranial computed tomography in 31 (78%) children. Overall, 18 (45%) children had a full recovery. Mild, moderate and severe neurological sequelae were shown by 7 (18%), 3 (8%) and 9 (22%) of the patients, respectively. Three fatal cases (7%) were observed. The presence of seizures (RR 15.6, 2.02-119.1) and absence of extrameningeal foci (RR 4.95, 1.10-22.1) were identified as risk factors by multivariate analysis. These findings emphasize the need quickly to diagnose tuberculosis in children in order to give appropriate and early treatment.

Fever and neutropenia in children with cancer in one pediatric hospital in Argentina

The authors retrospectively analyzed 863 episodes of neutropenia and fever in 635 children with cancer or hematological disease hospitalized between October 1988 and November 1994. The most frequent underlying diseases were solid tumors (45%) and acute lymphoblastic leukemia (29%). Clinical site of infection could be determined in 454 (53%) episodes. Bacteremia was documented in 114 (13%) cases. Gram-positive cocci were the microorganisms most frequently isolated (47% of the cases). Noninfectious complications could be determined in 140 (16%) episodes, and were mainly severe bleeding and metabolic impairment. The episodes were divided in two groups for comparative evaluation: group A, 404 episodes, study period 1988-1991, and group B, 459 episodes, 1992-1994. According to the results, more patients in group A than group B were younger than 1 year old and had profound neutropenia; fewer patients in group A than group B had an endovascular catheter, a higher frequency of manifest clinical site of infection at admission, and a prevalence of isolation of gram-negative bacilli. A higher percentage of patients in group B had neutropenia of more than 14 days, gram-positive cocci in culture, and lower mortality. Multivariate analysis by logistic regression in 340 patients revealed that the presence of a severe noninfectious complication, severe neutropenia, and positive blood culture correlated with high mortality rate (p < or = 0.001).