Nonspecific immunomodulators for recurrent respiratory tract infections, wheezing and asthma in children: a systematic review of mechanistic and clinical evidence

PURPOSE OF REVIEW

To provide an overview of the mechanistic and clinical evidence for the use of nonspecific immunomodulators in paediatric respiratory tract infection (RTI) and wheezing/asthma prophylaxis.

RECENT FINDINGS

Nonspecific immunomodulators have a long history of empirical use for the prevention of RTIs in vulnerable populations, such as children. The past decade has seen an increase in both the number and quality of studies providing mechanistic and clinical evidence for the prophylactic potential of nonspecific immunomodulators against both respiratory infections and wheezing/asthma in the paediatric population. Orally administered immunomodulators result in the mounting of innate and adaptive immune responses to infection in the respiratory mucosa and anti-inflammatory effects in proinflammatory environments. Clinical data reflect these mechanistic effects in reductions in the recurrence of respiratory infections and wheezing events in high-risk paediatric populations. A new generation of clinical studies is currently underway with the power to position the nonspecific bacterial lysate immunomodulator OM-85 as a potential antiasthma prophylactic.

SUMMARY

An established mechanistic and clinical role for prophylaxis against paediatric respiratory infections by nonspecific immunomodulators exists. Clinical trials underway promise to provide high-quality data to establish whether a similar role exists in wheezing/asthma prevention.

Neonatal and pediatric antimicrobial stewardship programs in Europe-defining the research agenda

The relationship between suboptimal use of antimicrobials and antimicrobial resistance has become increasingly clear. Despite significant international effort aimed at reducing inappropriate antimicrobial prescribing in hospitals, antimicrobial resistance remains a major public health threat. Antimicrobial Stewardship Programs (ASPs) comprise a series of measures aimed at optimizing the use of antimicrobials, while improving the quality of patient care and promoting cost-effectiveness. This discussion article aims to summarize some of the approaches that have been used in neonatal and pediatric ASPs, with a particular focus on the European healthcare setting. Current evidence demonstrates neonatal and pediatric ASPs to be safe, practical to implement, generally cost-effective and possibly associated with a reduction in antimicrobial resistance rates. This review identified that, despite the recognized need for additional evidence and information on implementation, published data on pediatric ASPs derives mainly from the United States, with very few published reports on formal ASPs in European children's hospitals. Consequently, the optimal method of implementation remains unknown within a European setting. Future research needs to include novel study designs on how best to introduce ASPs, monitoring of clinically relevant outcomes and cost-effectiveness with improved measurement of the impact on antimicrobial resistance.

Procalcitonin guidance to reduce antibiotic treatment of lower respiratory tract infection in children and adolescents (ProPAED): a randomized controlled trial

Background

Antibiotics are overused in children and adolescents with lower respiratory tract infection (LRTI). Serum-procalcitonin (PCT) can be used to guide treatment when bacterial infection is suspected. Its role in pediatric LRTI is unclear.

Methods

Between 01/2009 and 02/2010 we randomized previously healthy patients 1 month to 18 years old presenting with LRTI to the emergency departments of two pediatric hospitals in Switzerland to receive antibiotics either according to a PCT guidance algorithm established for adult LRTI or standard care clinical guidelines. In intention-to-treat analyses, antibiotic prescribing rate, duration of antibiotic treatment, and number of days with impairment of daily activities within 14 days of randomization were compared between the two groups.

Results

In total 337 children, mean age 3.8 years (range 0.1–18), were included. Antibiotic prescribing rates were not significantly different in PCT guided patients compared to controls (OR 1.26; 95% CI 0.81, 1.95). Mean duration of antibiotic exposure was reduced from 6.3 to 4.5 days under PCT guidance (−1.8 days; 95% CI −3.1, −0.5; P = 0.039) for all LRTI and from 9.1 to 5.7 days for pneumonia (−3.4 days 95% CI −4.9, −1.7; P<0.001). There was no apparent difference in impairment of daily activities between PCT guided and control patients.

Conclusion

PCT guidance reduced antibiotic exposure by reducing the duration of antibiotic treatment, while not affecting the antibiotic prescribing rate. The latter may be explained by the low baseline prescribing rate in Switzerland for pediatric LRTI and the choice of an inappropriately low PCT cut-off level for this population.

Trial Registration

Controlled-Trials.com ISRCTN17057980 ISRCTN17057980

A 4-year study on clinical characteristics of children hospitalized with rotavirus gastroenteritis

Rotavirus (RV) is a frequent cause of severe gastroenteritis (GE) in children. With the licensure of new RV vaccines, data on the burden of disease are important regarding immunization strategies. We reviewed the medical records of children hospitalized with RV infection in our institution between July 2002 and March 2006. Relevant data were extracted in a standardized fashion from records of hospitalized children with a positive RV antigen test in a stool sample. Severity of disease was graded by the 20-point Vesikari score. Population data were obtained from the Federal Office of Statistics. Six hundred eighty-six RVGE were identified and records of 608 hospitalizations (in 607 children) were available. In 539 (89%) cases, RVGE was the primary reason for hospitalization and 69 (11%) were nosocomial infections; yearly peaks occurred between February and May. Cumulative incidence of RVGE was 26.7/1,000 children <3 years of age. Median age of 539 children (55.6% male) with primary RVGE was 1.4 years and median stay in the hospital for both community acquired and nosocomial RVGE was 4 days (interquartile range 3-5). Thirtypercent and 94% of RV hospitalizations were in children <1 and <3 years of age, respectively. Mean Vesikari score was 15 (range 6-20; 96% >11). Intravenous fluids were administered in 378 (70%) patients, 130 (24%) patients were rehydrated via nasogastral tube, and 31 (5.7%) received rehydration by mouth. RVGE causes a substantial burden in children with an estimated risk for hospitalization due to RVGE of one in 37 children <3 years of age.

A multicenter, cross-sectional study on the prevalence and risk factors for nasal colonization with Staphylococcus aureus in patients admitted to children's hospitals in Switzerland

The rate of nasal carriage of Staphylococcus aureus and associated risk factors were determined in a cross-sectional study involving Swiss children's hospitals. S. aureus was isolated in 562 of 1363 cases. In a stepwise multivariate analysis, the variables age, duration of antibiotic use, and hospitalization of a household member were independently associated with carriage of S. aureus.

Randomized, comparative efficacy trial of oral penicillin versus cefuroxime for perianal streptococcal dermatitis in children

OBJECTIVE

To investigate the efficacy of penicillin compared with cefuroxime for group A beta-hemolytic Streptococcus pyogenes (GABHS) perianal dermatitis.

STUDY DESIGN

Children 1 to 16 years of age with signs and symptoms of perianal dermatitis and a positive anal swab were randomized to penicillin or cefuroxime treatment and were clinically re-evaluated on day 3 and at the end of treatment (cefuroxime, day 7; penicillin, day 10). An anal swab was obtained to document eradication of GABHS at the end of treatment. Severity of disease was assessed with a clinical score (perianal erythema, 5 points; perianal itch, 3 points; painful defecation, 3 points; constipation, 2 points).

RESULTS

Patients were enrolled and randomly assigned to penicillin (n = 18) or cefuroxime (n = 17) treatment. Treatment with penicillin was inferior to cefuroxime, which led to premature study termination after consultation with the ethics committee. Clinical improvement was more rapid in the cefuroxime group (P = .028) and GAHBS was not isolated from the anus the last day of therapy in 13 of 14 patients treated with cefuroxime compared with 7 of 15 patients treated with penicillin (P < .01).

CONCLUSIONS

Cefuroxime was more effective than penicillin and therefore should be considered as the treatment of choice for perianal dermatitis due to GABHS.

Clinical findings and unusual epidemiologic characteristics of human metapneumovirus infections in children in the region of Basel, Switzerland

Human metapneumovirus (hMPV) worldwide causes respiratory tract infections with features similar to those of RSV infection. We describe features of hMPV infections in children and compare some of the characteristics with those of RSV infections. From October 2004 to February 2006, 75 patients, 34 hospitalized and 41 outpatients, were diagnosed with hMPV infections by multiplex PCR applied to nasopharyngeal specimens. While hMPV was found rarely in the early phase of the study, a significant increase occurred in the second winter of the study period. Patients with hMPV infections were older than those with RSV infection; clinical characteristics were similar as was the rate of serious disease among hospitalized patients (intensive care treatment: 18% versus 8%). In conclusion, hMPV leads to endemic and epidemic respiratory disease with features similar to those of RSV and should be considered in the differential diagnosis of upper and lower respiratory tract disease.

Assessment of immunization status in hospitalized children followed by counseling of parents and primary care physicians improves vaccination coverage: an interventional study

This prospective, intervention-control study in hospitalized, underimmunized children assessed the effect of vaccination reminders to parents during hospitalization and provides postdischarge rates of catch-up immunizations. One month after hospital discharge, significantly more children in the intervention group (27%) than the controls (8%) had received catch-up immunizations (P < .001).

Three-year surveillance of intussusception in children in Switzerland

OBJECTIVE

We attempted to obtain baseline data on the incidence of intussusception and its association with gastroenteritis in a cross-sectional observational study in children.

METHODS

Admissions to all 38 pediatric units in Switzerland because of intussusception were reported to the Swiss Pediatric Surveillance Unit from April 2003 to March 2006. Patient and disease characteristics were assessed prospectively with the use of a standardized questionnaire based on the case definition for intussusception developed by the Brighton Collaboration. Completeness of reporting was verified through capture-recapture analysis.

RESULTS

There were 294 patients with reported intussusception; 35 cases were excluded for various reasons, and 29 additional patients were identified through International Classification of Diseases, 10th Revision, codes. After capture-recapture analysis, we estimated underreporting to the Swiss Pediatric Surveillance Unit to be 32% and we calculated a true number of 381 intussusception episodes. The highest level of diagnostic certainty was reached by 248 patients, and 20 fulfilled level 2 criteria; for the remaining 20 patients, available information was insufficient. The mean age of the patients was 2.7 years. The yearly mean incidence of intussusception was 38, 31, and 26 cases per 100,000 live births in the first, second, and third year of life, respectively, with no apparent seasonality. Seventy patients had a history of coinciding gastroenteritis, and 5 of 61 tested positive for rotavirus. Spontaneous devagination was observed for 38 patients; enemas reduced intussusception successfully in 183 cases, whereas surgical treatment was required in 67. All patients recovered without sequelae.

CONCLUSIONS

This is the first prospective nationwide surveillance of intussusception in childhood using a standardized case definition. Most cases occurred beyond infancy, and association with rotavirus gastroenteritis was rare.

Prevalence of nasal colonization with methicillin-resistant Staphylococcus aureus (MRSA) in children a multicenter cross-sectional study

In this cross-sectional multicenter study, we determined the rate of nasal carriage of methicillin-resistant Staphylococcus aureus (MRSA) in children admitted to 9 training hospitals in Switzerland during 1 month. From 1337 patients, 1363 nasal swabs were obtained (mean age 6.1 years, median 4.7 years, interquartile range 1.3-10.4 years) and 562 (41.3%) grew S. aureus. Only one isolate was MRSA (0.18%) which encoded mecA and femA genes as well as SCCmec type IV, whereas Panton-Valentine leukocidin (PVL) was absent.

Antibody responses induced by long-term vaccination with an octovalent conjugate Pseudomonas aeruginosa vaccine in children with cystic fibrosis

We assessed the serological responses over 10 years to repeated immunization of cystic fibrosis (CF) patients with an O-polysaccharide (OPS)-toxin A conjugate vaccine against Pseudomonas aeruginosa. A retrospective analysis was performed with sera from 25 vaccinated and 25 unvaccinated children treated at the same CF centre and matched for clinical management, age and gender. Yearly immunization led to sustained elevations of serum immunoglobulin G (IgG) antibody levels to all vaccine components. Eighteen unvaccinated patients but only eight vaccinated ones developed chronic pseudomonal lung infections. Infection rapidly caused further marked elevations of polysaccharide- but not toxin A-specific serum IgG in both immunized and nonimmunized patients, indicating that protection did not depend on the quantity of IgG present. However, qualitative analyses revealed that the protective capacity of specific serum IgG antibodies was linked to high affinity and to specificity for OPS serotypes rather than for lipopolysaccharide core epitopes.

Gelatinase B [matrix metalloproteinase (MMP)-9] and collagenases (MMP-8/-13) are upregulated in cerebrospinal fluid during aseptic and bacterial meningitis in children

We investigated the protein expression of gelatinases [matrix metalloproteinase (MMP)-2 and -9] and collagenases (MMP-8 and -13) in cerebrospinal fluid (CSF) from patients with bacterial (BM, n = 17) and aseptic (AM, n = 14) meningitis. In both, MMP-8 and -9 were increased in 100% of patients, whereas MMP-13 was detectable in 53% and 82% respectively. Three patients with clinical signs of meningitis, without CSF pleocytosis, scored positive for all three MMPs. MMP-8 appeared in two isoforms, granulocyte-type [polymorphonuclear cell (PMN)] and fibroblast/macrophage (F/M) MMP-8. Analysis of kinetic changes from serial lumbar punctures showed that these MMPs are independently regulated, and correlate only partly with CSF cytosis or levels of the endogenous inhibitor, tissue inhibitor of matrix metalloproteinase-1. In vitro, T cells, peripheral blood mononuclear cells (PBMCs) and granulocytes (PMN) release MMP-8 and -9, whereas MMP-13 could be found only in the former two cell types. Using models of exogenous (n-formyl-Met-Leu-Phe, T cell receptor cross-linking) and host-derived stimuli (interleukin-2), the kinetics and the release of the MMP-8, -9 and -13 showed strong variation between these immune cells and suggest release from preformed stocks. In addition, MMP-9 is also synthesized de novo in PBMCs and T cells. In conclusion, invading immune cells contribute only partially to MMPs in CSF during meningitis, and parenchymal cells are an equally relevant source. In this context, in patients with clinical signs of meningitis, but without CSF pleocytosis, MMPs seem to be a highly sensitive marker for intrathecal inflammation. The present data support the concept that broad-spectrum enzyme inhibition targeting gelatinases and collagenases is a potential strategy for adjunctive therapy in infectious meningitis.

Seroprevalence of Varicella-Zoster virus IgG antibodies in Swiss children during the first 16 months of age

QUESTION UNDER STUDY

To investigate the persistence of maternal IgG antibodies against Varicella-Zoster virus (VZV) in infants and young children.

METHODS

Serum specimens of children aged 0-16 months who had been hospitalized in our institution between 1994 and 1999 were identified from our routine serum collection. Exclusion criteria were: preterm delivery (<37 gestational weeks); suspected varicella infection or presence of exanthema of unknown etiology at time of serum collection; transfusion of blood products during 6 months preceding serum collection; foreign born mother; and previous VZV immunization. Serotesting for IgG antibodies against VZV was performed by use of a commercially available ELISA kit.

RESULTS

Two hundred and fifty three serum specimens from 240 patients were analyzed. Age distribution of patients at time of specimen collection was: 0-3 months: n=57; >3-6 months: n=47; >6-9 months: n=47; >9-12 months: n=48; >12-16 months: n=54. Seroprevalence rates for IgG antibodies against VZV in the different age groups were 90% (0-3 months), 38% (>3-6 months); 0% (>6-9 and >9-12 months); and 7% (>12-16 months).

CONCLUSIONS

Our results demonstrate high levels of passively acquired humoral immunity against varicella in Swiss infants during the first 3 months of life. Beyond the first 3 months of life IgG antibodies against VZV are lacking in the majority of patients and between 6 and 12 months of age all specimens tested were negative. Beyond the first year of life antibodies against varicella were detected in four samples, probably due to previous VZV infection. In accordance with current recommendations, VZV vaccination should ideally be administered to children 9 months of age and older, although our data indicate that successful immunization may be possible at earlier age (6 months onwards) in certain circumstances.

Influenza vaccination among healthcare workers in a university children's hospital

OBJECTIVES

To evaluate the attitudes of pediatric healthcare workers (HCWs) toward influenza vaccination and to increase their rate of immunization.

METHODS

A survey was conducted among pediatric HCWs using an anonymous questionnaire. Survey results were used to design an intervention to increase the immunization rate of staff. Immunization rates before (2003-2004) and after (2004-2005) intervention were assessed using immunization clinic records.

SETTING

A university children's hospital in Switzerland.

INTERVENTIONS

(1) An informational letter based on misconceptions noted in the survey, (2) educational conversations with head nurses, (3) more "walk-in" immunization clinics, and (4) a direct offer of influenza immunization on the wards.

RESULTS

Among vaccine nonrecipients, doubts about the efficacy and necessity of influenza immunization were prevalent and more often reported by nurses than physicians (75% vs 41%, P = .002; and 55% vs 23%, P = .001, respectively). Physicians more often than nurses reported lack of time as a reason for not receiving influenza vaccination (23% vs 5%, P = .01). After intervention, the immunization rate of HCWs increased from 19% to 24% (P = .03). The immunization rate of physicians increased from 43% to 64% (P = .004). No change was noted among nurses (13% vs 14%) and other HCWs (16% vs 16%).

CONCLUSIONS

Misconceptions about influenza vaccination were prevalent among pediatric staff, particularly nurses. Active promotion and educational efforts were successful in increasing the immunization rate of physicians but not nurses and other HCWs.

Predictive value of double tympanocentesis in acute otitis media

Advances in the understanding of acute otitis media (AOM), lessons learned from antibacterial trials, and the emergence of pathogens with decreased susceptibility to commonly used antibiotics explain the need to redefine the role of tympanocentesis. The diagnostic value of tympanocentesis at baseline to establish the bacterial cause of AOM is well accepted. However, relevant ethical and scientific arguments conclude that repeat (or double) tympanocentesis cannot be recommended as routine procedure, either for the individual patient or for each treatment trial. Relevant aspects on trial design for AOM, with special emphasis on the value of double tympanocentesis, are reviewed.

Fluoroquinolone Antibiotics in Infants and Children

The use of fluoroquinolones in children is limited because of the potential of these agents to induce arthropathy in juvenile animals and to potentiate development of bacterial resistance. No quinolone-induced cartilage toxicity as described in animal experiments has been documented unequivocally in patients, but the risk fro rapid emergence of bacterial resistance associated with widespread, uncontrolled fluoroquinolones use in children is a realistic threat. Overall, the fluoroquinolones have been safe and effective in the treatment of selected bacterial infections in pediatric patients. There are clearly defined indications for these compounds in children who are ill.

Reliability of varicella history in children and adolescents

QUESTION UNDER STUDY

Only limited data are available regarding the reliability of the varicella zoster virus (VZV) history in children and adolescents. Our goal was to determine positive and negative predictive values of varicella history in a prospective cross-sectional study.

METHODS

Patients 1-18 years of age who were hospitalised in our institution between 1999 and 2000 were eligible for participation when a blood specimen was taken for any medical reason. Patients with current varicella, immunodeficiency, immunoglobulin treatment in the previous 6 months, or significant language barriers were excluded. After informed consent had been obtained, parents were asked whether their child had a history of varicella (categorized as definite, probable, possible, negative or unknown). Anti-VZV-IgG antibodies were then tested by ELISA (Enzygnost). If the ELISA result was indeterminate, the specimen was analysed by fluorescent-antibody staining of membrane antigen in VZV-infected cells (FAMA), the serological gold standard.

RESULTS

449 patients (mean age 6.4 years, median 5.4 years) were enrolled. History of varicella was definite in 234 (52%), probable in 12 (3%), possible in 1, negative in 196 (44%) and unknown in 6 (1%) patients. Overall, 61% (95% CI: 56-65) of patients were positive for VZV antibodies. Seroprevalence was 25%, 68% and 95% in 1-4 year olds (group 1, n = 167), 5-8 year olds (group 2, n = 136) and 9-18 year olds (group 3, n = 146), respectively. The positive predictive value of a definite history of varicella was 98% (95% CI: 96-100) (93%, 100%, and 98% in groups 1, 2 and 3, respectively). The negative predictive value was 85% (95% CI: 80-90), decreasing with age (group 1: 97%; group 2: 77%; group 3: 26%).

CONCLUSIONS

The positive predictive value of a history of varicella is high in children and adolescents. In countries where universal immunization against varicella is not recommended, selectively immunizing adolescents with a negative history can reduce the rate of susceptible individuals efficiently.

Prospective surveillance of hospitalisations associated with varicella-zoster virus infections in children and adolescents

Our goal was to determine the epidemiology of severe varicella-zoster virus (VZV) infections in hospitalised paediatric patients. Admissions associated with VZV infection of patients aged 0-16 years were reported by all 38 paediatric units in Switzerland to the Swiss Paediatric Surveillance Unit (SPSU) during 3 consecutive years (4/2000-3/2003). We verified completeness of reporting by capture-recapture analysis with patient records identified by ICD-10 codes. Outcome of illness was assessed 6 months after hospitalisation. A total of 335 cases (235 identified by SPSU reports, 100 by ICD-10 code) were included in this study. Mean age of patients was 4.1 years (median 3.5 years, range 0-16 years); 54% were male. Some 293 (87%) patients presented with chickenpox, 42 (13%) with herpes zoster and 291 (87%) patients were not immunocompromised. A total of 319 complications occurred in 237 (71%) patients: secondary bacterial infections (n =109); central nervous system involvement (n =76); VZV pneumonitis (n =7); others (n =127). Eleven (3%) patients required intensive care and three died. On follow-up, 303 (96%) of 315 patients had completely recovered; sequelae were present in 12 (4%) patients. The calculated hospitalisation rate was 13 per 10(4) cases.

CONCLUSION

This study describes a sizeable hospitalisation and complication rate of varicella-zoster virus infections and provides a solid basis for future immunisation recommendations in Switzerland.

Seroprevalence and immunization history of selected vaccine preventable diseases in medical students

To evaluate protection against vaccine-preventable diseases in medical students, we obtained data on immunization status and history of diphtheria, tetanus, pertussis, poliomyelitis, measles, mumps, rubella, varicella and hepatitis B from students with elective periods in our institution. Further, serum antibodies against measles, mumps, rubella and varicella-zoster virus (VZV) and hepatitis B surface (HBs) antigen were determined on a voluntary basis. For students with incomplete immunization status or lack of protective antibodies, vaccination was offered for free. Success of catch-up immunizations was serologically confirmed 4 weeks later. From May 1999 to April 2003, 170 students were enrolled; their mean age was 26 years with a median of 25 years (range 22-48 years). Immunization records were complete in 148 (87%), incomplete in 11 (6.5%) and missing in 11 (6.5%) students. Only 26% of the cohort had a complete and up-to-date immunization status. Seroprevalence of IgG antibodies against measles, mumps, rubella, VZV and HBs (> or = 10 IU/l) in 149 students were 85, 85, 92, 97 and 90%, respectively. Indications for > or = 1 catch-up immunization were found in 125 (74%) students and were accepted by 97 of them (78%). Sixty two (99%) of 63 immunized students available for follow-up demonstrated an adequate serological response. In conclusion, the great majority of medical students had immunization gaps. Systematic immunization programmes for medical students should be implemented.

Reliability of varicella history in children and adolescents

QUESTION UNDER STUDY

Only limited data are available regarding the reliability of the varicella zoster virus (VZV) history in children and adolescents. Our goal was to determine positive and negative predictive values of varicella history in a prospective cross-sectional study.

METHODS

Patients 1-18 years of age who were hospitalised in our institution between 1999 and 2000 were eligible for participation when a blood specimen was taken for any medical reason. Patients with current varicella, immunodeficiency, immunoglobulin treatment in the previous 6 months, or significant language barriers were excluded. After informed consent had been obtained, parents were asked whether their child had a history of varicella (categorized as definite, probable, possible, negative or unknown). Anti-VZV-IgG antibodies were then tested by ELISA (Enzygnost). If the ELISA result was indeterminate, the specimen was analysed by fluorescent-antibody staining of membrane antigen in VZV-infected cells (FAMA), the serological gold standard.

RESULTS

449 patients (mean age 6.4 years, median 5.4 years) were enrolled. History of varicella was definite in 234 (52%), probable in 12 (3%), possible in 1, negative in 196 (44%) and unknown in 6 (1%) patients. Overall, 61% (95% CI: 56-65) of patients were positive for VZV antibodies. Seroprevalence was 25%, 68% and 95% in 1-4 year olds (group 1, n = 167), 5-8 year olds (group 2, n = 136) and 9-18 year olds (group 3, n = 146), respectively. The positive predictive value of a definite history of varicella was 98% (95% CI: 96-100) (93%, 100%, and 98% in groups 1, 2 and 3, respectively). The negative predictive value was 85% (95% CI: 80-90), decreasing with age (group 1: 97%; group 2: 77%; group 3: 26%).

CONCLUSIONS

The positive predictive value of a history of varicella is high in children and adolescents. In countries where universal immunization against varicella is not recommended, selectively immunizing adolescents with a negative history can reduce the rate of susceptible individuals efficiently.

Compliance with antenatal screening for hepatitis B surface antigen carrier status in pregnant women and consecutive procedures in exposed newborns

The goal of this study was to determine compliance with official recommendations for prevention of perinatal hepatitis B virus transmission from hepatitis B surface antigen (HBsAg) positive mothers to their offspring. All infants born to HBsAg positive mothers at the University Women's Hospital in Basel, Switzerland, in 2001 were identified and post-exposure immunisations were analysed. In addition, detailed written information on subsequent hepatitis B immunisations was obtained from the infants' paediatricians. A total of 1513 women gave birth to 1554 children and screening for HBsAg had been performed in 1503 (99%) women, of whom 8% were screened during delivery. A group of 18 (1.2%) women were HBsAg positive and 17 (95%) of the 19 exposed infants promptly received active and passive immunisation. One exposed infant was lost to follow-up and in one, postnatal vaccination was missed. Of the remaining 17 exposed infants, 9 (53%) received the full course of three active immunisations, but only two (12%) were immunised within the recommended time frame. On follow-up, six children were still too young for serological testing for successful immunisation. Among the remaining 11 immunised infants, serological testing had been performed in 4 (36%).

CONCLUSION

Compliance with recommendations for hepatitis B surface antigen screening was excellent in this study. The proportion of exposed infants receiving all three active immunisations was satisfactory, but more attention must be paid to complete and timely administration and serological testing in the future. This will require improved communication between neonatology units and care-providing paediatricians in private practices.

Vaccination of cystic fibrosis patients against Pseudomonas aeruginosa reduces the proportion of patients infected and delays time to infection

INTRODUCTION

Cystic fibrosis (CF) almost always leads to chronic airway infection with Pseudomonas aeruginosa. Despite advances in antibiotic therapy, after chronic infection rapid deterioration in lung function occurs, increasing morbidity and mortality. Prevention of infection by vaccination is desirable, but earlier trials produced disappointing results. The promising short term immunogenicity and safety of a new P. aeruginosa vaccine prompted us to evaluate its long term efficacy. We conducted a 10-year retrospective analysis of outcomes in a group of vaccinated patients.

MATERIALS AND METHODS

In 1989-1990, 30 young children with CF, mean age 7 years, with no prior history of infection with P. aeruginosa, were vaccinated against P. aeruginosa with a polyvalent conjugate vaccine. We report the follow-up of 26 of these patients from 1989 to 2001. The patients were given yearly vaccine boosters. Comparisons were made with a CF patient control group matched for gender, age and, where possible, genetic mutation. Vaccinated patients and controls were attending a single CF clinic and received the same clinical management throughout the study period. Main outcomes were time to infection, proportion of patients infected, development of P. aeruginosa mucoid phenotype, lung function and body weight.

RESULTS

The time to infection with P. aeruginosa was longer in the vaccination group than in the control group, and fewer vaccinated patients than controls became chronically infected (32% versus 72%; P < 0.001). The proportion of mucoid infections was higher in the control group (44%) than in the vaccinated group (25%). Patients >/=18 years of age at the end of the study had a lower mean forced expiratory volume at 1 s (FEV1) than did those 13-17 years of age, but this difference was small in the vaccinated group (73.6% versus 83.7%) compared with the controls (48.0% versus 78.7%). In the >/=18 year age category the mean FEV1% at 10 years was 73.6% (vaccinated) and 48.0% (controls) (P < 0.05). In the vaccinated group only 11 (44%) of 25 patients were underweight at the 10-year follow-up compared with 18 (72%) of 25 at the beginning of the study. In the control group 17 (68%) of 25 patients were underweight at 10-year follow-up compared with 16 (64%) of 25 at the beginning of the study.

CONCLUSION

Regular vaccination of young CF patients for a period of 10 years with a polyvalent conjugate vaccine reduced the frequency of chronic infection with P. aeruginosa. This was associated with better preservation of lung function. Vaccinated patients gained more weight during the study period, a possible indication of an improved overall health status.

Potential role of fluoroquinolone therapy in childhood otitis media

Increased resistance of pneumococci and other pathogens to available antibiotics raises concerns about bacteriologic and clinical failure in children with acute otitis media. Few therapeutic options exist for patients with recurrent infections or recent treatment failure. The limited experience from the compassionate use of fluoroquinolones in pediatrics and pediatric studies has not been linked unequivocally with arthrotoxicity, the primary safety concern in children. Newer 8-methoxyfluoroquinolones may have a role in selected cases associated with multidrug-resistant pathogens.

Transplacentally acquired immunoglobulin G antibodies against measles, mumps, rubella and varicella-zoster virus in preterm and full term newborns

IgG antibody values against measles, mumps, rubella and varicella-zoster virus in 71 full term and 101 preterm infants and their 152 mothers and the decay of maternally acquired antibodies during infancy were studied. Both magnitude of transplacental antibody passage and cord blood antibody values correlated with gestational age. After 6 months preterm infants born before 32 weeks of gestation had lost maternal antibodies.

Optimizing antibacterial therapy for community-acquired respiratory tract infections in children in an era of bacterial resistance

The spread of antibacterial resistance in bacteria that commonly cause childhood community-acquired respiratory tract infections (RTIs), such as acute otitis media, community-acquired pneumonia, and acute pharyngitis, is a major healthcare problem. One of the foremost concerns is the rapid increase in penicillin, macrolide, and multidrug resistance in Streptococcus pneumoniae. There is also a rising prevalence of macrolide resistance in Streptococcus pyogenes in pockets of the United States, and beta-lactamase production in Haemophilus influenzae is widespread. Although data are limited, some evidence suggests that resistance to antibacterials can impair bacteriologic and clinical outcomes in childhood RTIs. Optimizing antibacterial use is important both in the care of individual patients and within strategies to address the wider problem of antibacterial resistance. This involves encouraging judicious antibacterial use (i.e., reducing overuse for viral infection and prophylaxis), and preventing misuse through the wrong choice, dosage, and duration of therapy. Given that initial therapy is usually empiric, antibacterials used to treat community-acquired RTIs in children should ideally have the following properties: an optimal targeted spectrum of activity; high clinical and bacteriologic efficacy against respiratory pathogens, including resistant strains; simple, short-course therapy; and good tolerability and palatability. New antibacterials will continue to have a role in the treatment of RTIs in children, especially where resistance compromises existing therapies.

Acute Streptococcal Tonsillopharyngitis: A Review of Clinical Efficacy and Bacteriological Eradication

This review evaluates studies published between January 1997 and August 2003 comparing clinical outcome and bacteriological eradication rates for patients with acute streptococcal tonsillopharyngitis treated with penicillin or other antimicrobial agents. Studies were identified using MEDLINE, and clinical outcome and bacteriological eradication at end of treatment and 2 weeks after end of treatment were ascertained. Any longer-term follow-up was also noted, along with treatment-related adverse events and compliance. Clinical efficacy rates between penicillin and comparator antibiotics were generally high and similar. Bacterial eradication rates were more variable and, 2 weeks after treatment, ranged from 64% to 93% for penicillin and 31% to 98% for comparators. Simpler dosing schedules and shorter therapy durations produced higher compliance rates. This review highlights the similarities and differences between treatment with penicillin and a wide range of comparator antibiotics. Therapy for acute group A streptococcal pharyngitis should combine excellent clinical efficacy, high bacteriological eradication rates, good tolerance and a simple, convenient dosing regimen.

Role of Chlamydia pneumoniae and Mycoplasma pneumoniae as causative agents of community-acquired pneumonia in hospitalised children and adolescents

The aim of the study presented here was to determine the prevalence of Chlamydia pneumoniae versus Mycoplasma pneumoniae infections in paediatric patients with community-acquired pneumonia. A total of 50 patients (mean age, 5.5 years; median, 3.9 years) with community-acquired pneumonia were enrolled. Four patients were found to have Chlamydia pneumoniae infection (1 culture positive, 1 PCR positive and 2 serology positive) and 16 patients had Mycoplasma pneumoniae infection (2 PCR positive, 4 PCR and serology positive, 10 serology positive), including three patients with coinfection. The rates of Mycoplasma pneumoniae infection were 22%, 35% and 40% in children aged 1-3, >3-7 and >7 years, respectively. Acute Chlamydia pneumoniae infection was substantially less common than Mycoplasma pneumoniae infection in our study cohort.

Cost-effectiveness of a pneumococcal conjugate immunisation program for infants in Switzerland

OBJECTIVE

To compare projected economic costs and health benefits associated with using pneumococcal conjugate heptavalent vaccine as routine immunisation in healthy children in Switzerland.

DESIGN

A cost-utility analysis was performed from both the societal as well as the sickness funds' perspective.

SETTING

Simulated birth cohorts of 80,000 children (the approximate size of a birth cohort in Switzerland) were followed from birth up to age of 5.

MAIN OUTCOME MEASURES

Reduction in disease burden, costs of vaccination, cost-utility ratio (cost per quality-adjusted life year (QALY)).

RESULTS

With a vaccine coverage of 70% vaccination of newborns only would avert 4 deaths, 8 cases of meningitis, 37 cases of other invasive pneumococcal disease, 150 cases of pneumococcal pneumonia and about 2700 cases of otitis media (OM) per year. The net cost of the vaccination program would be 22 Mio. CHF per year for society and about 19 Mio. CHF for the sickness funds. This results in a cost-utility ratio of 35,700 CHF (approximately 26,300 USD (1)) per QALY from the societal perspective and 39,300 CHF (28,900 USD) per QALY from the sickness funds' perspective. Additional catch-up vaccination of all infants <24 months in the years after vaccine introduction would result in additional benefits at a cost of 33,600 CHF per additional QALY gained. However, if the catch-up vaccination should include all children <60 months, each additional QALY would be gained at a very high cost (162,000 CHF per additional QALY).

CONCLUSIONS

Routine vaccination of healthy infants <2 years in Switzerland can reduce mortality and long term neurologic impairment resulting from invasive pneumococcal disease at a reasonable cost-utility ratio.

Attitudes of pediatricians regarding influenza self-immunization: a survey in a Swiss university children's hospital

OBJECTIVE

To assess the attitude toward influenza immunization of doctors among physicians in our hospital.

METHODS

A self-administered questionnaire survey was performed in a voluntary and anonymous manner in early 2002 after influenza immunization for employees with patient contact had been promoted in the fall of 2001. Physicians were asked whether they had been immunized or not and which of the following reason(s) for doing so applied to them: to protect themselves; to protect their patients; to set a positive example. Solicited reasons for decline: not convinced about necessity; not convinced about efficacy; concerns about side effects; negative attitude toward the immunization initiative; fear of injection.

RESULTS

Questionnaires were sent to 90 pediatricians and returned by 46 (98%) of 47 immunized and 25 (58%) of 43 unimmunized participants. Self-protection and protection of patients had been equally important reasons for acceptance (87% each); 46% wanted to set a positive example for their patients by being immunized themselves. Unimmunized physicians expressed doubts about necessity (56%), efficacy (32%) and concerns about side effects (24%). Of immunized physicians 98% considered reimmunization for the next season as did 60% of those currently unimmunized.

CONCLUSIONS

Prevailing misconceptions indicate that increased educational efforts are necessary to improve acceptance of influenza vaccine in our institution.

Virosome influenza vaccine in children

The use of vaccines for the prophylaxis of influenza in children is limited. This is despite high annual rates of influenza in children and despite the complications caused by influenza in children with chronic respiratory illnesses. The disease burden of influenza on infants and young children is reviewed and the potential of recommended influenza vaccination in healthy children, to reduce the direct and indirect health and socio-economic costs, is considered. Clinical experience with a virosome-formulated subunit influenza vaccine in children is presented. These clinical trials in children have shown a virosome-formulated subunit influenza vaccine to be immunogenic and well tolerated, indicating that it might be recommended for immunising healthy infants and children against influenza virus.

Immunostimulation with OM-85 in children with recurrent infections of the upper respiratory tract: a double-blind, placebo-controlled multicenter study

OBJECTIVE

Recurrent upper respiratory tract infections (URTIs) are common illnesses in young children. As the immunoactive bacterial extract OM-85 has been shown to prevent these infections in both adults and children, the aim of the present trial was to investigate further its efficacy and safety in infection-prone children.

METHODS

This is a randomized, double-blind, placebo-controlled, multicenter study with OM-85 in 232 patients aged 36 to 96 months with recurrent URTIs. Treatment was one capsule daily during month 1 and during 10 days in months 3 to 5. URTI was defined by the presence of at least two of the following: rhinitis, pharyngitis, cough, hoarseness, temperature > or = 38.5 degrees C, or URTI-related prescription of an antibiotic.

RESULTS

OM-85-treated patients had a lower rate of URTIs (p < 0.05). The cumulated difference in URTIs between the two groups reached - 0.40 URTIs per patient in 6 months, corresponding to a 16% reduction in the active-treatment group with respect to placebo. The largest difference was observed in the patients having had three or more URTIs during the study period; odds ratios for three or more URTIs were 0.51 (95% confidence interval, 0.29 to 0.91) and 0.65 (95% confidence interval, 0.37 to 1.11) after 5 months and 6 months, respectively. The difference between OM-85 and placebo was independent of age but was more important in patients reporting a larger number of URTIs in the previous year. Patients' global assessment showed improvement in comparison to the previous season in the majority of the cases (OM-85, 78.4% of cases; placebo, 75.5%); however, there were more cases reporting worsening with placebo (6.4% vs 0.9%; p = 0.05).

CONCLUSIONS

OM-85 treatment significantly reduced the rate of URTIs, particularly in children with a history of frequent URTIs. Safety and tolerance of test medication were good, comparable to placebo.

The battle against emerging antibiotic resistance: should fluoroquinolones be used to treat children?

Inappropriate use of antibiotic drugs in humans and animals has led to widespread resistance among microbial pathogens. Resistance is the phenotypic expression corresponding to genetic changes caused by either mutation or acquisition of new genetic information. In some cases, multidrug resistance occurs. Streptococcus pneumoniae is one of the most important respiratory pathogens, playing a major role in both upper and lower respiratory tract infections. Pneumococcal resistance to antimicrobials may be acquired by means of horizontal transfer followed by homologous recombination of genetic material from the normal flora of the human oral cavity or by means of mutation. Resistance to penicillins and macrolides has been increasing for some time, but, recently, fluoroquinolone resistance has become an issue as well. We are concerned that, if fluoroquinolones are approved for use in children, their widespread use will result in rapid emergence of pneumococcal resistance, because children are more often colonized in the nasopharynx with high-density populations of pneumococci than are adults.

Azithromycin versus penicillin V for treatment of acute group A streptococcal pharyngitis

OBJECTIVE

To compare a 3-day azithromycin vs. a 10-day penicillin V regimen for treatment of acute group A streptococcal (GAS) pharyngitis in children and to determine whether viral infection and/or pharyngeal GAS carriage in patients and adult contacts affect clinical and bacteriologic efficacy.

METHODS

This multicenter, randomized, comparative, open label study compared 3-day, once daily 10 mg/kg azithromycin oral suspension with a 10-day regimen of 100,000 IU/kg/day penicillin V oral suspension in three divided doses in children with acute GAS pharyngitis. Clinical and bacteriologic efficacy and tolerability of the antibiotics were evaluated. Recurrence of symptoms and infection was monitored for 6 months.

RESULTS

In total, 292 children (age range, 2 to 12 years) received at least one dose of study medication. Clinical success (cure/improvement) with either antibiotic was similar at the end of therapy (Day 14; azithromycin, 95%; penicillin V, 97%) and at Day 28 (azithromycin, 94%; penicillin V, 95%). Bacteriologic eradication was significantly less with azithromycin than with penicillin V at Day 14 (azithromycin, 38%; penicillin V, 81%; P < 0.001) and at Day 28 (azithromycin, 31%; penicillin V, 68%; P < 0.001). There was no associated increase in GAS-related sequelae. The lower incidence of bacteriologic eradication with azithromycin was not the result of possible concomitant viral infections in the patients, GAS carriage in one parent/guardian or any reduced susceptibility in pretreatment GAS isolates. Both antibiotics were equally well-tolerated.

CONCLUSIONS

Treatment with 3-day, once daily 10 mg/kg azithromycin for GAS pharyngitis is associated with similar high levels of clinical efficacy, but lower levels of bacteriologic eradication, than with 10-day 100,000 IU/kg/day penicillin V.

Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children's Hospital Basel

OBJECTIVE

To review the diagnostic experience with acute haematogenous osteomyelitis (AHOM) and/or septic arthritis at our institution.

METHODS

Retrospective review of the medical records of those patients with a bacteriologically and/or radiologically confirmed diagnosis, hospitalised in the University Children's Hospital Basel, Switzerland between January 1980 and July 2000.

RESULTS

90 patients (61% males), 4 weeks to 14 years of age, met the inclusion criteria. Median duration of disease prior to hospitalisation was 3 days (range 0-14); 88% were admitted during the first week after onset of complaints. 81 patients received no antimicrobial therapy prior to hospitalisation and are the subject of this presentation. ESR (1st hour in mm; median 36; range 11-124), CRP (mg/l; median 64; range 0-221) and WBC (x 10(9)/l; median 13; range 5-34) were elevated in 100%, 82% and 58% of patients, respectively. Blood cultures (BC) and/or tissue cultures (TC) were performed in 79 (98%) patients. Overall, bacteria were isolated from 53 patients (65%) with Staph. aureus as the most frequent organism (n = 31; 50%). BC were performed in 67 patients and yielded 35 (52%) positive cultures; TC (n = 47) yielded 27 (57%) isolates. In 34 patients with both BC and TC performed, only 12 (35%) were positive in both tests. Diagnostic findings were observed in 23 (59%) of 39 plain radiographs, 31 (56%) of 55 sonograms, 39 (89%) of 44 99mTc-labeled bone scans and 4 (100%) of 4 MRI. 41 patients with diagnostic radiological findings had consecutive TC yielding 30 (73%) bacteriological isolates. Median duration of hospitalisation was 15 days (range 2-66).

CONCLUSION

Our data indicate that the diagnostic procedures of choice should be 1) early bone scan or MRI, 2) BC and 3) TC. Of supportive laboratory parameters, ESR and CRP were most valuable in our hands.

Diagnosis of acute haematogenous osteomyelitis and septic arthritis: 20 years experience at the University Children’s Hospital Basel

Objective: To review the diagnostic experience with acute haematogenous osteomyelitis (AHOM) and/or septic arthritis at our institution. Methods: Retrospective review of the medical records of those patients with a bacteriologically and/or radiologically confirmed diagnosis, hospitalised in the University Children's Hospital Basel, Switzerland between January 1980 and July 2000. Results: 90 patients (61% males), 4 weeks to 14 years of age, met the inclusion criteria. Median duration of disease prior to hospitalisation was 3 days (range 0-14); 88% were admitted during the first week after onset of complaints. 81 patients received no antimicrobial therapy prior to hospitalisation and are the subject of this presentation. ESR (1st hour in mm; median 36; range 11-124), CRP (mg/l; median 64; range 0-221) and WBC (x 10(9)/l; median 13; range 5-34) were elevated in 100%, 82% and 58% of patients, respectively. Blood cultures (BC) and/or tissue cultures (TC) were performed in 79 (98%) patients. Overall, bacteria were isolated from 53 patients (65%) with Staph. aureus as the most frequent organism (n = 31; 50%). BC were performed in 67 patients and yielded 35 (52%) positive cultures; TC (n = 47) yielded 27 (57%) isolates. In 34 patients with both BC and TC performed, only 12 (35%) were positive in both tests. Diagnostic findings were observed in 23 (59%) of 39 plain radiographs, 31 (56%) of 55 sonograms, 39 (89%) of 44 99mTc-labeled bone scans and 4 (100%) of 4 MRI. 41 patients with diagnostic radiological findings had consecutive TC yielding 30 (73%) bacteriological isolates. Median duration of hospitalisation was 15 days (range 2-66). Conclusion: Our data indicate that the diagnostic procedures of choice should be 1) early bone scan or MRI, 2) BC and 3) TC. Of supportive laboratory parameters, ESR and CRP were most valuable in our hands.

Multiple herpetic whitlow lesions in a 4-year-old girl: case report and review of the literature

Herpetic whitlow is a herpes simplex virus type 1 or 2 infection of the fingers characterised by erythema and painful, non-purulent vesicles. In children it typically occurs after auto-inoculation from herpes stomatitis, herpes labialis or genitalis. Occasionally, person-to-person transmission occurs from family members with herpes labialis. We report a 4-year-old girl with multiple herpetic whitlows secondary to herpetic stomatitis and present a review of the medical literature based on a systematic MEDLINE search of published paediatric patients (English, French and German language). Of 42 identified patients, 72% were younger than 2 years, most had endogenous or exogenous inoculation of herpes simplex virus type 1 and 65% were initially misdiagnosed as having "bacterial felon". Recurrences were reported in 23%.

CONCLUSION

herpetic whitlow should be suspected based on clinical signs. Specific diagnosis can be made by polymerase chain reaction or culture. The high rate of misdiagnosed cases indicates that this entity is not sufficiently known. Lesions are self-limited; surgical interventions can be harmful and should be avoided. Recurrences occur as frequently as in adults.

Seroprevalence of varicella-zoster virus immunoglobulin G antibodies in Swiss adolescents and risk factor analysis for seronegativity

BACKGROUND

Little is known about the seroprevalence of anti-varicella-zoster virus (VZV) serum antibodies in adolescents in Switzerland as in most other European countries.

METHODS

Serum specimens from 13- to 15-year-old students from eight urban and rural areas in Switzerland, obtained as part of an allergy risk assessment study project (SCARPOL), were available for analysis of IgG antibodies against VZV by enzyme-linked immunosorbent assay (ELISA) and confirmation by fluorescent antibody staining of membrane antigen in a subcohort. Serum specimens and comprehensive sociodemographic data had been collected during two study periods between 1992 and 1995.

RESULTS

Data and serum specimens were available from 1709 and 1788 subjects, respectively. Seroprevalence of anti-VZV antibodies as measured by ELISA was 95.5% (95% confidence interval, 94.5 to 96.4). When serum specimens that were indeterminate by ELISA were tested by FAMA, seroprevalence was 96.5% (95% confidence interval, 95.7 to 97.4). After logistic regression analysis, the number of siblings was the only factor that significantly influenced the presence of VZV antibodies (90.1% in those with no siblings, >96% with 1 or more siblings), whereas residence (urban vs. rural), parental education, nationality and gender did not.

CONCLUSIONS

Seroprevalence of anti-VZV serum antibodies is comparatively high among Swiss adolescents. Individuals who grow up without siblings have a significant risk of evading natural VZV infection in childhood, and they therefore form a potential target group for varicella immunization in Switzerland.

[Seroprevalence of IgG antibodies against measles, mumps and rubella in Swiss children during the first 16 months of life]

OBJECTIVE

To study the question of how long maternal IgG antibodies against measles, mumps and rubella persist in infants.

METHODS

Sera of children aged 0-16 months who had been hospitalised in our institution between 1994 and 1999 were identified from our routine serum collection. Exclusion criteria were: preterm delivery; suspected measles, mumps or rubella illness or exanthema of unknown aetiology; transfusion of blood products in the 6 months preceding serum collection; foreign-born mother; previous MMR immunisation. IgG antibodies were measured by use of commercially available ELISA kits.

RESULTS

254 serum specimens were analysed. Age distribution of patients was as follows: 0-3 months n = 58; > 3-6 months n = 48; > 6-9 months n = 52; > 9-12 months n = 42; > 12-16 months n = 54. The following seroprevalence rates for IgG antibodies were found (measles/mumps/rubella): 0-3 months 97%/62%/91%; > 3-6 months 40%/2%/42%; > 6-9 months 4%/2%/10%; > 9-12 months 2%/0%/12%; > 12-16 months 0%/7%/7%.

CONCLUSIONS

Our results demonstrate high levels of passive immunity against measles and rubella in Swiss infants during the first months of life, whereas immunity against mumps appears to be considerably less reliable. Beyond the first 3 months of life, IgG antibodies against all 3 illnesses are lacking in the majority of patients; beyond 12 months of age they are only rarely detectable. These results raise the question whether the first MMR immunisation, currently recommended at the age of 15 months in Switzerland, should be brought forward.

Brevibacterium casei sepsis in an 18-year-old female with AIDS

Brevibacterium sp. was isolated from the blood of an acutely ill 18-year-old female with AIDS. The isolate was identified as Brevibacterium casei by use of carbohydrate assimilation tests. Treatment was successful with intravenously administered ciprofloxacin. To our knowledge, this is the first report of sepsis caused by B. casei in a human immunodeficiency virus-infected patient.

Matrix metalloproteinase (MMP)-8 and MMP-9 in cerebrospinal fluid during bacterial meningitis: association with blood-brain barrier damage and neurological sequelae

To evaluate the spectrum and regulation of matrix metalloproteinases (MMPs) in bacterial meningitis (BM), concentrations of MMP-2, MMP-3, MMP-8, and MMP-9 and endogenous inhibitors of metalloproteinases (TIMP-1 and TIMP-2) were measured in the cerebrospinal fluid (CSF) of 27 children with BM. MMP-8 and MMP-9 were detected in 91% and 97%, respectively, of CSF specimens from patients but were not detected in control patients. CSF levels of MMP-9 were higher (P<.05) in 5 patients who developed hearing impairment or secondary epilepsy than in those who recovered without neurological deficits. Levels of MMP-9 correlated with concentrations of TIMP-1 (P<.001) and tumor necrosis factor-alpha (P=.03). Repeated lumbar punctures showed that levels of MMP-8 and MMP-9 were regulated independently and did not correlate with the CSF cell count. Therefore, MMPs may derive not only from granulocytes infiltrating the CSF space but also from parenchymal cells of the meninges and brain. High concentrations of MMP-9 are a risk factor for the development of postmeningitidal neurological sequelae.