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Background. Trimethoprim-sulfamethoxazole (TMP-SMZ) has been used extensively for the prevention of Pneumocystis carinii (also referred to as “Pneumocystis jiroveci”) pneumonia (PCP) and other opportunistic infections in human immunodeficiency virus (HIV)‐infected children. Because the efficacy of TMP-SMZ for treatment of bacterial infections is limited, it is sometimes poorly tolerated, and there is risk of emergence of drug-resistant strains associated with widespread use, we evaluated a regimen that included atovaquone and azithromycin. Methods. A randomized, double-blind, placebo-controlled trial was designed to determine whether atovaquone-azithromycin had equivalent efficacy to TMP-SMZ for the prevention of serious bacterial infections and to compare the long-term tolerance, PCP breakthrough rates, and nonserious bacterial infection rates among HIVinfected children aged 3 months to 19 years. Children qualified for PCP prophylaxis (on the basis of Centers for Disease Control and Prevention recommendations) were randomized to receive atovaquone-azithromycinorTMPSMZ daily for 2 years. Results. Data from 366 of the 369 eligible patients (median duration of follow-up, 3 years) showed that the estimated rates of serious bacterial infection‐related events were lower among atovaquone-azithromycinrecipients than among TMP-SMZ recipients (17.3 vs. 24.2 events per 100 patient-years; difference, 6.9 events per 100 patientyears; 95% confidence interval [CI], 0.22 to 14.12). Rates for all end points (serious bacterial infection, PCP, Mycobacterium avium complex infection, and serious and nonserious bacterial infection‐related deaths) were 19.7 and 27.7 events per 100 patient-years, respectively (difference, 7.9 events per 100 patient-years; 95% CI, 0.28 to 15.54 events per 100 patient-years). The results marginally favored atovaquone-azithromycin therapy statistically. Atovaquone-azithromycin and TMP-SMZ therapies had similar adverse event profiles. Conclusions. We conclude that, in HIV-infected children, atovaquone-azithromycin is as effective as TMPSMZ for the prevention of serious bacterial infections and is similarly tolerated.

5 JoseBelletti, 5 P= .002 test). This prompted us to analyze additional series of infants with sudden infant death syn- drome (SIDS). In 161 additional SIDS cases, 47 (35.1%) of 134 infants from Chile and 4 (14.8%) of 27 infants from Oxford, United Kingdom, were found to have P. carinii clusters in the lungs. The quantity of P. carinii cysts was small compared with the numbers seen in immunocompromised hosts with P. carinii pneumonitis. This study provides histological ev- idence that primary P. carinii infection is associated with SIDS. There is well-documented serological evidence that up to 94% of normal immunocompetent children have detectable antibody to Pneumocystis carinii by 30 months to 4 years of age (1, 2), which indicates that primary P. carinii infection is one of the most common infections in humans and that exposure occurs early in life. Experimental evidence shows that the host response pattern associated with primary P. carinii infection in otherwise healthy animals is milder (3-5) than that associated with the usually massive infection seen in an immunocompromised host. Data for humans are scant: P. carinii in low numbers or mild focal pneumonitis has rarely been reported as an autopsy find- ing for presumably immunocompetent children, and then the infection has been judged to be latent, incidental organisms (6). In contrast, there are abundant autopsy reports of interstitial plasma cell pneumonia in certain groups of debilitated, under

A retrospective review of medical records, microbiology and pathology laboratory records, and nosocomial infection surveillance data was undertaken to describe the experience with culture-documented aspergillus infection in pediatric cancer patients at our facility. Sixty-six patients were identified from a 34-year period. The most common underlying diagnosis was leukemia. Risk factors included neutropenia, immunosuppression, and prior antibiotic therapy. On the basis of clinical presentation, 23 patients were believed to have disseminated disease and 43 to have localized disease. The lung was the most frequently affected organ. Despite aggressive medical and surgical management, overall mortality was 85% within the first year after diagnosis. Patients who presented with disease in sites other than the lungs fared better than patients with initial pulmonary involvement (P=.0014). Aspergillosis continues to be associated with poor outcome. Development of improved medical and adjuvant therapies, including surgery, is warranted.

This is the first in a series of practice guidelines commissioned by the Infectious Diseases Society of America through its Practice Guidelines Committee. The purpose of these guidelines is to provide assistance to clinicians when making decisions on treating the conditions specified in each guideline. The targeted providers are internists, pediatricians, and family practitioners. The targeted patients and setting for the fever and neutropenia guideline are hospitalized individuals with neutropenia secondary to cancer chemotherapy. Panel members represented experts in adult and pediatric infectious diseases and oncology. The guidelines are evidence-based. A standard ranking system was used for the strength of the recommendations and the quality of the evidence cited in the literature reviewed. The document has been subjected to external review by peer reviewers as well as by the Practice Guidelines Committee and was approved by the IDSA Council. An executive summary, algorithms, and tables highlight the major recommendations. The guideline will be listed on the IDSA home page at http://www.idsociety.org.

Disseminated fungal infection (DFI) is an important cause of morbidity and mortality among immunosuppressed patients with cancer. To determine the role of abdominal computed tomography (CT) in the diagnosis and management of DFI, we studied the records of patients treated in a pediatric oncology center over an 11-year period. A total of 35 children had CT findings compatible with fungal abscesses in the liver, spleen, and/or kidneys and had fungal infection confirmed by culture, biopsy, or at autopsy. Patients were treated with antifungal agents (median duration of treatment, 57 days) until fever resolved and repeated CT scans demonstrated that the lesions had disappeared, regressed, or stabilized. The 3-month survival rate was 86%. An additional 29 patients with similar characteristics and risk factors had characteristic CT findings, but DFI was not documented with other procedures. These patients were empirically treated for presumed DFI; their courses and outcomes were similar to those for patients with documented DFI. These results suggest that it is reasonable to make a presumptive diagnosis of DFI for patients with characteristic CT findings and clinical features. With appropriate therapy, the prognosis for pediatric patients with cancer and documented or presumed DFI is good.

The use of empirical antimicrobial therapy has significantly reduced the morbidity and mortality associated with untreated infections in febrile neutropenic patients. This guideline describes clinical trials of the safety and efficacy of new antimicrobial drugs in this population of patients. Fever and neutropenia should be precisely defined in each protocol. Patients should be randomized to treatment with a new or active-control drug regimen, stratified on the basis of type of cancer and age, and treated until resolution--as defined in the protocol--is attained. Outcome should be assessed both for cases with a defined microbial etiology and for those without. Final microbiological outcome is important for cases with identified pathogens, but clinical outcome is paramount.

In modern use, toilet paper would seem to play an important role as a barrier to the transmission of enteric infection by the fecal-manual-oral route. A historical review reveals a dearth of information on this topic. The remarkable compliance with the hygienic practice of toilet paper use is in contrast to the more limited compliance with hand-washing policies touted universally as a sound infection-control measure.