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Objectives. The precise epidemiology of childhood pneumonia remains poorly defined. Accurate and prompt etiologic diagnosis is limited by inadequate clinical, radiologic, and laboratory diagnostic methods. The objective of this study was to determine as precisely as possible the epidemiology and morbidity of community-acquired pneumonia in hospitalized children. Methods. Consecutive immunocompetent children hospitalized with radiographically confirmed lower respiratory infections (LRIs) were evaluated prospectively from January 1999 through March 2000. Positive blood or pleural fluid cultures or pneumolysin-based polymerase chain reaction assays, viral direct fluorescent antibody tests, or viral, mycoplasmal, or chlamydial serologic tests were considered indicative of infection by those organisms. Methods for diagnosis of pneumococcal pneumonia among study subjects were published by us previously. Selected clinical characteristics, indices of inflammation (white blood cell and differential counts and procalcitonin values), and clinical outcome measures (time to defervescence and duration of oxygen supplementation and hospitalization) were compared among groups of children. Results. One hundred fifty-four hospitalized children with LRIs were enrolled. Median age was 33 months (range: 2 months to 17 years). A pathogen was identified in 79% of children. Typical respiratory bacteria were identified in 60% (of which 73% were Streptococcus pneumoniae) viruses in 45%, Mycoplasma pneumoniae in 14%, Chlamydia pneumoniae in 9%, and mixed bacterial/ viral infections in 23%. Preschool-aged children had as many episodes of atypical bacterial LRIs as older children. Children with typical bacterial or mixed bacterial/ viral infections had the greatest inflammation and disease severity. Multivariate logistic-regression analyses revealed that high temperature ([greater than or equal to] 38.4[degrees]C) within 72 hours after admission (odds ratio: 2.2; 95% confidence interval; 1.4-3.5) and the presence of pleural effusion (odds ratio: 6.6; 95% confidence interval: 2.1-21.2) were significantly associated with bacterial pneumonia. Conclusions. This study used an expanded diagnostic armamentarium to define the broad spectrum of pathogens that cause pneumonia in hospitalized children. The data confirm the importance of S pneumoniae and the frequent occurrence of bacterial and viral coinfections in children with pneumonia. These findings will facilitate age-appropriate antibiotic selection and future evaluation of the clinical effectiveness of the pneumococcal conjugate vaccine as well as other candidate vaccines. Pediatrics 2004;113:701-707; community-acquired pneumonia, child, epidemiology, diagnosis, etiology, hospitalized., The quest to define accurately and promptly the causative agents of lower respiratory infections (LRIs) in children has been impeded by inadequate clinical, radiologic, and laboratory diagnostic methods. A limited [...]

Results demonstrate construction of isogenic double mutants of Moraxella catarrhalis strains and their ability to adhere to human epithelial cells in vitro. Data reveal that besides UspA1 and 2 proteins, a second UspA2 protein is discovered which exhibit amino acid segments from UspA1 and 2 and also shows adhesin activity.

Newer drugs other than antibiotics must be used to treat antibiotic-resistant Streptococcus pneumoniae infections. Resistance patterns specific to a geographic area may need to be considered in addition to treatment agents. Determining the susceptibility of pneumococcal infections to penicillin and other antimicrobial agents is important. The clinician and laboratory should communicate with each other to provide the best treatment possible. Effects of penicillin resistance in Streptococcus pneumoniae and the organism's susceptibility to other antibiotics are discussed. Other streptococcal infections that may be penicillin-resistant are meningitis, sepsis, pneumonia and otitis media. Chloramphenicol, cephalosporin and other antimicrobials, beta-lactam antibiotics, and non-beta-lactam antibiotics are possible alternatives to penicillin.

Guidelines for the care of infants and children from birth to age 3 who have a fever of unknown origin were set forth. Such children constitute a significant proportion of ambulatory pediatric visits to physicians' offices and emergency departments. The guidelines developed by an expert panel called for hospitalization of infants and children and all febrile infants less than 28 days old for parenteral therapy, outpatient treatment and careful surveillance of low-risk febrile infants 28 to 90 days of age, and no laboratory tests or antibiotics for older children with a fever of less than 39 degrees C. The panel called for treatment of children 3 to 36 months with a fever of 39 degrees C or more and with a white blood bell count of 15,000/mm3 or more with antibiotics pending the outcome of a blood culture. It also stated that urine cultures be taken from all boys 6 months of age or less and from all girls 2 years of age or less who were being treated with antibiotics., Study objective. To develop guidelines for the care of infants and children from birth to 36 months of age with fever without source. Participants and setting. An expert panel of senior academic faculty with expertise in pediatrics and infectious diseases or emergency medicine. Design and intervention. A comprehensive literature search was used to identify all publications pertinent to the management of the febrile child. When appropriate, meta-analysis was used to combine the results of multiple studies. One or more specific management strategies was proposed for each of decision nodes in draft management algorithms. The draft algorithms, selected publications, and the meta-analyses were provided to the panel, which determined the final guidelines using the modified Delphi technique. Results. All toxic-appearing infants and children and all febrile infants less than 28 days of age should be hospitalized for parenteral antibiotic therapy. Febrile infants 28 to 90 days of age defined at low risk by specific clinical and laboratory criteria may be managed as outpatients if close follow-up is assured. Older children with fever less than 39.0 [degees] C without source need no laboratory tests or antibiotics. Children 3 to 36 months of age with fever of 39.0 [degrees] C or more and whose white blood cell count is 15 000/[MM.sup.3] or more should have a blood culture and be treated with antibiotics pending culture results. Urine cultures should be obtained from all boys 6 months of age or less and all girls 2 years of age or less who are treated with antibiotics. Conclusion. These guidelines do not eliminate all risk or strictly confine antibiotic treatment to children likely to have occult bacteremia. Physicians may individualize therapy based on clinical circumstances or adopt a variation of these guidelines based on a different interpretation of the evidence. Pediatrics 1993;92:1-12; practice guidelines, fever without source, bacteremia.

* Objective.--To assess which clinical features predict an increased likelihood of an abnormal computed tomographic (CT) scan and how frequently CT influences management of bacterial meningitis. Design.--Retrospective patient series. Setting.--University-affiliated hospitals in Dallas, Tex. Patients.--Three hundred thirty-seven children with bacterial meningitis, of whom 107 (32%) had undergone CT scans. Results.--One or more abnormalities were found in 52% of the initial scans. The most frequent indication for CT at our institution was persistent or secondary fever, and in 56% of these children, subdural effusion or empyema was noted. However, findings on CT rarely predicted a need for intervention. In contrast, children with focal seizures or focal neurologic signs were more likely to have brain parenchymal changes. Scans in 19 patients (12%) prompted surgical intervention, most commonly drainage of a subdural collection. The conditions of only nine children (8.4% of those who had undergone CT scans) improved following intervention that was initiated because of findings on CT. Conclusions.--Although CT scans are frequently abnormal in children with meningitis, CT seldom reveals findings that require specific intervention. (AJDC. 1992;146:1484-1487)

Pneumococci are a group of bacteria that are protected by an outer capsule. They can cause pneumonia and other serious infections. About 10 percent of cases of meningitis are caused by pneumococcal bacteria. About 10 percent of patients with pneumococcal meningitis die, while up to 30 percent are seriously affected. These rates have changed little, despite the availability of strong antibiotics that are active in infected meningeal tissues (membranes covering the brain and spinal cord). Experimental results suggest that a significant portion of pneumococcal meningitis symptoms are caused by the reactivity of immune cells to antibiotic-induced release of fragments from the bacterial capsule; this reactivity may result in inflammatory reactions involving human tissue. Steroids can suppress the activity of immune cells, and previous studies have suggested that steroid therapy may benefit children with pneumococcal meningitis. The current study reviewed the outcomes of 97 infants and children with the pneumococcal meningitis, 41 of whom were treated with steroids as well as antibiotics. The total duration of fever was significantly less in patients who were given steroids, and glucose levels in cerebrospinal fluid (CSF, the fluid that bathes the brain and spinal cord) were significantly higher in these children. Cerebrovascular instability, indicated by signs of sepsis (systemic infection), shock, or seizures, developed more often in children who received only antibiotics or were given steroids after antibiotic treatment. Likewise, cerebrovascular instability occurred less frequently in children who received steroids and antibiotics simultaneously and those who received steroids before antibiotic therapy. The death rates in the two groups were similar, but mortality was significantly higher in those who developed cerebrovascular instability. Steroid-treated patients less frequently developed overwhelming meningeal infection, which was associated with high mortality, seizures, and hearing loss. Subsequently, children who received steroids had a significantly lower rate of neurologic dysfunction and hearing loss. The report suggests that steroids, administered with antibiotics, improve the prognosis of children with pneumococcal meningitis. (Consumer Summary produced by Reliance Medical Information, Inc.)

Meningitis (inflammation of the membranes that surround the brain) can be caused by several organisms, including Haemophilus influenzae type B. This bacterium, like all Gram-negative bacteria, is surrounded by an outer membrane containing lipopolysaccharides (LPS) or endotoxins: when these substances contact host tissue, they initiate a powerful inflammatory response that includes inflammation, brain swelling, increased pressure within the skull, and other changes. Haemophilus influenzae type B LPS have certain unique structural properties that may affect results when they are evaluated quantitatively using a standard assay (the Limulus amebocyte lysate assay). This study of endotoxin levels in patients with Haemophilus influenzae type B meningitis was carried out using lipo-oligosaccharide (LOS) instead of LPS as a standard. The patients were 38 children (aged between six weeks and 13 years) with Haemophilus influenzae type B bacteria in their cerebrospinal fluid. The children underwent treatment with cefotaxime sodium and dexamethasone sodium phosphate; the clinical severity of their conditions was monitored daily in the hospital. Results showed a steep drop in LOS levels between the time of admission to the hospital and 17 to 48 hours after therapy started. In general, the concentrations of Haemophilus influenzae type B in CSF predicted the likelihood of complications: patients who developed neurologic abnormalities had high LOS concentrations in the first CSF sample analyzed. LOS levels were also correlated with the levels of interleukin 1B (a factor released by cells of the immune system), protein, and glucose in CSF, as well as with the duration of secondary fever (a temperature of 38.0 degrees Centigrade or higher occurring after a fever-free period). The findings indicate that the level of endotoxin, as determined by the test described, in the CSF of patients with Haemophilus influenzae type B meningitis can be an important prognostic factor. (Consumer Summary produced by Reliance Medical Information, Inc.)

Children who recover from bacterial meningitis often suffer permanent brain damage, which can express itself as loss of hearing, or neurological symptoms including paralysis and hydrocephalus. Much of this damage seems to result not from the bacterial infection of the meninges that cover the brain, but from the inflammation of the meninges that occurs as a part of the body's response to the infection. There have been some experimental studies to suggest that the corticosteroid drug dexamethasone may reduce the likelihood of permanent damage by reducing the inflammatory response. This has now been confirmed in a study involving 101 infants and children with meningitis. All the children were treated with the antibiotic drug cefotaxime to destroy the bacteria causing the meningitis. Fifty-two children also received dexamethasone treatment, while 49 received only a placebo drug in addition to the cefotaxime. As soon as 12 hours after the initiation of treatment, differences could be seen between the two groups. The pressure of the cerebrospinal fluid had already begun to drop in the corticosteroid-treated patients, while the pressure increased in the patients who received only antibiotic and placebo. Likewise, tumor necrosis factor alpha and platelet-activating factor were both reduced in the cerebrospinal fluid of the patients receiving the dexamethasone; these two substances are considered to play important roles in the inflammatory process. After a follow-up period averaging 15 months, permanent brain damage was more common among the patients who did not receive the dexamethasone. Seven of the 51 surviving children treated with dexamethasone suffered at least one symptom of permanent damage. In contrast, neurologic symptoms or hearing loss persisted in 18 of the 48 patients who survived after treatment with antibiotics only. These results add to the mounting body of evidence indicating that the corticosteroid treatment of the inflammatory response is a very important aspect of the treatment of meningitis in children. (Consumer Summary produced by Reliance Medical Information, Inc.)

The death rate among children suffering from bacterial meningitis (infections of the membranes surrounding their brain and spinal cord) ranges from two to five percent. In approximately 20 percent of meningitis cases, the children are left with various neurologic problems. Recent advances in drug manufacture have provided newer and more powerful antimicrobial drugs for the treatment of meningitis, but the outcomes of treatment have not correspondingly improved. Some research has suggested that the endotoxins, or biologic poisons, produced by bacteria also induce the release of molecules by the body to mediate the inflammation of the meninges that characterizes the disease. These include prostaglandins, interleukins and tumor necrosis factor. Other animal experiments have shown that when some of these agents are injected into uninfected animals, injuries to the meninges and brain similar to those produced by bacterial meningitis occur. The levels of these chemical products were measured within the cerebrospinal fluid of patients with bacterial meningitis, before and after treatment with either dexamethasone (a synthetic glucocorticoid, used to control inflammation) or a placebo (an inactive control substance). In addition all patients also received various antibiotic treatments to sterilize their cerebrospinal fluid. Various prostaglandins, interleukins and tumor necrosis factor are found in the cerebrospinal fluid of most bacterial meningitis patients. Treatment for 18 to 30 hours with dexamethasone was found to lower prostaglandins and specific interleukins. (Consumer Summary produced by Reliance Medical Information, Inc.)