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Background: Methicillin-resistant Staphylococcus aureus (MRSA) has emerged as a serious problem in the community setting, primarily as a cause of skin and soft tissue infections. Methods: A retrospective study based on the review of pediatric inpatients admitted to Lincoln Medical and Mental Health Center from March 2006 to February 2007 was performed. Results: Eighteen (55%) of the thirty-three patients identified were infected with community associated (CA) MRSA. All patients had skin and soft tissue infections. Seventeen (94%) of eighteen CA-MRSA isolates were susceptible to trimethoprim-sulfamethoxazole and tetracycline, respectively, and eleven (61%) were susceptible to levofloxacin. Conclusions: Skin and soft tissue infections are the most common clinical manifestation of CA-MRSA in our population. The 55% prevalence of MRSA in our patients suggests reconsidering empirical antimicrobial choices. Surgical intervention is important in the management of these infections, and clindamycin resistance among CA-MRSA isolates should be monitored locally to determine if empiric therapy is appropriate.

We identified main asthma risk factors for children living in the South Bronx, where asthma rates are eight times higher than the national average. This case-control study enrolled 261 children at Lincoln Medical and Mental Health Center from 2002 to 2003. We questioned the mothers on medical history and home environment. The most important risk factors for asthma in the South Bronx pediatric population are Hispanic ethnicity, family history of asthma, and exposure to tobacco smoke. South Bronx children limited to breast-feeding during the first 3 months of age are less likely to develop asthma.

Objectives:To characterize risk factors associated with pneumococcal disease and asymptomatic colonization during an outbreak of multidrug-resistantStreptococcus pneumoniae(MDRSP) among AIDS patients in a long-term–care facility (LTCF), evaluate the efficacy of antimicrobial prophylaxis in eliminating MDRSP colonization, and describe the emergence of fluoroquinolone resistance in the MDRSP outbreak strain.Design:Epidemiologic investigation based on chart review and characterization of SP strains by antimicrobial susceptibility testing and PFGE and prospective MDRSP surveillance.Setting:An 80-bed AIDS-care unit in an LTCF.Participants:Staff and residents on the unit.Results:From April 1995 through January 1996, 7 cases of MDRSP occurred. A nasopharyngeal (NP) swab survey of all residents (n = 65) and staff (n = 70) detected asymptomatic colonization among 6 residents (9%), but no staff. Isolates were sensitive only to rifampin, ofloxacin, and vancomycin. A 7-day course of rifampin and ofloxacin was given to eliminate colonization among residents: NP swab surveys at 1, 4, and 10 weeks after prophylaxis identified 1 or more colonized residents at each follow-up with isolates showing resistance to one or both treatment drugs. Between 1996 and 1999, an additional 6 patients were diagnosed with fluoroquinolone-resistant (FQ-R) MDRSP infection, with PFGE results demonstrating that the outbreak strain had persisted 3 years after the initial outbreak was recognized.Conclusions:Chemoprophylaxis likely contributed to the development of a FQ-R outbreak strain that continued to be transmitted in the facility through 1999. Long-term control of future MDRSP outbreaks should rely primarily on vaccination and strict infection control measures.

A rapidly growing mycobacterium was isolated five times from blood cultures from a 6-year-old female patient with relapsed pre-B-cell acute lymphocytic leukemia. All five isolates had identical nucleotide sequences for the first 500 bp of the 16S rRNA gene, indicative of a single species. High-performance liquid chromatography analysis of mycolic acids indicated that the species was similar to Mycobacterium smegmatis. Sequence analysis of the 16S rRNA gene (1,455 bp) for one isolate demonstrated that the species was closely related to Mycobacterium diernhoferi . Based on the phenotypic features and phylogenetic analysis, it was concluded that the isolates represented a novel rapidly growing Mycobacterium species. The name “ Mycobacterium hackensackense ” is proposed for this unique strain, 147-0552 T , which was deposited in the American Type Culture Collection as ATCC BAA-823 T .

Bioterrorism is an emerging public health and infection control threat. Potential biological agents include smallpox, anthrax, plague, tularemia, botulinum toxin, brucellosis, Q fever, viral encephalitis, hemorrhagic fever, and staphylococcal enterotoxin B. An understanding of the epidemiology, clinical manifestations, and management of the more likely candidate agents is critical to limiting morbidity and mortality from a biological event. Effective response requires an increased index of suspicion for unusual diseases or syndromes, with prompt reporting to health authorities to facilitate recognition of an outbreak and subsequent intervention. Hospital epidemiology programs will play a crucial role in this effort.

When an outbreak of pneumococcal disease occurs an institution--be it a hospital, nursing home, day care center, or other facility--management includes treatment of affected cases and prevention of new cases. Patients and staff should be tested for nasopharyngeal carriage and their vaccination status ascertained. Antibiotic use should be reviewed, especially if the causative strain is resistant.

A female infant is delivered by spontaneous vaginal delivery at 29 weeks of gestation. Her Apgar scores are 8 at 1 minute and 9 at 5 minutes. Her weight is 1,300 g, length is 38 cm, and head circumference is 27 cm. The mother is a 20-year-old primiparous African American female who had one previous live term pregnancy and one abortion. Her past medical and surgical histories are otherwise unremarkable. She had adequate prenatal care, and her prenatal laboratory test results were normal, including a negative screen for group B Streptococcus and normal findings on prenatal ultrasonography. She experienced premature contractions at 27 weeks, at which time a dose of betamethasone was administered. At 29 weeks of gestation, she went into labor. Clear amniotic fluid was drained after artificial rupture of membranes just prior to delivery. At the time of delivery, the mother did not have fever or tachycardia, although she had a white blood cell count of 16.9×103/mcL (16.9×109/L), with 58% neutrophils, 12% bands, 15% lymphocytes, and 12% monocytes by manual differential count. The mother did not receive antibiotics during the intrapartum period. The baby is admitted to the neonatal intensive care unit (NICU) due to prematurity and is treated with intravenous ampicillin and gentamicin for 48 hours until cultures are negative and the baby remains clinically stable. She begins oral feedings with expressed human milk (EBM) on the second day after birth. Small amounts of residue are present periodically after feedings. She otherwise remains clinically stable, breathing comfortably in room air. On day 13 after birth, she develops abdominal distention and vomits once. Greenish material is aspirated via the orogastric tube. Feedings are discontinued, and further evaluation is undertaken. A 41-day-old term boy presents with fussiness and a rectal temperature to 101.2°F (38.5°C). He …

The management of otitis media in this era of increasing antimicrobial resistance poses a clinical challenge to the pediatrician. Amoxicillin continues to be the drug of choice for first-line therapy. Several compounds represent second-line therapy, which must be effective against nonsusceptible Streptococcus pneumoniae , as well as β-lactamasepositive, ampicillin-resistant Haemophilus influenzae and Moraxella catarrhalis . Reevaluation of traditional therapy and chemoprophylaxis for acute otitis media (AOM) is an important aspect of judicious antimicrobial use, the focus of an overall strategy to deal with the emergence of resistance. Components of such a program include the appropriate diagnosis and management of AOM and otitis media with effusion, short-course (5–7 day) therapy for AOM, and restrictive criteria that limit continuous prophylaxis for recurrent AOM. Although the available 23-valent polysaccharide pneumococcal vaccine does not protect against otitis media, the efficacy of protein-conjugate pneumococcal vaccines in the prevention of AOM in young children is being evaluated in clinical trials.

The prevalence of drug-resistant Streptococcus pneumoniae (DRSP) has increased worldwide. Although unfavorable outcomes in meningitis due to DRSP have been well-described, the clinical impact of DRSP on other manifestations of pneumococcal infection warrants further study. Empiric combination vancomycin and extended-spectrum cephalosporin (cefotaxime or ceftriaxone) therapy is indicated for the following clinical indications: purulent meningitis, life-threatening pneumonia, and suspected sepsis in patients predisposed to invasive pneumococcal disease, for example, sickle cell disease, HIV infection, and nephrotic syndrome. In addition to clinical management issues, other implications of the emergence of DRSP include identification of resistant strains, local and national surveillance, and prevention. Preventive measures include judicious antibiotic use, appropriate use of the currently available 23-valent pneumococcal vaccine, and development and implementation of a protein-conjugate vaccine.

Parainfluenza viruses (PIV) have been categorized into four discrete types (types 1-4), based on antigenic similarities. Here is described an evaluation of nucleoprotein (NP) sequence variability among nine patients infected with the type 1 virus. The examination of short segments of the NP sequence was sufficient to define significant variability both within and between patient samples. These data, in conjunction with previous studies of hemagglutinin-neuraminidase and fusion protein sequences from PIV-infected patient populations suggest a lack of absolute stability among isolates within each virus type. Potentially, antigenic variability exists to the extent that an immune response elicited toward one isolate may not be fully protective against another of the same type. Thus, sequence variability could contribute to natural re-infections with PIV, as well as to previous vaccine failures. Results highlight the importance of analyzing viruses that break through vaccine-induced immunity, in order to measure the influence of virus diversity on PIV vaccine outcome.

Objective: We investigated the possibility that antimicrobial-resistant pneumococci were causing invasive disease in children with sickle-cell disease (SCD). Study design: Records of all children with SCD observed at the Mid-South Sickle Cell Center (MSSCC) at LeBonheur Children's Medical Center were reviewed from January 1990 to June 1994. Children with SCD and pneumococcal sepsis were identified. The Streptococcus pneumoniae isolates from these children were examined for serotype and antimicrobial susceptibilities. Two additional children not observed in the MSSCC had pneumococcal sepsis caused by penicillin-resistant isolates and were also included. Results: Antimicrobial susceptibility testing of the six penicillin-resistant isolates revealed that four were resistant to trimethoprim-sulfamethoxazole, two to erythromycin, and one to clindamycin. The two isolates that were resistant to ceftriaxone also were multiply resistant. From the MSSCC, 26 children had pneumococcal sepsis during the 4 1/2-year period studied. Five of these children (19%) died. Four (15%), including one who died, were infected with penicillin-resistant strains. Conclusion: Pneumococcal sepsis, meningitis, and infections of other foci in children with SCD may be caused by S. pneumoniae that is resistant to one or more antimicrobial agents, including penicillin. The addition of vancomycin to the antibiotics currently used for initial management should be considered in areas where the antibiotic resistance of S. pneumoniae is prevalent. (J PEDIATR 1995;127: 526-32)

Recent reports from South Africa,1 Spain,2 Hungary,3 Texas,4-6 and Memphis7,8 document an increasing incidence of penicillin-resistant Streptococcus pneumoniae infections in children. The emergence of penicillin-resistant pneumococci that also demonstrate decreased susceptibility to extended-spectrum cephalosporins presents an even greater clinical challenge.6-9 This commentary reviews recent developments in the epidemiology, identification, and management of penicillin- and cephalosporin-resistant pneumococcal disease in children. Pneumococcal susceptibility to penicillin is defined as a minimal inhibitory concentration (MIC) 1.0 µ/mL. Pneumococcal penicillin resistance is mediated by alterations in penicillin-binding proteins involved in cell wall synthesis.10

BACKGROUND Although the first reports of infection due to penicillin-nonsusceptible Streptococcus pneumoniae in the United States were in children, these strains have circulated widely in recent years, with the prevalence increasing dramatically among the elderly. Regional surveillance of pneumococcal susceptibility profiles may assist clinicians in management decisions, increase awareness of this microbial threat, and target potential areas of intervention. METHODS As part of ongoing surveillance, we surveyed single-patient pneumococcal blood isolates in our 440-bed Staten Island community teaching hospital from June 1, 1996, through May 31, 1998. RESULTS Overall, of 47 single-patient isolates, 16 (35%) were penicillin nonsusceptible. Of 35 isolates from adults, 15 (44%) were nonsusceptible, compared with 1 of 12 (8%) from children. Seven of the nonsusceptible isolates (44%) were from persons > or = 65 years old and represented 47% of the isolates from this age group. CONCLUSIONS Community-acquired penicillin-nonsusceptible pneumococcal bacteremia is not simply a pediatric problem, but also a threat to the elderly.

There is a paucity of published information available on extrapulmonary cryptococcosis (EC) in children infected with human immunodeficiency virus, the etiologic agent of the acquired immunodeficiency syndrome. We surveyed investigators in pediatric acquired immunodeficiency syndrome around the country regarding their experience with EC. Investigators from 33 (87%) of 38 institutions responded and information on 13 patients from 11 institutions was analyzed. EC was the acquired immunodeficiency syndrome indicator disease in 9 (69%) of 13 patients. Median age was 8 years with a range of 2 to 17 years. Human immunodeficiency virus risk factors were transfusion (5 patients), hemophilia (4 patients) and perinatal exposure (4 patients). Meningitis, seen in 62% of patients, was the most common clinical manifestation. Although 2 patients with fulminant disease died before therapy was started, 10 (91%) of 11 had a clinical response to amphotericin B with or without flucytosine. Our study indicates a spectrum of EC in pediatric human immunodeficiency virus infection ranging from fulminant, fatal fungemia to chronic meningitis and fever of unknown origin. Cryptococcosis was generally not the cause of death in patients who initially responded to amphotericin B therapy. Optimal antifungal therapy, including the role of fluconazole, warrants further study.

The intentional delivery of Bacillus anthracis spores through mailed letters or packages established the clinical reality of bioterrorism in the United States in autumn 2001. An understanding of the epidemiology, clinical manifestations, and management of the more credible biologic agents is critical to limiting morbidity and mortality from a bioterrorism attack.1-5 Children may be particularly vulnerable to a bioterrorist attack for several reasons.6 They have a more rapid respiratory rate, a lower breathing zone, increased skin permeability, higher ratio of skin surface area to mass, and less fl uid reserve than adults. Accurate and rapid diagnosis may be more diffi cult in children because of their inability to describe symptoms. Their caretakers may become ill or require quarantine during a bioterrorist event. Preventive and therapeutic agents recommended for adults exposed or potentially exposed to agents of bioterrorism have not been studied in infants and children.7

Cancer of the colon is the second most common visceral cancer in the United States (lung cancer is the first). It is usually diagnosed in patients older than 40 years, with a peak incidence at 70 years of age. Rarely, are cases seen in the pediatric population. In this study, we report a case of a 13-year-old girl with an 11-month history of intermittent abdominal pain whose diagnosis was delayed due to vague symptoms and a low index of suspicion for this condition.