Experience with the Hickman catheter in bone marrow transplantation and intensive cytostatic chemotherapy

Long-Term indwelling right atrial (Hickman) catheters were placed in 37 patients undergoing bone marrow transplantation or intensive chemotherapy for acute leukemia and other malignancies. Blood sampling, application of blood products or intravenous drugs and parenteral nutrition were impressively facilitated. Parents were easily trained for catheter care at home. The median duration of function has been 85 (2-312) days. 7 catheters had to be changed because of dislocation - especially in smaller children - or fluid leakage. In 6 severely neutropenic patients bacteremia was observed which resolved without catheter removal. The cause of death in 9 children with functioning catheter was due to the underlying disease (graft rejection, relapse). The use of Hickman-catheters improved venous access and supportive care in children with acute leukemia or other malignancies at an acceptable complication rate.     

Prospective study of 125 cases of Staphylococcus aureus bacteremia in children in New Zealand.

BACKGROUND: Staphylococcus aureus bacteremia is a common complication of S. aureus infection. There are few pediatric studies defining the incidence and associated morbidity and mortality of S. aureus bacteremia and no such New Zealand studies. We conducted a prospective study of S. aureus bacteremia in children in New Zealand. METHODS: From July 1, 1996 to December 31, 1998, we included all children < 16 years of age with S. aureus bacteremia in Auckland and Christchurch. Relevant information regarding patient demographics, clinical course and outcome and laboratory results was recorded. RESULTS: One hundred twenty-five cases of true S. aureus bacteremia were identified. There were 4 deaths within 30 days of the onset of bacteremia. Fourteen (11%) of the children were < 1 month of age. Maori children (relative risk, 2.0; 95% confidence interval, 1.3 to 3.2) were twice as likely and Pacific Island children (relative risk, 2.5; 95% confidence interval, 1.6 to 3.8) 2.5 times as likely as white children to acquire S. aureus bacteremia. The peak incidence of S. aureus bacteremia was observed in Pacific Island children < 1 year of age (105 cases/100,000 children/year). Twenty-seven percent of cases were related to intravenous catheters. Seventy percent of cases were community-acquired. Ninety-eight percent of non-catheter-related cases in children > 1 month of age were community-acquired. There was a low rate of methicillin resistance (6%). CONCLUSIONS: S. aureus bacteremia is largely community-acquired in children in New Zealand and is more common in Pacific Island and Maori populations. Although there is a low associated mortality, a significant number are potentially preventable cases secondary to intravenous catheters.     

Prospective evaluation of percutaneous central venous silastic catheters in newborn infants with birth weights of 510 to 3,920 grams

With improved neonatal survival, especially of very low birth weight infants, our efforts should be directed toward reduction of morbidity. Sick preterm infants require total parenteral nutrition for prolonged periods of time due to extreme prematurity and feeding intolerance. However, the use of surgically placed Broviac catheters has been associated with a high complication rate. A prospective study of 53 percutaneous central venous Silastic catheterizations for administration of total parenteral nutrition was performed in 45 newborn infants. At the time of catheter insertion, 37 babies weighted less than 1,500 g and 19 weighed less than 1,000 g. Percutaneous central venous catheters were placed successfully the first time in 50 of 55 attempts. In three babies, insertion was successful on second attempt. The catheters remained in place for 25.4 +/- 16.7 days ([mean +/- SD] range two to 80 days). In babies weighing less than 1,000 g, the catheters remained in place for a longer period of time (34.0 +/- 18.0; range 12 to 80 days). Sixty-six percent of the catheters were removed electively. There were four cases of bacteremia (7.5%), and the overall incidence of mechanical complications was 26.4%. We conclude that percutaneous central venous catheters can be used safely and effectively in newborn infants for prolonged administration of total parenteral nutrition, especially in neonates weighing less than 1,000 g.     

Liver enzyme abnormalities in gram-negative bacteremia of premature infants

BACKGROUND: Hyperbilirubinemia and liver enzyme abnormalities are commonly observed in sepsis. However, the frequency in premature neonates and the specific relation to gram-negative bacteria are not known. PATIENTS AND METHODS: Charts of all preterm infants who had positive blood cultures for either gram-negative bacteria or coagulase-negative staphylococci were reviewed. Neonates with gram-negative bacteremia (n = 54) were compared with neonates with coagulase-negative staphylococcal bacteremia (n = 31). In addition infants with gram-negative bacteremia and elevated liver enzymes (n = 25) were compared with infants with gram-negative bacteremia and normal liver enzymes (n = 29). RESULTS: Liver enzyme abnormalities accompanied 46.3% (25 of 54) of gram-negative bacteremia and 12.9% (4 of 31) of episodes of coagulase-negative staphylococcal bacteremia (P = 0.002). Serum concentrations of liver enzymes were significantly higher in infants with gram-negative bacteremia than in those with coagulase-negative staphylococcal bacteremia (P < 0.0001), but no difference in alkaline phosphatase serum values was observed. Infants with gram-negative bacteremia and elevated liver enzymes were not fed for a longer period than infants with gram-negative bacteremia and normal liver enzymes (7.3 +/- 6.3 days vs. 4.0 +/- 4.3 days, P = 0.03), and this was accompanied by significant conjugated hyperbilirubinemia (P < 0.0001). Ventilation, total parenteral nutrition and medications were not responsible for the observed differences. Klebsiella pneumoniae bacteremia was commonly associated with elevated liver enzymes (12 of 18), whereas none of the infants with Pseudomonas aeruginosa bacteremia had elevated liver enzymes. CONCLUSIONS: Gram-negative bacteremia is commonly associated with cholestasis in premature neonates. Liver enzyme abnormalities are more common than elevated conjugated bilirubin, not all gram-negative bacteria have the same effect and the lack of enteral feeding seems to play a more significant role than the administration of parenteral nutrition.     

Antibiotic lock with vancomycin and urokinase can successfully treat colonized central venous catheters in pediatric cancer patients

We used an antibiotic lock technique with vancomycin in combination with urokinase in 10 consecutive eligible children with Gram-positive catheter-related bacteremia persisting after appropriate intravenous antibiotics. Treatment was successful in sterilizing all colonized central venous catheters, avoiding device removal and delay of further chemotherapy. The antibiotic lock technique may represent a safe and effective therapeutic option in patients with selected, uncomplicated catheter-related bacteremias resistant to systemic antimicrobial therapy, particularly when maintaining a venous access is mandatory.     

Does the empiric use of vancomycin in pediatrics increase the risk for Gram-negative bacteremia?

BACKGROUND: Gram-negative bacteremia in children, a major cause of morbidity and mortality, may in part be induced by intensive treatment procedures and nonspecific use of antibiotics. Our primary objective was to study the causal relationship between the use of vancomycin and Gram-negative bacteremia, for which this antibiotic is not specifically indicated. METHODS: The study was conducted in a 105-bed tertiary care children's hospital in the period of 1994 to 1997. The study pertains to a cohort of children with suspected bacteremia, in whom a blood culture was performed during hospital stay. Using the bacteriologic laboratory registration system, we selected all pediatric cases with bacteriologically proved Gram-negative bacteremia (n = 105) and a random sample of 225 pediatric controls with negative blood cultures. Using logistic regression analysis we examined associations between Gram-negative bacteremia and the following factors: preceding use of antibiotics, antacids, corticosteroids, surgery, mechanical ventilation, parenteral nutrition, and invasive instrumentation; and the intensity of care assessed with the Therapeutic Intensity Scoring System (TISS 28). RESULTS: Gram-negative bacteremia was positively associated with the use of aminoglycosides, cephalosporins, surgical interventions, central venous catheters, parenteral nutrition, antacids and dexamethasone. The strongest association was with the use of vancomycin (odds ratio, 8.1; 95% confidence interval, 3.1 to 20.9). In a multiple logistic regression model containing all above-mentioned variables, the use of vancomycin remained positively and strongly associated with Gram-negative bacteremia (odds ratio, 3.88; 95% confidence interval, 1.34 to 11.21). Further adjustments and restrictions in the analysis did not materially change these findings concerning vancomycin. CONCLUSIONS: Among children suspected of bacteremia there are several drugs and clinical procedures influencing the risk for Gram-negative bacteremia. Empiric use of vancomycin is strongly and independently associated with Gram-negative bacteremia. The safety of using vancomycin solely on the basis of suspicion of bacteremia in children may not be warranted.     

Nutritional care and candidates for small bowel transplantation

Twenty two children were evaluated for small bowel transplantation between 1989 and 1994. Eight were unfit for transplantation and died within three months; a raised plasma bilirubin concentration (> 200 mumol/l) predicted death from liver failure within six months (p = 0.0001). The 11 children who were not managed by a multidisciplinary nutritional care team were less well nourished at referral, had more complications with intravenous feeding catheters, and greater early mortality while awaiting transplantation (p < 0.05). It is recommended that children with chronic intestinal failure be referred for assessment early, before liver dysfunction is established.     

Bacteremia-associated pneumococcal pneumonia and the benefit of initial parenteral antimicrobial therapy

OBJECTIVES: To describe clinical characteristics of patients with bacteremia-associated pneumococcal pneumonia (BAPP) and evaluate features that may distinguish these patients from those with uncomplicated pneumococcal bacteremia. To determine the impact of the route of initial antibiotic therapy on the clinical course of patients with BAPP. DESIGN/METHODS: Retrospective review of children with pneumococcal bacteremia comparing those with pneumonia to those without focal infections. RESULTS: We identified 110 patients with BAPP and 112 patients with pneumococcal bacteremia alone. Patients with pneumonia were significantly older (mean age, 34 vs. 19 months; P = 0.002) and more likely to present with cough/congestion (28% vs. 14%; P = 0.01) or difficulty breathing (12% vs. 4%; P = 0.047). There was no difference in mean temperature (39.5 vs. 39.7 degrees C; P = 0.3), mean white blood cell count WBC (21.9 vs. 22.6 x 1000/mm,3 P = 0.5) or presence of tachypnea (23% vs. 22%, P = 0.8). Sixty-one patients (55%) with pneumonia were discharged home from the initial visit in the emergency department. Those who received a parenteral antibiotic before discharge, when compared with the group who received an oral antibiotic alone, were more likely to have an improved condition (95% vs. 67%, P = 0.03) and were less likely to be admitted to the hospital (0% vs. 24%; P = 0.007) at follow-up. CONCLUSIONS: Children with bacteremia-associated pneumococcal pneumonia are older and more likely to complain of cough/congestion or difficulty breathing than those with uncomplicated pneumococcal bacteremia. The use of a parenteral antibiotic at the initial visit for children with bacteremia-associated pneumococcal pneumonia resulted in a lower admission rate and more likely parental report of improved condition at follow-up than those for children treated only with an oral antibiotic.     

Klebsiella pneumoniae bacteremia in children. Fifty-seven cases in 10 years

A review was performed of the 57 cases of Klebsiella pneumoniae bacteremia that occurred in children at our institution during a 10-year period. The rate of K pneumoniae bacteremia relative to all blood cultures in which bacteria were isolated was 1.1%. Children younger than 12 months of age accounted for 38 cases (67%). There were 8 children (14%) who were afebrile at the time bacteremia was documented; other presenting clinical features were generally indistinguishable from those that characterize pediatric bacteremia of more common causes. Fourteen children (25%) were receiving broad-spectrum parenteral antibiotic therapy at the time bacteremia was documented. In 53 patients (93%), an underlying condition predisposing to opportunistic infection was identified, the most common of which were lesions of the gastrointestinal tract (56%), presence of an indwelling central venous catheter (35%), and neutropenia (25%). Klebsiella pneumoniae was a constituent of polymicrobial bacteremia in 15 patients (26%). The overall mortality rate associated with this infection was 20%, with over one half of all deaths occurring in infants who were afebrile at the time bacteremia was documented. Klebsiella pneumoniae bacteremia is a relatively uncommon, serious infection that usually occurs in young children with predisposing underlying conditions, and is associated with a significant mortality rate.     

Lack of association between neutropenia and the incidence of bacteremia associated with indwelling central venous catheters in febrile pediatric cancer patients

To assess the incidence of bacteremia in pediatric cancer patients with indwelling central venous catheters with fever, we reviewed the records of all 67 such patients sequentially admitted during a 10-month period at our institution. There were a total of 140 episodes of fever in these 67 patients. In 55 of the episodes (39%) patients were nonneutropenic (absolute neutrophil count, greater than 500/mm3); 85 episodes (61%) were associated with neutropenia. Twenty-four percent of all episodes of fever in nonneutropenic patients were related to bacteremia vs. 9.5% of episodes of fever in the presence of neutropenia (P less than 0.05). When clinical evidence of an exit site infection was absent, the incidence of bacteremia in the neutropenic and nonneutropenic groups was similar (11% in the neutropenic group; 10% in the nonneutropenic group). We conclude that bacteremia is frequently observed in febrile pediatric cancer patients with indwelling venous catheters who are not neutropenic, particularly if there is clinical evidence of an exit site infection. Thus empiric antibiotic therapy is warranted in all pediatric oncology patients with indwelling catheters who develop fever.     

Risk of secondary bacterial infection in infants hospitalized with respiratory syncytial viral infection

Because infants hospitalized with respiratory syncytial virus (RSV) infection frequently receive antibiotics, our study was undertaken to determine what the actual risk of secondary bacterial infections in patients with RSV infection is and what effect antibiotic treatment might have on the course of illness. In a 9-year prospective study of 1706 children hospitalized with acute respiratory illnesses, 565 children had documented RSV infections. A subsequent bacterial infection rarely developed in those with RSV lower respiratory tract disease. The rate of subsequent bacterial infection was 1.2% in the total group of children infected with RSV, and 0.6% in the 352 children who received no antibiotics. A significantly greater proportion (4.5%) of subsequent bacterial infections occurred in infants who received parenteral antibiotics (p = 0.01), and especially in a subgroup who received parenteral antibiotics for 5 or more days (11%, p less than 0.001). We conclude that the risk of secondary bacterial infection appears to be low for most infants with RSV infection. In a few infants given parenteral broad-spectrum antibiotics the risk may be greater, but whether this is related to the antibiotic therapy or to other risk factors is not clear.     

Retrospective comparison of management of gastro-enteritis in hospitalised children

In Hong Kong, bacterial pathogens, the majority of them Salmonellae, cause approximately one-third of paediatric admissions for diarrhoea. This study retrospectively reviewed inpatient gastro-enteritis management, with particular focus on antibiotic use. Antibiotics are generally recommended for Salmonella gastro-enteritis in infants under 3 months of age but not for older infants and children unless they are so toxic that bacteraemia is suspected. Three groups of children admitted with acute gastro-enteritis were randomly identified from a computerised discharge database. Based on pathological reports held in the case records department, the final groups for analysis were Salmonella (n = 86), rotavirus (n = 55) and non-specified (n = 126). Epi Info version 6 (CDC, Atlanta) was used for data entry and analysis. Compared with a combined rotavirus/non-specified group, the Salmonella group were significantly more likely to have blood (OR 6.1, 95% CI 3.2-11.7, p < 0.0001) and mucus (OR 4.8, 95% CI 2.6-8.9, p < 0.0001) in the stool, fever during admission (OR 3.6, 95% CI 1.6-8.4, p = 0.001), more stools per day (median 6.2 vs 4.2, p < 0.0001), a longer stay in hospital (median 3.4 vs 2 days, p < 0.0001) and to be younger (median 7.1 vs 14.6 mths, p < 0.0001). The Salmonella group were more likely to have been given antibiotics (38% vs 15%, OR 3.6, 95% CI 1.9-6.9, p < 0.0001) but age did not influence the likelihood that antibiotics would be given.     

Risk factors for an adverse outcome in bacterial meningitis in the tropics: a reappraisal with focus on the significance and risk of seizures

The relationship of presentation to outcome in children with meningitis was analysed. The relative risk (95% confidence interval) of an adverse outcome (death or neurological sequelae) associated with presentation with at least three of ten features (age < or = 2 yrs, ill for > 7 days, antibiotic treatment, focal nerve deficits, abnormal posturing, abnormal muscle tone, lack of typical meningeal signs, shock, unrousable coma and seizures) was 4.9 (2.7, 8.8), p < 0.0001. The first six features were particularly associated with neurological sequelae, and shock and coma with death. Seizures were associated with either outcome. Two seizure types could be distinguished: seizures which occurred before or on diagnosis only (type I seizures) and seizures which occurred before and/or after diagnosis (type II seizures). Death occurred in 0/41 children without seizures and in 14/34 and 11/34 children with type I and type II seizures, respectively (p < 0.0001). Neurological sequelae occurred in 3/42 children without seizures and in 5/20 and 14/23 with type I and type II seizures, respectively (p < 0.0001).     

Prevention and therapy of bacterial infections for children with asplenia or hyposplenia

The asplenic state, whether functional or anatomic, is associated with an increased risk of life threatening infection or postsplenectomy sepsis (PSS). Because the risk of bacteremia with encapsulated bacteria is enhanced in children with asplenia, vaccination to prevent infection by Streptococcus pneumoniae, Haemophilus influenzae type b (Hib) and Neiserria meningitidis is recommended. Despite the increasing prevalence of penicillin-resistant S pneumoniae, prophylactic penicillin use is also recommended for children with asplenia who are younger than five years of age, and for at least one year following splenectomy. Continuation of antibiotic prophylaxis beyond these times depends on individual clinical circumstances and the prevalence of penicillin-resistant S pneumoniae in the community. When children with asplenia develop fever or nonspecific symptoms, they should be assessed immediately. If bacterial sepsis is suspected, blood and other appropriate body fluids should be cultured, and treatment should begin immediately with parenteral broad spectrum antibiotics that are also effective against the strains of S pneumoniae circulating in the community. In children with asplenia with overwhelming S pneumoniae bacteremia, the mortality rate is high, even with prompt initiation of appropriate antibiotic therapy. Thus, preventive measures are important.     

Clinical characteristics of children with fever and transient neutropenia who experience serious bacterial infections

A review of consecutive previously healthy children with fever and newly discovered neutropenia without underlying malignancy, evaluated during a three-year period, was performed. A total of 68 episodes occurred in 68 patients; blood culture was performed on each. Of 17 patients who appeared compromised (ill, irritable, toxic) on presentation, five (30%) had either bacteremia or bacterial meningitis. All five patients had clinical evidence of a fulminant disease process on examination. By contrast, all 51 patients who appeared to be well on presentation were culture-negative. Fever and new-onset neutropenia in children is a heterogeneous disorder with several outcomes. Any child with fever and newly discovered neutropenia who appears ill should be presumed to be at high risk for systemic bacterial infection and receive hospitalization for parenteral antibiotic therapy. By contrast, the previously healthy child older than two months of age with fever and new-onset neutropenia who appears to be well, and whose clinical evaluation does not indicate a serious underlying disease process, is at low risk for accompanying systemic bacterial infection; hospitalization with empiric antibiotic therapy pending culture results is not warranted for the majority of such children. Close outpatient monitoring with serial evaluation of the peripheral blood absolute neutrophil count to document bone marrow recovery is recommended for such cases.     

Right atrial catheters in children with cancer: a decade of experience in the use of tunnelled, exteriorized devices at a single institution

In the period 1980-1988, data were collected (prospectively from 1985) on the clinical utilization of exteriorized, tunnelled, right atrial catheters in children with cancer undergoing treatment at a single institution. A total of 231 devices were placed in 180 patients. Individual catheters were in place for a median of 314 days, with a total experience of more than 83,000 days. This form of long-term venous access was used for the administration of antineoplastic agents and other drugs, blood products (especially platelet concentrates and packed red blood cells), parenteral nutrition and infusion of other fluids, obtaining samples of venous blood, and giving intravenous contrast media and radiolabeled substances for radiological investigations. Almost 80% of catheters were removed electively (on completion of scheduled therapy or at death), with the remainder requiring removal in the management of infection or device displacement. Infections were manifest in two-thirds of the children, most commonly (60%) at the catheter exit site on the anterior chest wall. "Clinically significant" infection occurred with a frequency of 2.1 episodes per 1,000 patient days, with Staphylococcal species predominating except for the circumstances of catheter colonization in which Gram-negative, waterborne organisms were most in evidence. Empirical, intravenous, combined antibiotic therapy was effective in approximately 90% of "clinically significant" episodes. Mechanical complications (traveling, leakage, or catheter occlusion) occurred less frequently and were managed by repairing or replacing the device, or clearing the block. Indwelling catheters, of the Broviac or Hickman types, offer major advantages with acceptable morbidity in the management of children with malignant diseases.     

Non-typhi Salmonella bacteremia in children

BACKGROUND: Non-typhi Salmonella (NTS) infections are a frequent cause of self-limited diarrheal illness in healthy children. Bacteremia is a known complication of NTS infection, but the management of children with bacteremia has been based on limited data. OBJECTIVE: To study the outcomes of pediatric patients with NTS bacteremia. METHODS: Retrospective review of patients with NTS bacteremia covering a 16-year period at an urban pediatric hospital. Clinical data from the initial visits and any follow-up visits or hospitalizations were abstracted from the medical record. RESULTS: We studied 144 patients. Median age was 10.5 months. Fifty-four patients were hospitalized at the initial visit including all the patients with immunodeficiency (n = 12). Of the 90 patients initially managed as outpatients, 79 were subsequently admitted; only 1 of these patients developed a focal complication. Persistent bacteremia was found in 51 (41%) patients. Among nonimmunocompromised patients, persistent bacteremia was noted in 34% [95% confidence interval (CI), 20 to 52%] of those initially treated with oral antibiotics, 52% (CI 30 to 74%) of those initially treated with a parenteral dose of antibiotics and in 31% (CI 22 to 43%) of those who were not initially given antibiotics. No laboratory or clinical factors predicted persistent bacteremia. Twelve patients developed focal infections: 3 of 119 previously healthy children (2.5%, CI 0.5 to 7%); and 9 of 25 children with underlying medical conditions (36%, CI 19 to 57%). Focal infections included meningitis (3), osteomyelitis (4), septic arthritis (2), pneumonia (2) and cholangitis (1). CONCLUSIONS: NTS bacteremia occurs in otherwise healthy children, although the risk of focal infections is small. Patients with NTS bacteremia frequently have persistent bacteremia at follow-up regardless of initial antibiotic treatment.     

Candida species bloodstream infections in hospitalised children: A 10‐year experience

In a 10‐year retrospective study we assessed the epidemiology of candidemia and the association between the presence and removal of indwelling central venous catheters, antifungal use and clinical outcomes among hospitalised children. Demographic and clinical information were retrieved from the electronic medical records. One hundred six episodes of candidemia were identified in 83 unique patients. Candida parapsilosis was the most prevalent (52%) species, followed by C. albicans (25%). Non‐oncologic children receiving fluconazole within 30 days of developing candidemia were most likely to develop C. parapsilosis infection (40%, P = 0.006), independent of total parenteral nutrition (odds ratio (OR) 2.5, 95% confidence interval (CI): 0.6–11, P = 0.3). Crude mortality rate was 12% and significantly higher for children less than 2 years (OR: 6.7, 95% CI: 1.9–23, P = 0.003), and those infected with C. lusitaniae (OR: 9, 95% CI: 1.6–51, P = 0.02). The aggregate use of antifungal agents decreased overtime (χ²: 16.7, P < 0.0001). Fluconazole remained the most common antifungal agent used during the study.     

Management of infants and young children with fever without source

There is considerable variation in the clinical management of infants and children with FWS. Community pediatricians generally do not follow clinical practice guidelines that are taught and used at academic training institutions. These guidelines are presented in Sidebar 1 (see page 677) and Sidebar 2. In general, the guidelines provided that all febrile neonates (>38.0 degrees C) should have a "full sepsis evaluation", including lumbar puncture, and be admitted for parenteral antibiotic therapy. Non-toxic appearing infants 29-90 days of age with FWS >38.0 degrees C can be managed using low risk laboratory and clinical criteria. Non-toxic appearing infants >90 days of age who have received Hib and PCV-7 vaccines are at low risk for occult bacteremia and meningitis. Therefore, the only laboratory tests necessary in this age group with FWS >39.0 degrees C are a urinalysis and urine culture for circumcised males <6 months of age and uncircumcised males and females <24 months of age.     

Persistent bacteremia due to coagulase-negative staphylococci in low birth weight neonates

During a 6-month period in 1987, 13 low birth weight neonates without indwelling central intravascular catheters had persistent (positive blood cultures for greater than or equal to 6 days) coagulase-negative staphylococcal bacteremia despite adequate antibiotic therapy. Daily blood cultures remained persistently positive for a mean of 13 days (range 6 to 25 days). This group of infants was compared with other low birth weight infants with similar birth weights and nonpersistent coagulase-negative staphylococcal bacteremia, defined as two or more positive blood cultures accompanied by supporting clinical manifestations of sepsis. During this period, coagulase-negative staphylococcal represented 29% of all bacteremias, and 33% of coagulase-negative staphylococcal bacteremias were persistent. Other than soft tissue abscesses, none of the infants with persistent coagulase-negative staphylococcal bacteremia had a defined focus of infection. Abdominal distention (P = .001) and thrombocytopenia (P less than .03) occurred significantly more frequently in the patients with persistent coagulase-negative staphylococcal bacteremia than in those with nonpersistent bacteremia. Of the 13 patients with persistent coagulase-negative staphylococcal bacteremia, 2 received methicillin and 11 received vancomycin. No antibiotic tolerance to either antibiotic could be demonstrated. Serum concentrations of vancomycin far exceeded the minimum bactericidal concentration in all cases in which vancomycin was prescribed. No in vitro differences could be demonstrated between persistent and nonpersistent coagulase-negative staphylococcal strains for slime production, biotype, proteins from modified whole cell lysates developed by sodium dodecyl sulfate-polyacrylamide gel electrophoresis, and opsonophagocytosis by adult neutrophils in the presence of pooled human sera. Additionally, plasmid profile analysis and phage typing revealed no common strain causing the persistent bacteremia.(ABSTRACT TRUNCATED AT 250 WORDS)