Recurrence of group B streptococcal meningitis

Group B Streptococcus is the most frequent cause of neonatal sepsis. However, recurrences are rare. We report a case of recurrent meningitis due to Streptococcus B in a 2-month-old infant. Streptococcus B identified was hypervirulent clone ST-17 serotype III, which is known for its neurotropism. We found five other cases of recurrent group B streptococcal meningitis in the literature, which we report here. Many reports have identified breastfeeding and persistent colonization as the mode of transmission in recurrent Streptococcus B infections. We also discuss different ways to prevent recurrent group B streptococcal infections. Oral antibiotic therapy against carriage does not seem to be effective and there is no consensus on management of breastfeeding.     

Penicillin V and rifampin for the treatment of group A streptococcal pharyngitis: a randomized trial of 10 days penicillin vs 10 days penicillin with rifampin during the final 4 days of therapy

To improve the bacteriologic and clinical cure rates of streptococcal pharyngitis, 79 children were randomly assigned to receive penicillin V alone for 10 days (39 patients) or penicillin for the same duration and rifampin during the last 4 days of penicillin therapy (40 patients). Eleven patients given penicillin had evidence of bacteriologic failure (including eight with relapse of clinical illness) on repeat cultures done 4 to 7 days after treatment, whereas there were no failures in children given combination therapy (P = 0.0015). All eight symptomatic children improved with penicillin-rifampin therapy and subsequent cultures were negative, whereas three asymptomatic children continued to harbor group A streptococci even after combination therapy. Antibody response by antistreptolysin O or antideoxyribonuclease B assay was seen in 50.6% of patients; the antibody responses in both groups were comparable. These results show that addition of rifampin to the penicillin regimen improves the clinical and bacteriologic cure rates in children with streptococcal pharyngitis.     

Penicillin plus rifampin eradicates pharyngeal carriage of group A streptococci

We evaluated the efficacy of rifampin in eradicating chronic pharyngeal carriage of group A streptococci. Carriers were defined as healthy children whose throat cultures showed persistence of group A streptococci 3 weeks after receiving benzathine penicillin G intramuscularly. Subsequent M and T typing of group A streptococcal isolates and limited serologic studies confirmed that enrolled patients were carriers. Thirty-eight carriers (37 completed the study) were randomly assigned to three groups: group 1 (13 patients) received no treatment; group 2 (10) received benzathine penicillin intramuscularly; group 3 (14) received benzathine penicillin intramuscularly plus rifampin orally (10 mg/kg twice a day for eight doses). Throat cultures were obtained every 3 weeks for at least 9 weeks. Group 2 and 3 patients who still had positive cultures 3 weeks after treatment were crossed to the opposite group. Cultures became negative in 93% (13 of 14) of patients in group 3, compared with 23% in group 1 and 30% in group 2 (P less than 0.001 and P less than 0.01, respectively). Including patients crossed over, the penicillin plus rifampin regimen was effective in 17 (89%) of 19 treatment courses and was significantly superior to no therapy or to penicillin alone (P less than 0.0005 and P less than 0.005, respectively). We conclude that rifampin plus benzathine penicillin intramuscularly is an effective regimen for those selected patients in whom eradication of group A streptococcal carriage is judged to be desirable.     

Fatal ureaplasmal pneumonia and sepsis in a newborn infant

Ureaplasma urealyticum was isolated in pure culture from blood tracheal aspirate and lung tissue in a newborn infant, who died of a severe pneumonia within 48h after birth. The clinical course was characterized by persistent pulmonary hypertension of the newborn (PPHN). Post-mortem examination revealed extensive hyaline membrane formation combined with signs of inflammation in both lungs. The clinical and histopathological picture resembled that of early onset group B haemolytic streptococcal pneumonia/sepsis.     

Frequency of symptomatic relapses of group A beta-hemolytic streptococcal tonsillopharyngitis in children from 4 pediatric practices following penicillin, amoxicillin, and cephalosporin antibiotic treatment

The objective was to determine the frequency of early symptomatic relapses following antibiotic treatment for group A beta-hemolytic streptococcal (GABHS) tonsillopharyngitis in children from Rochester, New York; Houston, Texas; Spokane, Washington; and Los Angeles, California (2004--2006). The study included 4278 patients. The proportion with a bacteriologic relapse of GABHS tonsillopharyngitis within 1 to 5 days of completing a 10-day treatment course was 8% (penicillin and bicillin), 6% (amoxicillin), 2% (first-generation cephalosporin), and 1% (second-generation and third-generation cephalosporin; P = .0001); symptomatic relapses occurred within 6 to 20 days after completion of therapy in 16%, 14%, 9%, and 7% of cases (P = .0001). Cases from New York and Washington had higher penicillin or amoxicillin failure rates than cases from Texas and California. The frequency of symptomatic relapses of GABHS tonsillopharyngitis, therefore, differs according to the antibiotic treatment selected; the trend for such relapses being penicillin or amoxicillin > cephalosporins although geographic differences may occur.     

Benzathine penicillin G for rheumatic fever prophylaxis: 2-Weekly versus 4-weekly regimens

Rheumatic fever is still one of the major public health problems in Egypt and the developing countries. It is characterized by a high tendency to recur following streptococcal infections. The use of long acting penicillin for prophylaxis against strep infections was a good achievement in this field, yet, recurrences have been reported in patients following monthly prophylactic programs. Clinical experience in Alexandria have shown for a long time that giving penicillin every 2 weeks is followed by less recurrences of rheumatic fever. Recently, reports came showing that effective penicillin levels are not maintained except for 2 to 3 weeks after the injection. In the present study, we compared two regimens of prophylaxis with 190 patients in the 2-weekly regimen, and 170 patients in the 4-weekly regimen being followed up for 2 consecutive years. Two hundred and sixty nine streptococcal infections occurred during this period. Although the streptococcal infection rate was equal in both groups, the rheumatic fever recurrence rate and the RF attack rate were significantly higher in the group of patients on the 4-weekly schedule. The results of this study have shown the superiority of the 2-weekly schedule in the adequate control of RF recurrences. We suggest that this schedule should be implemented for secondary prophylaxis of rheumatic fever in Egypt and other areas with severe RF.     

Lack of impact of early antibiotic therapy for streptococcal pharyngitis on recurrence rates

To determine whether recurrence rates for group A beta-hemolytic streptococcal (GABHS) pharyngitis are related to the time of initiation of antibiotic therapy, we randomly assigned 113 patients with GABHS pharyngitis either to a group that began a 10-day course of penicillin V at the time of diagnosis or to a group that began the same antibiotic regimen after a dealy of 48 hours. Follow-up throat culture specimens were obtained 4 days, 2 months, and 4 months after the completion of antibiotic therapy, as well as during any interim episodes of acute pharyngitis. Serotyping of all GABHS isolates was performed to distinguish between recurrences with homologous serotypes and new acquisitions with heterologous serotypes. There was no significant difference between the two treatment groups in age, gender, duration of illness before enrollment in the study, initial clinical presentation, or compliance. Of the 50 patients in the immediate-treatment group, 6 (12%) had homologous serotypes of GABHS isolated on one of the follow-up throat cultures. Of the 63 patients in the delayed-treatment group, 9 (14%) had homologous serotypes of GABHS isolated on one of the follow-up throat cultures. These data indicate that a 48-hour delay in the initiation of penicillin therapy for GABHS pharyngitis does not reduce the recurrence rate.     

Complement activation and group B streptococcal infection in the newborn: similarities to endotoxin shock.

Serial measurements of CH50, C3, C4, and factor B were performed on three newborn infants with group B streptococcal sepsis. Two of the septic infants had a colonized but noninfected identical twin. All three infants with group B streptococcal sepsis had hypotension, prolonged coagulation times, neutropenia, and respiratory failure. During the course of the sepsis, factor B was depressed 30% to 35%, C3 was depressed 40% to 60%, and CH50 was depressed by 100% when compared to their cord blood levels. Two of the infants also had a 50% to 70% depression of C4. In contrast, no significant decrease in complement levels occurred in the siblings of the twins or in two additional control infants. These data are characteristic of older patients with Gram-negative sepsis and strongly suggest that the group B Streptococcus has endotoxin-like properties.     

Symptomatic relapse of group A beta-hemolytic streptococcal tonsillopharyngitis in children

The frequency of symptomatic relapses following various antibiotic treatments for group A beta-hemolytic streptococcal tonsillopharyngitis was evaluated in 1080 pediatric patients. Within 5 days of completing therapy, the rank-order frequency of treatment failures was (1) penicillin, (2) amoxicillin, (3) first-generation cephalosporins, (4) beta-lactamase stable cephalosporins and amoxicillin-clavulanate ( P = .005). Retreatment of symptomatic failures resulted in another symptomatic relapse more often with penicillin than with cephalosporins (P = .02). Clinicians should be aware that the rate of symptomatic failures after antibiotic therapy for group A beta-hemolytic streptococcal tonsillopharyngitis differs by drug and is not an uncommon event.     

A multicenter therapeutic study of 1100 children with brucellosis

A 6-year multicenter therapeutic study was performed on 1100 children with brucellosis in order to compare several antibiotic combinations and duration of treatment. The patients were randomized to receive oral therapy with oxytetracycline, doxycycline, rifampin and trimethoprim-sulfamethoxazole (TMP/SMX) either alone or in combination with each other or combined with streptomycin or gentamicin injections. The patients were also randomized into three groups based on the duration of oral therapy: 500 patients were treated for 3 weeks; 350 for 5 weeks; and 250 for 8 weeks. When intramuscular aminoglycosides were used, streptomycin was given for 2 weeks and gentamicin for 5 days. In oral monotherapy oxytetracycline, doxycycline and rifampin showed comparable results with low relapse rates (less than or equal to 9%) and no statistically significant differences were found among 3-, 5- or 8-week durations of therapy. TMP/SMX alone showed an unacceptably high relapse rate (30%) with all durations of therapy. In combined oral therapy rifampin plus oxytetracycline, rifampin plus TMP/SMX and oxytetracycline plus TMP/SMX showed comparable results with low relapse rates ranging from 4 to 8% in patients receiving therapy for 3 or 5 weeks, no relapses occurred in patients treated for 8 weeks. When oral monotherapy was combined with either streptomycin or gentamicin, very few relapses were seen, irrespective of the duration of treatment.(ABSTRACT TRUNCATED AT 250 WORDS)     

Rifampin and penicillin for the elimination of group B streptococci in nasally colonized infant rats

Although multiple antibiotic strategies to eradicate group B streptococci (GBS) from colonized infants and women have been utilized, no regimen has been successful in eliminating GBS carriage reliably. Because rifampin has been successful in terminating nasopharyngeal colonization with other bacteria, we tested both the in vitro sensitivity of GBS to rifampin and the in vivo efficacy of rifampin in eliminating GBS from a new animal model of nasally colonized infant rats. The minimal inhibitory concentration of rifampin for 18 clinically derived strains of type III GBS ranged from 0.1 to 0.4 micrograms/ml. Atraumatic nasal inoculation of infant rats with 10(6)-10(7) colony forming units of GBS twice daily for 4 days resulted in heavy asymptomatic carriage for at least 10 days. Colonized animals were divided into four treatment groups: saline, oral rifampin, intraperitoneal penicillin, or oral rifampin plus intraperitoneal penicillin. Treatment was administered every 12 h for 4 days. All 78 saline-treated controls and 47 of 52 (90.4%) penicillin-treated animals had continued GBS carriage 36 h after completion of therapy. In contrast, only 18 of 52 (34.6%) rifampin-treated animals and seven of 54 (13.0%) rifampin plus penicillin-treated animals remained GBS-positive. No rifampin-resistant GBS were detected. Combination rifampin plus penicillin therapy was significantly more effective in terminating GBS carriage compared to saline or penicillin alone (p less than 0.0001) or to rifampin (p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Group B streptococcal infection with 2 recurrences in a newborn]

Group B III streptococcus (GBS) is a predominant pathogen in neonates in France. Relapse is rare and two successive relapses are exceptional: only three cases have been yet reported. CASE REPORT: A newborn infant of 18 days of age presented a first episode of invasive group B III streptococcal infection with meningitis and ventriculitis. At 53 days of age, a second episode with bacteriemia and parotidis appeared. At 63 days of age, she presented a third episode with meningitis. Genome analysis of the three bacterial strains isolated during the three episodes showed the same clonal origin. COMMENTS: We discuss the incidence of the treatment, the eventual presence of a penicillin-tolerant GBS, the possible relapse or recurrence of the pathogen and the role of the relative immunodeficiency in infant.     

Are all recurrences of “pure” Sydenham chorea true recurrences of acute rheumatic fever?

We are conducting prospective studies of patients in Santiago, Chile, who have had an attack of rheumatic fever and are receiving continuous secondary prophylaxis with monthly injections of benzathine penicillin G. Throat cultures are obtained just prior to injection each month, and serum antistreptococcal antibody titers (antistreptolysin O and antideoxyribonuclease B) are performed at least every 3 months. During the course of these studies we have observed 17 recurrences of "pure" chorea in 10 patients (six girls). In four recurrences the timing of serologic studies and onset of chorea appeared to exclude the occurrence of an immunologically significant group A streptococcal infection within the preceding 6 to 9 months. In one case the period of serologic follow-up was too brief to allow a definite determination. In the remaining 12 recurrences serologic evidence was suggestive or confirmatory of recent streptococcal infection; however, in several instances the titer elevations were quite modest. Our data suggest that in certain chorea-prone patients, Sydenham chorea may recur after streptococcal infections too weak and transient to be readily detectable or, alternatively, after stimuli other than streptococcal infection.     

低剂量利妥昔单抗治疗儿童肾病综合征疗效及安全性的前瞻性随机对照研究北大核心CSCD

目的对比利妥昔单抗(rituximab,RTX)低剂量(200 mg/m^(2))与推荐剂量(375 mg/m^(2))重复使用治疗频复发型肾病综合征(frequently relapsing nephrotic syndrome,FRNS)或激素依赖型肾病综合征(steroiddependent nephrotic syndrome,SDNS)维持缓解的疗效和安全性。方法采用随机对照试验研究法,选择2020年9月—2021年12月在安徽省儿童医院儿童肾脏科接受系统治疗的29例FRNS/SDNS患儿为研究对象,按随机数字表法分为推荐剂量组(n=14)和低剂量组(n=15)。分析比较两组患儿的一般特征、RTX治疗前后CD19变化、复发次数、糖皮质激素使用剂量、RTX不良反应及住院费用等差异。结果与治疗前相比,低剂量组与推荐剂量组在应用RTX后均能使B淋巴细胞耗竭,且复发次数减少、糖皮质激素使用剂量下降(P<0.05)。低剂量组RTX治疗后的临床疗效与推荐剂量组相当(P>0.05);而低剂量组第2~4次住院费用下降(P<0.05)。两组在使用RTX过程中及后期随访中无严重不良反应,发生的不良反应差异无统计学意义(P>0.05)。结论低剂量与推荐剂量重复RTX治疗临床疗效和安全性相当,可显著降低FRNS/SDNS复发次数及糖皮质激素使用剂量,在整个治疗周期内无明显不良反应,适合临床推广。     

Halofantrine efficacy in non-immune children with imported acute Plasmodium falciparum malaria Infection

A rising incidence of imported acute malaria has been observed in non-immune traveller children returning from the tropics to France. Halofantrine efficacy has been poorly assessed in non-immune children. In order to assess halofantrine efficacy in non-immune children with acute uncomplicated Plasmodium falciparum malaria, we collected data of children with positive blood smears in an open prospective study. Children with neurological manifestations, vomiting and congenital long QT were excluded. All children were hospitalised and received halofantrine (24 mg/kg divided into three doses per day) on an empty stomach. Persistent fever after day 3 defined failure. Relapse was defined by a positive blood smear with or without systemic symptoms within a 1 month follow-up period. In total, 52 children were enrolled. No failure was observed, but relapses occurred in 14/52. On univariate analysis, the mean age of children with relapse was significantly lower (P<0.05). Moreover, diarrhoea was more frequently associated with relapses (P<0.04). Age and diarrhoea were significant independent factors contributing to relapses. Conclusion:this study shows that with a relapse rate of 27%, this regimen with a 1-day course of halofantrine is not to be recommended.     

肾小球系膜区微量IgM沉积在儿童微小病变型肾病综合征中的意义

目的 探讨肾小球系膜区微量IgM 沉积在儿童微小病变型原发性肾病综合征(PNS)中的意义。方法 以临床诊断为PNS、病理诊断为微小病变(MCD)及肾组织微量IgM 沉积的106 例患儿为研究组,无免疫复合物沉积的MCD 型PNS 患儿81 例为对照组,回顾性分析两组患儿的临床特点、微量IgM 沉积对糖皮质激素及免疫抑制剂疗效的影响。患儿均口服足量泼尼松治疗,对糖皮质激素耐药者或频复发者联用免疫抑制剂治疗。结果 研究组糖皮质激素耐药率高于对照组(27.2% vs 12.3%,PPP>0.05)。研究组和对照组频复发病例联用MMF 治疗后复发频率均显著减少(P结论 MCD 型PNS 患儿肾脏的微量IgM 沉积可能是糖皮质激素耐药及频复发的重要因素;糖皮质激素耐药及频复发患儿联用MMF 治疗可能是较好的治疗方案。     

Diagnosis of neonatal Streptococcus B infection by the latex test

The detection of group B streptococcal soluble antigens was performed in 139 newborn infants suspected of infection. A qualitative agglutination test of sensitized latex particles (Wellcogen Strep B) was performed in the urine. The diagnosis of group B streptococcal infection was assessed by retrospective analysis of patient files using previously defined criteria. The correlation between the agglutination test result and the presence or absence of streptococcal infection was statistically significant; the test had a sensitivity of 81%, specificity of 97%, positive predictive value of 76% and negative predictive value of 98%. This study confirms the interest of such a test in the early diagnosis of group B streptococcal infection in infants.     

Issues of antimicrobial resistance in group B streptococcus in the era of intrapartum antibiotic prophylaxis

The implementation of a culture screening-based approach to intrapartum antibiotic prophylaxis has been associated with substantial reduction in the incidence of early-onset group B streptococcal disease. Antibiotic prophylaxis is recognized as an interim strategy awaiting the licensure of a safe and effective conjugate vaccine for prevention of group B streptococcal infections in all susceptible populations. This article addresses concerns relating to antimicrobial resistance among group B streptococci that have arisen from use of intrapartum antibiotic prophylaxis and from increases in resistance in other gram-positive bacteria related genetically to group B streptococci.     

Childhood brucellosis: a study of 102 cases

One hundred two children, 45 days to 14 years of age, with proven brucellosis were studied to illustrate the epidemiologic, clinical and laboratory findings and to assess the outcome of antimicrobial therapy. The main source of infection was the consumption of raw milk in 80% of the patients. The predominant presenting symptoms and signs were fever, arthralgia, malaise, weight loss, arthritis, hepatosplenomegaly and lymphadenopathy. Brucella melitensis was isolated from 75% of 87 patients. Diverse hematologic and biochemical abnormalities were found. Different durations and combinations of trimethoprim-sulfamethoxazole or tetracycline plus streptomycin or rifampin were used for therapy. Eight-five patients were followed for an average of 14 months. Twelve (85.7%) of 14 patients treated with two-antibiotic combinations for 3 weeks relapsed, as did 5 (8%) of 62 patients treated for at least 6 weeks (P less than 0.001). No relapses occurred in 9 patients treated with trimethoprim-sulfamethoxazole and rifampin for 8 to 12 weeks plus streptomycin for the first 3 weeks. Longer duration and combination of antibiotic therapy seem warranted to improve outcome and to prevent relapses.     

Outcome after first relapse in children with acute lymphoblastic leukemia: A population-based study of 315 patients from the nordic society of pediatric hematology and oncology (NOPHO)

This study reports the outcome after relapse of acute lymphoblastic leukemia (ALL) in a population-based study of 809 children over 1 year of age diagnosed July 1981 through June 1986 and with non-B acute lymphoblastic leukemia in the five Nordic countries. By January 1994, 315 children had suffered at least one relapse. The bone marrow was involved in 216 cases. There were 69 isolated CNS relapses, 25 isolated testicular recurrences and five relapses in other extramedullary sites. Of the 315 children with relapse, 94 are still in a second complete remission 12–138 (median: 78) months after relapse. The overall probability of a second event free survival (P-2.EFS) and survival after relapse was 0.28 and 0.33 respectively. The probability of remaining in second remission at 11 years was significantly correlated to the duration of first remission (P < 0.001), the site of relapse (P < 0.001) and gender (P = 0.004). The P-2.EFS for early, intermediate, and late bone marrow involved relapses were 0.08, 0.19, and 0.50 respectively. For early, intermediate and late isolated CNS relapses the P-2.EFS were 0.21, 0.38 and 0.61, respectively. The P-2.EFS for boys with isolated testicular relapses was 0.69. Girls with isolated CNS relapse (P < 0.001) and with bone marrow involved relapse (P = 0.04) had a significantly better prognosis than boys. Children with initial high risk criteria, especially T-ALL and mediastinal mass who relapsed, had a very poor prognosis. Conclusion: In this population-based study, about 30% of children with ALL obtained a long second remission and possible cure. © 1995 Wiley-Liss, Inc.