Catheter-associated bloodstream infections in pediatric hematology-oncology patients: factors associated with catheter removal and recurrence

The aims of this study were to analyze the factors associated with antibiotic failure leading to tunneled central venous catheter (CVC) removal during catheter-associated bloodstream infections (CABSIs) and with recurrence and reinfection in children with cancer. All cases of CABSI in patients attending the Department of Pediatric Hematology-Oncology between November 2000 and November 2003 were reviewed. A total of 207 episodes of CABSI, including multiple episodes involving the same catheter, were identified in 146 of 410 tunneled CVCs (167 Hickman, 243 implantable ports). The most common organism isolated was coagulase-negative Staphylococcus (CONS). The CVC was removed in 96 (46%) episodes. Hypotension, persistent bacteremia, previous stem cell transplantation, multiple CABSIs in the same CVC, exit-site infection, inappropriate empiric antibiotic therapy, and Candida infection were all significantly associated with increased risk of catheter removal (P < 0.05, odds ratios 7.81, 1.14, 2.22, 1.93, 3.04, 2.04 and 24.53, respectively). There were 12 episodes of recurrent infection, all except 1 caused by CONS (odds ratio 20.5, P = 0.006). Inappropriate empiric therapy, especially in implantable ports, was the only mutable risk factor for antibiotic failure. Because CONS was the predominant isolate in these devices, adding glycopeptides to the empiric therapy for suspected implantable-port CABSI might decrease the removal rate. This issue should be explored in future controlled trials.     

Mycetoma of the renal pelvis caused by Fusarium species.

A preterm infant, with posterior urethral valves had a mycetoma of the renal pelvis caused by Fusarium species. Prolonged treatment with amphotericin B alone or with flucytosine failed. Combined surgical drainage and medical therapy resulted in full resolution.     

Sporotrichoid lymphangitis due to group A Streptococcus.

We describe what is, to our knowledge, the first case of sporotrichoid lymphangitis caused solely by group A Streptococcus in an otherwise healthy patient. Infection with pyogenic pathogens, such as streptococci and staphylococci, as well as with the most common causes of sporotrichoid lymphangitis (i.e., Sporothrix schenkii, Nocardia brasiliensis, Mycobacterium marinum, and Leishmania species) should be considered in differential diagnosis for some patients.     

Pediatric convulsive status epilepticus in Honduras, Central America

Convulsive status epilepticus (SE) in children is an important public health problem, particularly in low-resource countries. A surveillance study was performed with consecutive enrollment of all children presenting with convulsive SE to Hospital Escuela Materno-Infantil Emergency Department in Tegucigalpa, Honduras over a 13-week period in 2003. In the 47 children with SE, the mean age was 4.5 years and the median seizure duration was 95 min. Mortality and morbidity were higher in children from rural locations, with all six deaths and three cases of new neurologic abnormalities occurring in rural children who had acute symptomatic SE. We conclude that childhood SE is common in the low-resource developing country of Honduras. Given the long delays in obtaining initial treatment in pediatric emergency facilities, availability of prehospital treatment may be of particular importance in this setting.     

Dental infection as the cause of pyrexia of unknown origin--two case reports

Two cases of pyrexia of unknown origin are described in which no cause was found despite exhaustive inpatient investigation until occult dental infection was detected: extraction of the teeth involved was followed by resolution of the pyrexia. Dental infection should be considered as an unusual but eminently treatable cause of pyrexia of unknown origin.     

Comparative disposition and whole-body autoradiographic distribution of [2-14C]azidothymidine and [2-14C]thymidine in mice

Azidothymidine (AZT) is the only approved drug for treatment of acquired immunodeficiency syndrome caused by human immunodeficiency virus. The drug is known to be metabolized by mammalian systems. The objectives of this study were: 1) to investigate the biologic fate of AZT using whole-body autoradiography; and 2) to compare the biologic fate of AZT with that of the parent molecule thymidine (dThd). Male Sprague-Dawley mice were given (intravenously) a tracer dose of [2-14C]AZT (273 microCi/kg) or [2-14C]dThd (218 microCi/kg). Treated animals were sacrificed at various time periods (2 min, 5 min, 4 hr and 24 hr) and processed for whole-body autoradiography. Tissue distribution of radioactivity in the autoradiographs was quantitated using computer-aided image analysis. The elimination of AZT and dThd was also examined by radiochemical analyses of urine, feces and expired air of treated animals over a 24-hr period. Twenty-four hr following AZT treatment, the radioactivity excreted in urine, feces and in exhaled air (as 14CO2) accounted for 86, 4.6 and 3.7% of the dose, respectively. Within 2 min after administration of AZT, maximum radioactivity was detected in the kidney. The brain, spinal cord and testes were conspicuous because of virtual lack of radioactivity. All other parenchymatous organs (liver, lung, heart and spleen) had apparent similar levels of radioactivity that were higher than those in the connective tissues. At a later time period (4 hr), the radioactivity in most organs was eliminated except in the renal medulla, contents of gastrointestinal tract, urinary bladder and mouth cavity.(ABSTRACT TRUNCATED AT 250 WORDS)     

HYPERVENTILATION AND DIZZINESS: CASE REPORTS AND MANAGEMENT

SUMMARY Dizziness is a common symptom in patients presenting to an otorhinolaryngologist. Hyperventilation accounts for up to 5% of cases with dizziness and is a contributory factor in a further 20% of cases. Six cases of dizziness due to hyperventilation are presented to illustrate the authors' simple management policy. A high index of suspicion in the absence of an organic cause of dizziness and a simple provocation test will identify these cases. Management is aimed at demonstrating resting hypocapnia, investigations to exclude organic causes of hyperventilation and rehabilitation in collaboration with a clinical psychologist ensures the appropriate treatment for the dizziness and can avoid the development of chronic somatisation behaviours.     

Departmental consumption of antibiotic drugs and subsequent resistance: a quantitative link

OBJECTIVE: To look for a quantitative model linking departmental consumption of antibiotic drugs to the subsequent isolation of resistant hospital-acquired coliform pathogens. MATERIALS AND METHODS: Included in the study were all patients with hospital-acquired bloodstream infections caused by a coliform pathogen, detected in six departments of internal medicine of one university hospital during the period 1991-1996, who had not been hospitalized in the month before the infection (n = 394). Departmental consumption of antibiotics in the year before the infection [expressed as defined daily dosages (DDD)/100 patient days], antibiotic treatment given to the individual patient before the infection, the day of hospital stay on which the infection occurred, and the department and the calendar year were all included in a logistic model to predict the isolation of a resistant pathogen. We looked at five drugs: gentamicin, amikacin, cefuroxime, ceftazidime and ciprofloxacin. RESULTS: Five logistic models were fitted for the resistance to each of the antibiotic drugs. The multivariable-adjusted odds ratios for a pathogen resistant to the specific antibiotic were 1.03 [95% confidence interval (CI) 0.70-1.50] for gentamicin, 1.80 (95% CI 1.00-3.24) for amikacin, 1.12 (95% CI 1.02-1.23) for cefuroxime, 1.45 (95% CI 1.19-1.76) for ceftazidime and 1.06 (95% CI 0.57-1.97) for ciprofloxacin, per 1 DDD/100 patient days. CONCLUSIONS: The departmental consumption of cephalosporin drugs and amikacin in six autonomous departments of medicine in the same hospital was associated with a measurable and statistically significant increase in the probability of infection caused by a resistant pathogen.