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The Pediatric Infectious Disease Journal® Newsletter

1998; Lippincott Williams & Wilkins; Volume: 17; Issue: 11 Linguagem: Inglês

10.1097/00006454-199811000-00001

1532-0987

John D. Nelson, George H. McCracken,

Respiratory and Cough-Related Research

NOVEL PROPHYLAXIS FOR AOM For years alternatives to antibiotics have been sought for prophylaxis of recurrent acute otitis media (AOM). Uhari and associates from Oulu, Finland (Pediatrics 1998;102:879) reported recently the results of their second study of xylitol sugar to prevent AOM. Xylitol is a natural 5 carbon sugar alcohol that is incorporated into chewing gum in Finland as a sweetener and an effective means to reduce cavities in children by inhibiting growth of Streptococcus mutans. It also inhibits growth of pneumococci in vitro. Children who received xylitol-containing gum, syrup or lozenge had one-third fewer episodes of AOM and antibiotic prescriptions than did those given placebo. In addition to inhibiting growth, xylitol also reduces adhesion of pneumococci to nasopharyngeal cells, but the authors' earlier study did not show an effect on pneumococcal colonization (Brit Med J 1996;313: 1180). Whatever the mechanism, the results are provocative and require confirmation. Com-pliance could be a problem because xylitol-containing substances were administered five times daily. In addition, xylitol is not currently available in the United States as a chewing gum or syrup. We wonder whether the chewing motion helps with patency of the eustachian tube orifice and ventilation of the middle ear. SMASHING SUCCESS The Kaiser Permanente Northern California Vaccine Study Group, spearheaded by Doctors Steven Black and Henry Shinefield presented the preliminary results of their pneumococcal conjugate vaccine study at the Interscience Conference on Antimicrobial Agents and Chemotherapy in San Diego on September 25, 1998. The trial involved more than 38,000 children who received either conjugated pneumococcal vaccine containing 7 serotypes or, as a control, meningococcal vaccine at 2, 4 and 6 months of age and a booster at 15 months. To date they have evaluated only invasive pneumococcal disease. For serotypes contained in the vaccine, there were 22 cases of bacteremia in controls and none in the pneumococcal vaccine group. For non-vaccine types it was 3 versus 5, respectively. For all pneumococcal serotypes, vaccine efficacy was approximately 90% (100% for vaccine type only). Rates of acute otitis media are currently being assessed. This is a remarkable achievement and should lead to FDA approval of the vaccine sometime in late 1999 or early 2000. Doctors Black and Shinefield should be commended for their extraordinary leadership in evaluation of this vaccine and, previously, of the Haemophilus influenzae type b vaccine. LYME ARTHRITIS Gerber and associates in Connecticut observed 90 children with Lyme arthritis (Pediatrics 1998;102:905). At diagnosis, they were from 1.8 to 16 years old (mean, 8.3 years) and only 26% had a history of early Lyme disease. This finding was most likely a result of treatment for those who had had erythema migrans chronicum, the classic early manifestation of the disease. The knee was involved in 90% of children and small joints were rarely involved. Almost one-half of the patients had recurrent episodes of arthritis for up to 8 years but the median time was only 6 months. Follow-up by telephone, performed 2 to 12 years after onset, revealed ongoing complaints of musculoskeletal discomfort in only 4 patients and it was uncertain whether these were related to the original diagnosis. These data are reassuring that the long-term outcome from Lyme arthritis is excellent. RESPIRATORY VIRUSES AND AOM We know that upper respiratory viral infections predispose to acute otitis media, but with modern technology of polymerase chain reaction (PCR) testing, we are now able to detect viral nucleotides in culture-negative specimens. In a collaborative study of investigators from Sao Paulo, Brazil and Charlottesville, VA (Pediatrics 1998;102:291) RNA of rhinovirus, respiratory syncytial virus and corona virus was detected in 69 (75%) of 92 children with AOM (44 middle ear fluid samples and 57 nasopharyngeal aspirates). There were no significant differences in treatment failures, relapses, or presence of ear effusion between children with or without viral infection detected in middle ear fluid. The rate of viral infection might have been higher if the influenza viruses, parainfluenza viruses and adenoviruses had been also studied. Prevention of viral infections in infants and young children by immunization could be effective in reducing the incidence of AOM. DON'T GO NEAR THE WATER Three athletes were diagnosed with leptospirosis after they participated in triathlon events in Wisconsin and Illinois. Interviews with 588 participants in those events revealed that 12% had at least two of the symptoms or signs fitting the case definition: chills, headache, myalgia, diarrhea, eye pain or red eyes. Of those case-patients, 73% sought medical attention and 39% were hospitalized. The source was most likely the lake water in which the athletes competed. Leptospires are excreted in urine of infected animals and eventually get to streams and lakes. Swimming is great exercise but every good thing has its downside. THE READERS WRITE In the April 1998 edition of this newsletter we had an item in which we quoted John Bennett's opinion about the term "hyalohyphomycosis". He does not like it. (Dr. Bennett is the big fungus expert at the NIH. If he doesn't like something, we don't like it.) James R. Miller, M.D. of Wright-Patterson Medical Center begs to disagree. He wrote to us: While I agree that the term is confusing and encountered only rarely, it is useful. We can no longer assume that all septate, "hyaline" or light-colored molds are Aspergillus species. What other term describes the finding of a mold that looks like an Aspergillus in tissue in the absence of a definitive culture diagnosis? We accept mucormycosis for infections caused by organisms that look like zygomycetes and phaeohyphomycosis for pigmented molds. Why not hyalohyphomycosis for hyaline molds that are seen but not cultured? The numbers of infections caused by Fusarium, Penicillum, Acremonium, etc., are increasing each year. PRIMAXIN FOR NEONATES Dr. Jennifer Schranz and Cathy Knee at Merck wrote to us in response to the Abramson and Holland article about off-label use of antibiotics which appeared in the August 1998 issue of The Pediatric Infectious Disease Journal. They wished to point out that Merck recently received approval from the FDA for use of imipenem-cilastatin (Primaxin®) in pediatric patients, including neonates. Approval was based on their submission of data from 178 patients 3 months of age or older and 135 patients in the first 3 months of life. The dosages they recommend for neonates weighing more than 1500 grams are as follows: 25 mg/kg doses given every 12 hours in the first week of age, every 8 hours from 1-4 weeks of age and every 6 hours in the second and third months. For older infants and children they recommend 15-25 mg/kg doses given every 6 hours. They cite one study (Antimicrob Ag Chemother 1990;34:1172) of small premature infants weighing 670-1890 grams in which 20 mg/kg was given every 12 hours. Remember that Primaxin is contraindicated in patients with central nervous system infections because it appears to increase the likelihood of seizures. Meropenem (Merrem®) has pretty much replaced Primaxin, but meropenem is not approved for use in neonates. In actual practice we use these antibiotics infrequently and rarely give them as empiric initial treatment. They are reserved for situations in which the pathogens are resistant to cephalosporins, aminoglycosides and broad spectrum penicillins; however, we do use meropenem as initial empiric therapy in cases of intraabdominal infection which is likely to have polymicrobic bowel flora and the alternative would be a two or three drug regimen.