Miriam E. Tucker

WASHINGTON — Nitrofurantoin should be considered as a fluoroquinolone-sparing agent for women with mild to moderate symptoms of uncomplicated cystitis, Dr. Thomas M. Hooton said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Nitrofurantoin, first approved in 1953 for the treatment of urinary tract infection (UTI), has been overshadowed in the last several decades, first by trimethoprim-sulfamethoxazole (TMP-SMX), and more recently by fluoroquinolones. But the old drug's role is being reexamined in light of increasing antimicrobial resistance. “Nitrofurantoin is over 50 and still going strong,” said Dr. Hooton, professor of medicine at the University of Washington, Seattle.

Guidelines issued in 1999 by the Infectious Diseases Society of America listed TMP-SMX as first-line treatment for uncomplicated, acute, symptomatic bacterial cystitis except when resistance is greater than 10%–20%, in which case fluoroquinolones should be used (Clin. Infect. Dis. 1999;29:745–58).

Nitrofurantoin, the IDSA said at the time, “may become more useful as resistance to TMP-SMX increases,” but was not considered first-line because of concerns about effectiveness (85% cure rate versus 90%–95% for other first-line agents) and safety, particularly regarding the rare but potentially serious occurrence of acute pulmonary reaction and the even rarer peripheral neuritis.

Although it's important to keep those concerns in mind, several new developments have occurred since those guidelines were issued that may shift the risk/benefit calculation, Dr. Hooton said.

One is the dramatic rise in resistance of Escherichia coli causing uncomplicated cystitis in women. In a Seattle study conducted over a 5-year period during the 1990s, E. coli resistance to TMP-SMX doubled, from 9% to 18%, whereas resistance to nitrofurantoin and ciprofloxacin remained unchanged, at 0%–2% for the entire study period (JAMA 1999;281:736–8).

Moreover, a safety review of published and unpublished data on nitrofurantoin revealed an extremely low rate (0.00094%) of acute pulmonary reactions and even lower rates of other major adverse events (Drugs 2001;61:353–64).

Most reported adverse events occurred in patients using nitrofurantoin for long-term UTI prophylaxis and few studies have evaluated either efficacy or safety of short-term nitrofurantoin use. With that in mind, Dr. Hooton and his associates recently completed a randomized trial aimed at demonstrating noninferiority (difference of 10% or less) of 5-day nitrofurantoin (Macrobid) 100 mg twice daily, compared with TMP-SMX 160/800 mg twice daily in 303 healthy nonpregnant women aged 18–45 years with uncomplicated acute cystitis.

As expected, the majority (86%) of infections were due to E. coli, 8% were due to Staphylococcus saprophyticus, and another 2% to group B streptococcus. Resistance to TMP-SMX was 12%, compared with 3% to nitrofurantoin. Clinical cure rates were approximately 90% at 5–9 days and 80% at 28–30 days for both treatment groups. Microbiologic cure rates are still being evaluated, Dr. Hooton said.

The proportion of women who reported having taken all doses was 95% for the 5 days of nitrofurantoin and 99% for the 3-day TMP-SMX regimen. There were no significant differences in adverse events, reported by approximately 40% in both treatment groups. Gastrointestinal side effects were the most common in both groups. The proportion of subjects who discontinued because of side effects was 1% for TMP-SMX and 2% for nitrofurantoin, whereas 11% of the TMP-SMX group required treatment for an adverse event, compared with 6% for nitrofurantoin, he said.

Considering all these recent data—and the fact that nitrofurantoin and TMP-SMX are available in generic formulation, whereas none of the fluoroquinolones except ciprofloxacin are—it might make sense to reserve fluoroquinolones for women who are allergic to TMP-SMX or have risk factors for resistance, have moderate to severe symptoms clearly affecting their daily routine, or who might find it difficult to return for care, Dr. Hooton said at the conference, sponsored by the American Society for Microbiology.

WASHINGTON — Nitrofurantoin should be considered as a fluoroquinolone-sparing agent for women with mild to moderate symptoms of uncomplicated cystitis, Dr. Thomas M. Hooton said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Nitrofurantoin, first approved in 1953 for the treatment of urinary tract infection (UTI), has been overshadowed in the last several decades, first by trimethoprim-sulfamethoxazole (TMP-SMX), and more recently by fluoroquinolones. But the old drug's role is being reexamined in light of increasing antimicrobial resistance. “Nitrofurantoin is over 50 and still going strong,” said Dr. Hooton, professor of medicine at the University of Washington, Seattle.

Guidelines issued in 1999 by the Infectious Diseases Society of America listed TMP-SMX as first-line treatment for uncomplicated, acute, symptomatic bacterial cystitis except when resistance is greater than 10%–20%, in which case fluoroquinolones should be used (Clin. Infect. Dis. 1999;29:745–58).

Nitrofurantoin, the IDSA said at the time, “may become more useful as resistance to TMP-SMX increases,” but was not considered first-line because of concerns about effectiveness (85% cure rate versus 90%–95% for other first-line agents) and safety, particularly regarding the rare but potentially serious occurrence of acute pulmonary reaction and the even rarer peripheral neuritis.

Although it's important to keep those concerns in mind, several new developments have occurred since those guidelines were issued that may shift the risk/benefit calculation, Dr. Hooton said.

One is the dramatic rise in resistance of Escherichia coli causing uncomplicated cystitis in women. In a Seattle study conducted over a 5-year period during the 1990s, E. coli resistance to TMP-SMX doubled, from 9% to 18%, whereas resistance to nitrofurantoin and ciprofloxacin remained unchanged, at 0%–2% for the entire study period (JAMA 1999;281:736–8).

Moreover, a safety review of published and unpublished data on nitrofurantoin revealed an extremely low rate (0.00094%) of acute pulmonary reactions and even lower rates of other major adverse events (Drugs 2001;61:353–64).

Most reported adverse events occurred in patients using nitrofurantoin for long-term UTI prophylaxis and few studies have evaluated either efficacy or safety of short-term nitrofurantoin use. With that in mind, Dr. Hooton and his associates recently completed a randomized trial aimed at demonstrating noninferiority (difference of 10% or less) of 5-day nitrofurantoin (Macrobid) 100 mg twice daily, compared with TMP-SMX 160/800 mg twice daily in 303 healthy nonpregnant women aged 18–45 years with uncomplicated acute cystitis.

As expected, the majority (86%) of infections were due to E. coli, 8% were due to Staphylococcus saprophyticus, and another 2% to group B streptococcus. Resistance to TMP-SMX was 12%, compared with 3% to nitrofurantoin. Clinical cure rates were approximately 90% at 5–9 days and 80% at 28–30 days for both treatment groups. Microbiologic cure rates are still being evaluated, Dr. Hooton said.

The proportion of women who reported having taken all doses was 95% for the 5 days of nitrofurantoin and 99% for the 3-day TMP-SMX regimen. There were no significant differences in adverse events, reported by approximately 40% in both treatment groups. Gastrointestinal side effects were the most common in both groups. The proportion of subjects who discontinued because of side effects was 1% for TMP-SMX and 2% for nitrofurantoin, whereas 11% of the TMP-SMX group required treatment for an adverse event, compared with 6% for nitrofurantoin, he said.

Considering all these recent data—and the fact that nitrofurantoin and TMP-SMX are available in generic formulation, whereas none of the fluoroquinolones except ciprofloxacin are—it might make sense to reserve fluoroquinolones for women who are allergic to TMP-SMX or have risk factors for resistance, have moderate to severe symptoms clearly affecting their daily routine, or who might find it difficult to return for care, Dr. Hooton said at the conference, sponsored by the American Society for Microbiology.

WASHINGTON — Nitrofurantoin should be considered as a fluoroquinolone-sparing agent for women with mild to moderate symptoms of uncomplicated cystitis, Dr. Thomas M. Hooton said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Nitrofurantoin, first approved in 1953 for the treatment of urinary tract infection (UTI), has been overshadowed in the last several decades, first by trimethoprim-sulfamethoxazole (TMP-SMX), and more recently by fluoroquinolones. But the old drug's role is being reexamined in light of increasing antimicrobial resistance. “Nitrofurantoin is over 50 and still going strong,” said Dr. Hooton, professor of medicine at the University of Washington, Seattle.

Guidelines issued in 1999 by the Infectious Diseases Society of America listed TMP-SMX as first-line treatment for uncomplicated, acute, symptomatic bacterial cystitis except when resistance is greater than 10%–20%, in which case fluoroquinolones should be used (Clin. Infect. Dis. 1999;29:745–58).

Nitrofurantoin, the IDSA said at the time, “may become more useful as resistance to TMP-SMX increases,” but was not considered first-line because of concerns about effectiveness (85% cure rate versus 90%–95% for other first-line agents) and safety, particularly regarding the rare but potentially serious occurrence of acute pulmonary reaction and the even rarer peripheral neuritis.

Although it's important to keep those concerns in mind, several new developments have occurred since those guidelines were issued that may shift the risk/benefit calculation, Dr. Hooton said.

One is the dramatic rise in resistance of Escherichia coli causing uncomplicated cystitis in women. In a Seattle study conducted over a 5-year period during the 1990s, E. coli resistance to TMP-SMX doubled, from 9% to 18%, whereas resistance to nitrofurantoin and ciprofloxacin remained unchanged, at 0%–2% for the entire study period (JAMA 1999;281:736–8).

Moreover, a safety review of published and unpublished data on nitrofurantoin revealed an extremely low rate (0.00094%) of acute pulmonary reactions and even lower rates of other major adverse events (Drugs 2001;61:353–64).

Most reported adverse events occurred in patients using nitrofurantoin for long-term UTI prophylaxis and few studies have evaluated either efficacy or safety of short-term nitrofurantoin use. With that in mind, Dr. Hooton and his associates recently completed a randomized trial aimed at demonstrating noninferiority (difference of 10% or less) of 5-day nitrofurantoin (Macrobid) 100 mg twice daily, compared with TMP-SMX 160/800 mg twice daily in 303 healthy nonpregnant women aged 18–45 years with uncomplicated acute cystitis.

As expected, the majority (86%) of infections were due to E. coli, 8% were due to Staphylococcus saprophyticus, and another 2% to group B streptococcus. Resistance to TMP-SMX was 12%, compared with 3% to nitrofurantoin. Clinical cure rates were approximately 90% at 5–9 days and 80% at 28–30 days for both treatment groups. Microbiologic cure rates are still being evaluated, Dr. Hooton said.

The proportion of women who reported having taken all doses was 95% for the 5 days of nitrofurantoin and 99% for the 3-day TMP-SMX regimen. There were no significant differences in adverse events, reported by approximately 40% in both treatment groups. Gastrointestinal side effects were the most common in both groups. The proportion of subjects who discontinued because of side effects was 1% for TMP-SMX and 2% for nitrofurantoin, whereas 11% of the TMP-SMX group required treatment for an adverse event, compared with 6% for nitrofurantoin, he said.

Considering all these recent data—and the fact that nitrofurantoin and TMP-SMX are available in generic formulation, whereas none of the fluoroquinolones except ciprofloxacin are—it might make sense to reserve fluoroquinolones for women who are allergic to TMP-SMX or have risk factors for resistance, have moderate to severe symptoms clearly affecting their daily routine, or who might find it difficult to return for care, Dr. Hooton said at the conference, sponsored by the American Society for Microbiology.

WASHINGTON — Nitrofurantoin should be considered as a fluoroquinolone-sparing agent for women with mild to moderate symptoms of uncomplicated cystitis, Dr. Thomas M. Hooton said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Nitrofurantoin, first approved in 1953 for the treatment of urinary tract infection (UTI), has been overshadowed in the last several decades, first by trimethoprim-sulfamethoxazole (TMP-SMX), and more recently by fluoroquinolones. Now the old drug's role is being reexamined in light of increasing antimicrobial resistance. “Nitrofurantoin is over 50 and still going strong,” said Dr. Hooton, professor of medicine at the University of Washington, Seattle.

Guidelines issued in 1999 by the Infectious Diseases Society of America listed TMP-SMX as first-line treatment for uncomplicated, acute, symptomatic bacterial cystitis except when resistance is greater than 10%–20%, in which case fluoroquinolones should be used (Clin. Infect. Dis. 1999;29:745–58).

Nitrofurantoin, the IDSA said at the time, “may become more useful as resistance to TMP-SMX increases,” but was not considered first-line due to concerns about effectiveness (85% cure rate vs. 90%–95% for other first-line agents) and safety, particularly regarding the rare but serious occurrence of acute pulmonary reaction and the even rarer peripheral neuritis.

While it's important to keep those concerns in mind, several new developments have occurred since those guidelines were issued that may shift the risk/benefit calculation, Dr. Hooton said.

One is the dramatic rise in resistance of Escherichia coli causing uncomplicated cystitis in women. In a Seattle study conducted over a 5-year period during the 1990s, E. coli resistance to TMP-SMX doubled, from 9% to 18%, while resistance to nitrofurantoin and ciprofloxacin remained unchanged, at 0%–2% for the entire study period (JAMA 1999;281:736–8).

Moreover, a safety review of published and unpublished data on nitrofurantoin revealed an extremely low rate (0.00094%) of acute pulmonary reactions and even lower rates of other major adverse events (Drugs 2001;61:353–64).

Dr. Hooton and his associates recently completed a randomized trial aimed at demonstrating noninferiority (difference of 10% or less) of 5-day nitrofurantoin (Macrobid) 100 mg twice daily, compared with TMP-SMX 160/800 mg twice daily in 303 healthy nonpregnant women aged 18–45 years with uncomplicated acute cystitis. As expected, the majority (86%) of infections were due to E. coli, 8% were due to Staphylococcus saprophyticus, and another 2% to group B streptococcus. Resistance to TMP-SMX was 12% vs. 3% to nitrofurantoin. Clinical cure rates were approximately 90% at 5–9 days and 80% at 28–30 days for both treatment groups. Microbiologic cure rates are still being evaluated, Dr. Hooton said.

The proportion of women who reported having taken all doses was 95% for the 5 days of nitrofurantoin and 99% for the 3-day TMP-SMX regimen. There were no significant differences in adverse events. GI side effects were the most common in both groups. The proportion of subjects who discontinued due to side effects was 1% for TMP-SMX and 2% for nitrofurantoin, while 11% of the TMP-SMX group required treatment for an adverse event vs. just 6% for nitrofurantoin, he reported.

Considering these data—and the fact that nitrofurantoin and TMP-SMX are available in generic formulation while none of the fluoroquinolones except ciprofloxacin are—it might make sense to reserve fluoroquinolones for those women who are allergic to TMP-SMX or have risk factors for resistance, have moderate to severe symptoms clearly affecting their daily routine, or who might find it difficult to return for care. “I think we should be trying to avoid fluoroquinolones when we can,” Dr. Hooton said at the conference, sponsored by the American Society for Microbiology.

TMP-SMX might still be considered first-line for women with no history of allergy, no antibiotic use in the past 3 months (for any reason), no recent hospitalization, and where TMP-SMX resistance is not known to be 20% or greater. On the other hand, “One might argue that since nitrofurantoin is not inferior, why not use it first-line? I certainly feel more comfortable about the drug's safety and efficacy given these new study data,” Dr. Hooton said.

WASHINGTON — Nitrofurantoin should be considered as a fluoroquinolone-sparing agent for women with mild to moderate symptoms of uncomplicated cystitis, Dr. Thomas M. Hooton said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Nitrofurantoin, first approved in 1953 for the treatment of urinary tract infection (UTI), has been overshadowed in the last several decades, first by trimethoprim-sulfamethoxazole (TMP-SMX), and more recently by fluoroquinolones. Now the old drug's role is being reexamined in light of increasing antimicrobial resistance. “Nitrofurantoin is over 50 and still going strong,” said Dr. Hooton, professor of medicine at the University of Washington, Seattle.

Guidelines issued in 1999 by the Infectious Diseases Society of America listed TMP-SMX as first-line treatment for uncomplicated, acute, symptomatic bacterial cystitis except when resistance is greater than 10%–20%, in which case fluoroquinolones should be used (Clin. Infect. Dis. 1999;29:745–58).

Nitrofurantoin, the IDSA said at the time, “may become more useful as resistance to TMP-SMX increases,” but was not considered first-line due to concerns about effectiveness (85% cure rate vs. 90%–95% for other first-line agents) and safety, particularly regarding the rare but serious occurrence of acute pulmonary reaction and the even rarer peripheral neuritis.

While it's important to keep those concerns in mind, several new developments have occurred since those guidelines were issued that may shift the risk/benefit calculation, Dr. Hooton said.

One is the dramatic rise in resistance of Escherichia coli causing uncomplicated cystitis in women. In a Seattle study conducted over a 5-year period during the 1990s, E. coli resistance to TMP-SMX doubled, from 9% to 18%, while resistance to nitrofurantoin and ciprofloxacin remained unchanged, at 0%–2% for the entire study period (JAMA 1999;281:736–8).

Moreover, a safety review of published and unpublished data on nitrofurantoin revealed an extremely low rate (0.00094%) of acute pulmonary reactions and even lower rates of other major adverse events (Drugs 2001;61:353–64).

Dr. Hooton and his associates recently completed a randomized trial aimed at demonstrating noninferiority (difference of 10% or less) of 5-day nitrofurantoin (Macrobid) 100 mg twice daily, compared with TMP-SMX 160/800 mg twice daily in 303 healthy nonpregnant women aged 18–45 years with uncomplicated acute cystitis. As expected, the majority (86%) of infections were due to E. coli, 8% were due to Staphylococcus saprophyticus, and another 2% to group B streptococcus. Resistance to TMP-SMX was 12% vs. 3% to nitrofurantoin. Clinical cure rates were approximately 90% at 5–9 days and 80% at 28–30 days for both treatment groups. Microbiologic cure rates are still being evaluated, Dr. Hooton said.

The proportion of women who reported having taken all doses was 95% for the 5 days of nitrofurantoin and 99% for the 3-day TMP-SMX regimen. There were no significant differences in adverse events. GI side effects were the most common in both groups. The proportion of subjects who discontinued due to side effects was 1% for TMP-SMX and 2% for nitrofurantoin, while 11% of the TMP-SMX group required treatment for an adverse event vs. just 6% for nitrofurantoin, he reported.

Considering these data—and the fact that nitrofurantoin and TMP-SMX are available in generic formulation while none of the fluoroquinolones except ciprofloxacin are—it might make sense to reserve fluoroquinolones for those women who are allergic to TMP-SMX or have risk factors for resistance, have moderate to severe symptoms clearly affecting their daily routine, or who might find it difficult to return for care. “I think we should be trying to avoid fluoroquinolones when we can,” Dr. Hooton said at the conference, sponsored by the American Society for Microbiology.

TMP-SMX might still be considered first-line for women with no history of allergy, no antibiotic use in the past 3 months (for any reason), no recent hospitalization, and where TMP-SMX resistance is not known to be 20% or greater. On the other hand, “One might argue that since nitrofurantoin is not inferior, why not use it first-line? I certainly feel more comfortable about the drug's safety and efficacy given these new study data,” Dr. Hooton said.

WASHINGTON — Nitrofurantoin should be considered as a fluoroquinolone-sparing agent for women with mild to moderate symptoms of uncomplicated cystitis, Dr. Thomas M. Hooton said at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Nitrofurantoin, first approved in 1953 for the treatment of urinary tract infection (UTI), has been overshadowed in the last several decades, first by trimethoprim-sulfamethoxazole (TMP-SMX), and more recently by fluoroquinolones. Now the old drug's role is being reexamined in light of increasing antimicrobial resistance. “Nitrofurantoin is over 50 and still going strong,” said Dr. Hooton, professor of medicine at the University of Washington, Seattle.

Guidelines issued in 1999 by the Infectious Diseases Society of America listed TMP-SMX as first-line treatment for uncomplicated, acute, symptomatic bacterial cystitis except when resistance is greater than 10%–20%, in which case fluoroquinolones should be used (Clin. Infect. Dis. 1999;29:745–58).

Nitrofurantoin, the IDSA said at the time, “may become more useful as resistance to TMP-SMX increases,” but was not considered first-line due to concerns about effectiveness (85% cure rate vs. 90%–95% for other first-line agents) and safety, particularly regarding the rare but serious occurrence of acute pulmonary reaction and the even rarer peripheral neuritis.

While it's important to keep those concerns in mind, several new developments have occurred since those guidelines were issued that may shift the risk/benefit calculation, Dr. Hooton said.

One is the dramatic rise in resistance of Escherichia coli causing uncomplicated cystitis in women. In a Seattle study conducted over a 5-year period during the 1990s, E. coli resistance to TMP-SMX doubled, from 9% to 18%, while resistance to nitrofurantoin and ciprofloxacin remained unchanged, at 0%–2% for the entire study period (JAMA 1999;281:736–8).

Moreover, a safety review of published and unpublished data on nitrofurantoin revealed an extremely low rate (0.00094%) of acute pulmonary reactions and even lower rates of other major adverse events (Drugs 2001;61:353–64).

Dr. Hooton and his associates recently completed a randomized trial aimed at demonstrating noninferiority (difference of 10% or less) of 5-day nitrofurantoin (Macrobid) 100 mg twice daily, compared with TMP-SMX 160/800 mg twice daily in 303 healthy nonpregnant women aged 18–45 years with uncomplicated acute cystitis. As expected, the majority (86%) of infections were due to E. coli, 8% were due to Staphylococcus saprophyticus, and another 2% to group B streptococcus. Resistance to TMP-SMX was 12% vs. 3% to nitrofurantoin. Clinical cure rates were approximately 90% at 5–9 days and 80% at 28–30 days for both treatment groups. Microbiologic cure rates are still being evaluated, Dr. Hooton said.

The proportion of women who reported having taken all doses was 95% for the 5 days of nitrofurantoin and 99% for the 3-day TMP-SMX regimen. There were no significant differences in adverse events. GI side effects were the most common in both groups. The proportion of subjects who discontinued due to side effects was 1% for TMP-SMX and 2% for nitrofurantoin, while 11% of the TMP-SMX group required treatment for an adverse event vs. just 6% for nitrofurantoin, he reported.

Considering these data—and the fact that nitrofurantoin and TMP-SMX are available in generic formulation while none of the fluoroquinolones except ciprofloxacin are—it might make sense to reserve fluoroquinolones for those women who are allergic to TMP-SMX or have risk factors for resistance, have moderate to severe symptoms clearly affecting their daily routine, or who might find it difficult to return for care. “I think we should be trying to avoid fluoroquinolones when we can,” Dr. Hooton said at the conference, sponsored by the American Society for Microbiology.

TMP-SMX might still be considered first-line for women with no history of allergy, no antibiotic use in the past 3 months (for any reason), no recent hospitalization, and where TMP-SMX resistance is not known to be 20% or greater. On the other hand, “One might argue that since nitrofurantoin is not inferior, why not use it first-line? I certainly feel more comfortable about the drug's safety and efficacy given these new study data,” Dr. Hooton said.

Consider congenital rubella syndrome in infants with compatible signs, particularly immigrants from countries without rubella control programs, the Centers for Disease Control and Prevention advised.

In 2004, a 10-week-old infant born to a mother who had emigrated from the Côte d'Ivoire was brought to an emergency department in New Hampshire with fever, vomiting, irritability, and poor feeding.

While she was in the hospital, the infant—who had been born with a cataract in her left eye—was diagnosed with microcephaly, patent ductus arteriosus, bilateral hearing impairment, and hepatosplenomegaly, as well as failure to thrive (MMWR 2005;54:1160–1).

Congenital rubella syndrome was suspected and confirmed by positive rubella IgM and positive urine and nasopharyngeal cultures. The genetic sequence was found to be that of a wild-type rubella virus similar to one found in Uganda in 2001, the CDC said.

Soon after conception, the mother had come into contact with refugees from one of four transit centers in Cote d'Ivoire where there had been a rubella outbreak during February-April 2004.

She had reported no history of symptoms of acute rubella infection such as rash, fever, lymphadenopathy, or arthralgia.

However, subclinical infections are estimated to occur in up to 50% of rubella cases.

Consider congenital rubella syndrome in infants with compatible signs, particularly immigrants from countries without rubella control programs, the Centers for Disease Control and Prevention advised.

In 2004, a 10-week-old infant born to a mother who had emigrated from the Côte d'Ivoire was brought to an emergency department in New Hampshire with fever, vomiting, irritability, and poor feeding.

While she was in the hospital, the infant—who had been born with a cataract in her left eye—was diagnosed with microcephaly, patent ductus arteriosus, bilateral hearing impairment, and hepatosplenomegaly, as well as failure to thrive (MMWR 2005;54:1160–1).

Congenital rubella syndrome was suspected and confirmed by positive rubella IgM and positive urine and nasopharyngeal cultures. The genetic sequence was found to be that of a wild-type rubella virus similar to one found in Uganda in 2001, the CDC said.

Soon after conception, the mother had come into contact with refugees from one of four transit centers in Cote d'Ivoire where there had been a rubella outbreak during February-April 2004.

She had reported no history of symptoms of acute rubella infection such as rash, fever, lymphadenopathy, or arthralgia.

However, subclinical infections are estimated to occur in up to 50% of rubella cases.

Consider congenital rubella syndrome in infants with compatible signs, particularly immigrants from countries without rubella control programs, the Centers for Disease Control and Prevention advised.

In 2004, a 10-week-old infant born to a mother who had emigrated from the Côte d'Ivoire was brought to an emergency department in New Hampshire with fever, vomiting, irritability, and poor feeding.

While she was in the hospital, the infant—who had been born with a cataract in her left eye—was diagnosed with microcephaly, patent ductus arteriosus, bilateral hearing impairment, and hepatosplenomegaly, as well as failure to thrive (MMWR 2005;54:1160–1).

Congenital rubella syndrome was suspected and confirmed by positive rubella IgM and positive urine and nasopharyngeal cultures. The genetic sequence was found to be that of a wild-type rubella virus similar to one found in Uganda in 2001, the CDC said.

Soon after conception, the mother had come into contact with refugees from one of four transit centers in Cote d'Ivoire where there had been a rubella outbreak during February-April 2004.

She had reported no history of symptoms of acute rubella infection such as rash, fever, lymphadenopathy, or arthralgia.

However, subclinical infections are estimated to occur in up to 50% of rubella cases.

The incidence of early-onset neonatal group B streptococcal disease in the United States has dropped by a third since guidelines for universal screening of pregnant women were issued, the Centers for Disease Control and Prevention reported.

The guidelines, which call for routine screening of pregnant women for rectovaginal group B streptococcal (GBS) colonization at 35–37 weeks' gestation and administration of intrapartum antimicrobial prophylaxis to carriers, were jointly issued in 2002 by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the CDC (MMWR Recomm. Rep. 2002;51[RR-11]:1–22).

In 2004, the incidence of GBS disease in newborns aged 0–6 days (early-onset disease) had decreased by 31% from the period of 2000–2001, immediately before universal screening was implemented, the CDC said (MMWR 2005;54:1205–8).

Late-onset GBS disease—occurring in infants aged 7–89 days—did not change during 1996–2004, the period for which data were analyzed from the CDC's Active Bacterial Core surveillance (ABCs) system. The ABCs areas represented approximately 337,000 live births in 1996 and 427,000 live births in 2004. A total of 308 cases of neonatal GBS disease were reported in 2004, 47% early-onset and 53% late-onset. Overall, 55% with neonatal GBS disease were white, 42% black, and 3% other races; 51% were female.

Among early-onset cases with complete data, the proportion born at less than 37 weeks' gestation increased significantly, from 20% (40 of 204) in 2000 to 29% (41 of 141) in 2004. Among late-onset cases with complete data in 2004, 55% (81 of 147) were born preterm. Case-fatality ratios were consistently higher among preterm infants, both in the early- and late-disease groups. Nine of the 40 preterm infants with early-onset disease died (23%) vs. none of the 66 term infants with late-onset GBS.

The rate of late-onset disease surpassed that of early-onset disease for the first time in 2003, a trend that continued in 2004. Racial disparities in the incidence of both early- and late-onset GBS disease persisted: In 2004, rates of early-onset disease were 0.73 per 1,000 live births for black infants vs. 0.26 per 1,000 for white infants. For late-onset disease, those rates were 0.83 per 1,000 live births for black infants vs. 0.28 per 1,000 for whites.

The incidence of early-onset neonatal group B streptococcal disease in the United States has dropped by a third since guidelines for universal screening of pregnant women were issued, the Centers for Disease Control and Prevention reported.

The guidelines, which call for routine screening of pregnant women for rectovaginal group B streptococcal (GBS) colonization at 35–37 weeks' gestation and administration of intrapartum antimicrobial prophylaxis to carriers, were jointly issued in 2002 by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the CDC (MMWR Recomm. Rep. 2002;51[RR-11]:1–22).

In 2004, the incidence of GBS disease in newborns aged 0–6 days (early-onset disease) had decreased by 31% from the period of 2000–2001, immediately before universal screening was implemented, the CDC said (MMWR 2005;54:1205–8).

Late-onset GBS disease—occurring in infants aged 7–89 days—did not change during 1996–2004, the period for which data were analyzed from the CDC's Active Bacterial Core surveillance (ABCs) system. The ABCs areas represented approximately 337,000 live births in 1996 and 427,000 live births in 2004. A total of 308 cases of neonatal GBS disease were reported in 2004, 47% early-onset and 53% late-onset. Overall, 55% with neonatal GBS disease were white, 42% black, and 3% other races; 51% were female.

Among early-onset cases with complete data, the proportion born at less than 37 weeks' gestation increased significantly, from 20% (40 of 204) in 2000 to 29% (41 of 141) in 2004. Among late-onset cases with complete data in 2004, 55% (81 of 147) were born preterm. Case-fatality ratios were consistently higher among preterm infants, both in the early- and late-disease groups. Nine of the 40 preterm infants with early-onset disease died (23%) vs. none of the 66 term infants with late-onset GBS.

The rate of late-onset disease surpassed that of early-onset disease for the first time in 2003, a trend that continued in 2004. Racial disparities in the incidence of both early- and late-onset GBS disease persisted: In 2004, rates of early-onset disease were 0.73 per 1,000 live births for black infants vs. 0.26 per 1,000 for white infants. For late-onset disease, those rates were 0.83 per 1,000 live births for black infants vs. 0.28 per 1,000 for whites.

The incidence of early-onset neonatal group B streptococcal disease in the United States has dropped by a third since guidelines for universal screening of pregnant women were issued, the Centers for Disease Control and Prevention reported.

The guidelines, which call for routine screening of pregnant women for rectovaginal group B streptococcal (GBS) colonization at 35–37 weeks' gestation and administration of intrapartum antimicrobial prophylaxis to carriers, were jointly issued in 2002 by the American College of Obstetricians and Gynecologists, the American Academy of Pediatrics, and the CDC (MMWR Recomm. Rep. 2002;51[RR-11]:1–22).

In 2004, the incidence of GBS disease in newborns aged 0–6 days (early-onset disease) had decreased by 31% from the period of 2000–2001, immediately before universal screening was implemented, the CDC said (MMWR 2005;54:1205–8).

Late-onset GBS disease—occurring in infants aged 7–89 days—did not change during 1996–2004, the period for which data were analyzed from the CDC's Active Bacterial Core surveillance (ABCs) system. The ABCs areas represented approximately 337,000 live births in 1996 and 427,000 live births in 2004. A total of 308 cases of neonatal GBS disease were reported in 2004, 47% early-onset and 53% late-onset. Overall, 55% with neonatal GBS disease were white, 42% black, and 3% other races; 51% were female.

Among early-onset cases with complete data, the proportion born at less than 37 weeks' gestation increased significantly, from 20% (40 of 204) in 2000 to 29% (41 of 141) in 2004. Among late-onset cases with complete data in 2004, 55% (81 of 147) were born preterm. Case-fatality ratios were consistently higher among preterm infants, both in the early- and late-disease groups. Nine of the 40 preterm infants with early-onset disease died (23%) vs. none of the 66 term infants with late-onset GBS.

The rate of late-onset disease surpassed that of early-onset disease for the first time in 2003, a trend that continued in 2004. Racial disparities in the incidence of both early- and late-onset GBS disease persisted: In 2004, rates of early-onset disease were 0.73 per 1,000 live births for black infants vs. 0.26 per 1,000 for white infants. For late-onset disease, those rates were 0.83 per 1,000 live births for black infants vs. 0.28 per 1,000 for whites.

WASHINGTON — Implementation of a Medicaid-funded program that would disburse child restraint systems to low-income children and educate families about their use would be more cost effective to Medicaid than are most currently administered vaccines, Jesse A. Goldstein reported at the annual meeting of the American Academy of Pediatrics.

As with all routine vaccines, such a program would be cost-saving to society in terms of parental work loss and future productivity. And, akin to what the federally funded Vaccines for Children accomplishes for vaccination, “this program would reduce the disparities in child passenger safety prevalent in low-income communities by addressing the major barriers to adequate restraint practices—namely, access and education,” said Mr. Goldstein, a fourth-year medical student at the University of Pennsylvania, Philadelphia.

The data come from the Partners for Child Passenger Safety, a research collaboration of State Farm Insurance Companies, Children's Hospital of Philadelphia, and the University of Pennsylvania (www.traumalink.chop.edu

For the current analysis, a hypothetical group of 100,000 low-income children were enrolled at birth and followed through 8 years of recommended child restraint system (CRS) use. Injury rates were derived from the PCPS database of State Farm policyholders involved in crashes from 1999 to 2003 in which a child aged 8 years or younger was present. Mortality data came from the Fatality Analysis Reporting System, and other data came from published and unpublished sources.

Program costs included administration and education, initial disbursement of convertible seats beginning at birth, reinvestment for booster seats at age 4 years, and a 5% annual replacement rate. It was assumed that the program would increase appropriate CRS use for low-income children by 23% for 0− to 3-year-olds and by 35% for children aged 4–7 years. Under these assumptions, implementation of the program would prevent 63 injuries and 2 deaths per 100,000 children. Over the course of 8 years, it would prevent 400 injuries and 17 deaths, resulting in 564 life-years saved, Mr. Goldstein reported.

Without the proposed program, annual crash-related outcome costs were estimated at $4.2 million in medical costs, $350,000 in parental work loss, and $8.3 million in future victim productivity per 100,000 children. Implementation of CRS disbursement and education would reduce annual medical costs by about $1 million, parental work loss costs by $100,000, and future productivity costs by $2.7 million.

Over the 8-year projection, the program would save nearly $7 million in medical costs. At the same time, program administration costs were estimated at $6 million for the first year and $10 million cumulatively.

From the societal perspective (including all medical and nonmedical costs), the program would be cost-saving. From Medicaid's perspective—including only medical costs—the program would need to spend $17,000 to save one life-year. “This value is well below the threshold of $50,000-$80,000 that most are willing to pay for an added year of life,” Mr. Goldstein noted.

Indeed, a CRS disbursement/education program falls into the lower-cost end of the list of vaccines currently funded under VFC, well below the cost per life-year saved for varicella vaccine ($19,700 or $65,000, depending on the vaccine price estimate), hepatitis B vaccine ($26,000), and pneumococcal vaccine ($147,000). Only Haemophilus influenzae type b (cost saving to insurer) and measles-mumps- rubella ($6,000) were more cost effective.

Several states have programs that supply child safety seats among low-income populations using a variety of funding mechanisms, but most do not involve Medicaid.

A legislative proposal in Illinois would increase seatbelt violation fines from the current $25 to $200 to provide child safety seats on a sliding-scale fee to low-income families. It also would allow Medicaid to reimburse the time of certified child passenger safety technicians at eligible locations to educate families who receive sliding-fee child safety seats, said Jahari Piersol of the Illinois Department of Transportation.

WASHINGTON — Implementation of a Medicaid-funded program that would disburse child restraint systems to low-income children and educate families about their use would be more cost effective to Medicaid than are most currently administered vaccines, Jesse A. Goldstein reported at the annual meeting of the American Academy of Pediatrics.

As with all routine vaccines, such a program would be cost-saving to society in terms of parental work loss and future productivity. And, akin to what the federally funded Vaccines for Children accomplishes for vaccination, “this program would reduce the disparities in child passenger safety prevalent in low-income communities by addressing the major barriers to adequate restraint practices—namely, access and education,” said Mr. Goldstein, a fourth-year medical student at the University of Pennsylvania, Philadelphia.

The data come from the Partners for Child Passenger Safety, a research collaboration of State Farm Insurance Companies, Children's Hospital of Philadelphia, and the University of Pennsylvania (www.traumalink.chop.edu

For the current analysis, a hypothetical group of 100,000 low-income children were enrolled at birth and followed through 8 years of recommended child restraint system (CRS) use. Injury rates were derived from the PCPS database of State Farm policyholders involved in crashes from 1999 to 2003 in which a child aged 8 years or younger was present. Mortality data came from the Fatality Analysis Reporting System, and other data came from published and unpublished sources.

Program costs included administration and education, initial disbursement of convertible seats beginning at birth, reinvestment for booster seats at age 4 years, and a 5% annual replacement rate. It was assumed that the program would increase appropriate CRS use for low-income children by 23% for 0− to 3-year-olds and by 35% for children aged 4–7 years. Under these assumptions, implementation of the program would prevent 63 injuries and 2 deaths per 100,000 children. Over the course of 8 years, it would prevent 400 injuries and 17 deaths, resulting in 564 life-years saved, Mr. Goldstein reported.

Without the proposed program, annual crash-related outcome costs were estimated at $4.2 million in medical costs, $350,000 in parental work loss, and $8.3 million in future victim productivity per 100,000 children. Implementation of CRS disbursement and education would reduce annual medical costs by about $1 million, parental work loss costs by $100,000, and future productivity costs by $2.7 million.

Over the 8-year projection, the program would save nearly $7 million in medical costs. At the same time, program administration costs were estimated at $6 million for the first year and $10 million cumulatively.

From the societal perspective (including all medical and nonmedical costs), the program would be cost-saving. From Medicaid's perspective—including only medical costs—the program would need to spend $17,000 to save one life-year. “This value is well below the threshold of $50,000-$80,000 that most are willing to pay for an added year of life,” Mr. Goldstein noted.

Indeed, a CRS disbursement/education program falls into the lower-cost end of the list of vaccines currently funded under VFC, well below the cost per life-year saved for varicella vaccine ($19,700 or $65,000, depending on the vaccine price estimate), hepatitis B vaccine ($26,000), and pneumococcal vaccine ($147,000). Only Haemophilus influenzae type b (cost saving to insurer) and measles-mumps- rubella ($6,000) were more cost effective.

Several states have programs that supply child safety seats among low-income populations using a variety of funding mechanisms, but most do not involve Medicaid.

A legislative proposal in Illinois would increase seatbelt violation fines from the current $25 to $200 to provide child safety seats on a sliding-scale fee to low-income families. It also would allow Medicaid to reimburse the time of certified child passenger safety technicians at eligible locations to educate families who receive sliding-fee child safety seats, said Jahari Piersol of the Illinois Department of Transportation.

WASHINGTON — Implementation of a Medicaid-funded program that would disburse child restraint systems to low-income children and educate families about their use would be more cost effective to Medicaid than are most currently administered vaccines, Jesse A. Goldstein reported at the annual meeting of the American Academy of Pediatrics.

As with all routine vaccines, such a program would be cost-saving to society in terms of parental work loss and future productivity. And, akin to what the federally funded Vaccines for Children accomplishes for vaccination, “this program would reduce the disparities in child passenger safety prevalent in low-income communities by addressing the major barriers to adequate restraint practices—namely, access and education,” said Mr. Goldstein, a fourth-year medical student at the University of Pennsylvania, Philadelphia.

The data come from the Partners for Child Passenger Safety, a research collaboration of State Farm Insurance Companies, Children's Hospital of Philadelphia, and the University of Pennsylvania (www.traumalink.chop.edu

For the current analysis, a hypothetical group of 100,000 low-income children were enrolled at birth and followed through 8 years of recommended child restraint system (CRS) use. Injury rates were derived from the PCPS database of State Farm policyholders involved in crashes from 1999 to 2003 in which a child aged 8 years or younger was present. Mortality data came from the Fatality Analysis Reporting System, and other data came from published and unpublished sources.

Program costs included administration and education, initial disbursement of convertible seats beginning at birth, reinvestment for booster seats at age 4 years, and a 5% annual replacement rate. It was assumed that the program would increase appropriate CRS use for low-income children by 23% for 0− to 3-year-olds and by 35% for children aged 4–7 years. Under these assumptions, implementation of the program would prevent 63 injuries and 2 deaths per 100,000 children. Over the course of 8 years, it would prevent 400 injuries and 17 deaths, resulting in 564 life-years saved, Mr. Goldstein reported.

Without the proposed program, annual crash-related outcome costs were estimated at $4.2 million in medical costs, $350,000 in parental work loss, and $8.3 million in future victim productivity per 100,000 children. Implementation of CRS disbursement and education would reduce annual medical costs by about $1 million, parental work loss costs by $100,000, and future productivity costs by $2.7 million.

Over the 8-year projection, the program would save nearly $7 million in medical costs. At the same time, program administration costs were estimated at $6 million for the first year and $10 million cumulatively.

From the societal perspective (including all medical and nonmedical costs), the program would be cost-saving. From Medicaid's perspective—including only medical costs—the program would need to spend $17,000 to save one life-year. “This value is well below the threshold of $50,000-$80,000 that most are willing to pay for an added year of life,” Mr. Goldstein noted.

Indeed, a CRS disbursement/education program falls into the lower-cost end of the list of vaccines currently funded under VFC, well below the cost per life-year saved for varicella vaccine ($19,700 or $65,000, depending on the vaccine price estimate), hepatitis B vaccine ($26,000), and pneumococcal vaccine ($147,000). Only Haemophilus influenzae type b (cost saving to insurer) and measles-mumps- rubella ($6,000) were more cost effective.

Several states have programs that supply child safety seats among low-income populations using a variety of funding mechanisms, but most do not involve Medicaid.

A legislative proposal in Illinois would increase seatbelt violation fines from the current $25 to $200 to provide child safety seats on a sliding-scale fee to low-income families. It also would allow Medicaid to reimburse the time of certified child passenger safety technicians at eligible locations to educate families who receive sliding-fee child safety seats, said Jahari Piersol of the Illinois Department of Transportation.

WASHINGTON — Oral cephalosporins, whether given for 5 or 10 days, are more effective than penicillin in the treatment of Group A streptococcal tonsillopharyngitis, Dr. Janet R. Casey and Dr. Michael E. Pichichero reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Data were derived from a metaanalysis involving a total of 11,426 patients from 47 trials in the United States and Europe, said Dr. Casey and Dr. Pichichero, both of the Elmwood Pediatric Group and the University of Rochester, N.Y.

Among 10 European studies comparing 10 days of penicillin versus 10 days of cephalosporins in the bacterial eradication of Group A streptococcus (GAS) in a total of 1,656 pediatric patients with tonsillopharyngitis, the odds ratio was 4.27 in favor of cephalosporins. In 25 such U.S. trials, involving 5,469 patients, cephalosporins didn't fare quite as well, although they were still superior to penicillin, with an odds ratio of 2.70. Clinical cures for 10-day regimens were similar for the two continents, with odds ratios of 2.38 in Europe (7 trials/1,488 children) and 2.46 in the United States (22 trials/4,990 children).

Studies of 4–5 days of cephalosporins versus 10 days of penicillin were analyzed in a total of 6 European and U.S. trials involving 1,149 adults and in 6 trials from both continents involving 3,152 children. Odds ratios for bacterial eradication favored the shorter cephalosporin regimen for the 9 combined European trials (1.30) and even more so in the 3 U.S. trials (2.41). On both continents, the superiority of cephalosporins in bacterial eradication was more pronounced in children than in adults (odds ratios 1.34 vs. 1.09 in Europe and 2.94 vs. 1.65 in the United States).

Bacterial cure rates with cephalosporins were strongly superior to penicillin in trials from the United Kingdom, Germany, France, and Sweden, with odds ratios ranging from 3.35 to 4.77. Although cephalosporin cure rates remained consistent in the different countries, penicillin bacterial cure rates varied widely, with a low of 66% in Sweden. That's probably because 2 of the 3 trials conducted there were among patients with recurrent GAS tonsillopharyngitis, in whom penicillin would be expected to be even less effective, Dr. Casey and Dr. Pichichero said at the meeting, sponsored by the American Society for Microbiology.

WASHINGTON — Oral cephalosporins, whether given for 5 or 10 days, are more effective than penicillin in the treatment of Group A streptococcal tonsillopharyngitis, Dr. Janet R. Casey and Dr. Michael E. Pichichero reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Data were derived from a metaanalysis involving a total of 11,426 patients from 47 trials in the United States and Europe, said Dr. Casey and Dr. Pichichero, both of the Elmwood Pediatric Group and the University of Rochester, N.Y.

Among 10 European studies comparing 10 days of penicillin versus 10 days of cephalosporins in the bacterial eradication of Group A streptococcus (GAS) in a total of 1,656 pediatric patients with tonsillopharyngitis, the odds ratio was 4.27 in favor of cephalosporins. In 25 such U.S. trials, involving 5,469 patients, cephalosporins didn't fare quite as well, although they were still superior to penicillin, with an odds ratio of 2.70. Clinical cures for 10-day regimens were similar for the two continents, with odds ratios of 2.38 in Europe (7 trials/1,488 children) and 2.46 in the United States (22 trials/4,990 children).

Studies of 4–5 days of cephalosporins versus 10 days of penicillin were analyzed in a total of 6 European and U.S. trials involving 1,149 adults and in 6 trials from both continents involving 3,152 children. Odds ratios for bacterial eradication favored the shorter cephalosporin regimen for the 9 combined European trials (1.30) and even more so in the 3 U.S. trials (2.41). On both continents, the superiority of cephalosporins in bacterial eradication was more pronounced in children than in adults (odds ratios 1.34 vs. 1.09 in Europe and 2.94 vs. 1.65 in the United States).

Bacterial cure rates with cephalosporins were strongly superior to penicillin in trials from the United Kingdom, Germany, France, and Sweden, with odds ratios ranging from 3.35 to 4.77. Although cephalosporin cure rates remained consistent in the different countries, penicillin bacterial cure rates varied widely, with a low of 66% in Sweden. That's probably because 2 of the 3 trials conducted there were among patients with recurrent GAS tonsillopharyngitis, in whom penicillin would be expected to be even less effective, Dr. Casey and Dr. Pichichero said at the meeting, sponsored by the American Society for Microbiology.

WASHINGTON — Oral cephalosporins, whether given for 5 or 10 days, are more effective than penicillin in the treatment of Group A streptococcal tonsillopharyngitis, Dr. Janet R. Casey and Dr. Michael E. Pichichero reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Data were derived from a metaanalysis involving a total of 11,426 patients from 47 trials in the United States and Europe, said Dr. Casey and Dr. Pichichero, both of the Elmwood Pediatric Group and the University of Rochester, N.Y.

Among 10 European studies comparing 10 days of penicillin versus 10 days of cephalosporins in the bacterial eradication of Group A streptococcus (GAS) in a total of 1,656 pediatric patients with tonsillopharyngitis, the odds ratio was 4.27 in favor of cephalosporins. In 25 such U.S. trials, involving 5,469 patients, cephalosporins didn't fare quite as well, although they were still superior to penicillin, with an odds ratio of 2.70. Clinical cures for 10-day regimens were similar for the two continents, with odds ratios of 2.38 in Europe (7 trials/1,488 children) and 2.46 in the United States (22 trials/4,990 children).

Studies of 4–5 days of cephalosporins versus 10 days of penicillin were analyzed in a total of 6 European and U.S. trials involving 1,149 adults and in 6 trials from both continents involving 3,152 children. Odds ratios for bacterial eradication favored the shorter cephalosporin regimen for the 9 combined European trials (1.30) and even more so in the 3 U.S. trials (2.41). On both continents, the superiority of cephalosporins in bacterial eradication was more pronounced in children than in adults (odds ratios 1.34 vs. 1.09 in Europe and 2.94 vs. 1.65 in the United States).

Bacterial cure rates with cephalosporins were strongly superior to penicillin in trials from the United Kingdom, Germany, France, and Sweden, with odds ratios ranging from 3.35 to 4.77. Although cephalosporin cure rates remained consistent in the different countries, penicillin bacterial cure rates varied widely, with a low of 66% in Sweden. That's probably because 2 of the 3 trials conducted there were among patients with recurrent GAS tonsillopharyngitis, in whom penicillin would be expected to be even less effective, Dr. Casey and Dr. Pichichero said at the meeting, sponsored by the American Society for Microbiology.

WASHINGTON — Consider the diagnosis of legionnaires' disease in any child with pneumonia who doesn't respond to β-lactam antibiotic therapy, Dr. David Greenberg and his associates advised in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Legionnaires' disease is considered a rare cause of community-acquired pneumonia in children. Most of the published literature on the subject is in the form of case reports, and nearly all have used serologic tests, for which sensitivity and specificity are uncertain. Awareness of Legionella as a potential cause of pediatric pneumonia is important because the disease doesn't respond to standard empiric therapy and may be quite severe and life-threatening, said Dr. Greenberg of Soroka University Medical Center, Beer-Sheva, Israel.

A Medline search identified 76 reported cases of legionnaires' disease in children. Of those, 33 (43%) came from the United States, possibly because of a higher index of suspicion for the disease among U.S. physicians and the availability of specific diagnostic tests for Legionella. Spain was second, with 10 cases, followed by Italy with 7. Another 13 countries reported five or fewer cases each. None were reported from developing countries, probably because diagnostic tests are not available there, the investigators noted at the meeting, sponsored by the American Society for Microbiology.

Patients ranged in age from 5 days to 19 years, with a mean of 24 months.

Symptoms and signs were nonspecific, including fever in nearly all the patients. Cough, tachypnea, and hypoxia also were common.

Results of laboratory tests also were nonspecific and not helpful in making the diagnosis.

Of 63 patients with chest radiographs, pulmonary infiltrates were seen in 97% and pleural effusion in 30%.

Forty-one (54%) of the 76 cases were classified as hospital-acquired. These patients were more likely to be newborns and to have underlying diseases. The 35 patients with community-acquired legionnaires' disease were less likely to be immunosuppressed (37% vs. 90%).

Mortality was 41% in the hospital-acquired cases and 23% in the community-acquired cases. Compared with the 51 who survived, the 25 who died were younger and were more likely to have underlying diseases. Children who received inappropriate antibiotics were three times more likely to die than were those appropriately treated (76% vs. 24%), Dr. Greenberg and his associates said.

Environmental links to Legionella were identified in 23 (88%) of the hospital-acquired cases, compared with just 3 (33%) of those acquired in the community. Tap water, hot water tanks, showerheads, respiratory therapy equipment, and humidifiers were the most common sites of colonization. These findings suggest that all hospitals—including children's hospitals—should routinely culture their water supply for Legionella, they advised.

WASHINGTON — Consider the diagnosis of legionnaires' disease in any child with pneumonia who doesn't respond to β-lactam antibiotic therapy, Dr. David Greenberg and his associates advised in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Legionnaires' disease is considered a rare cause of community-acquired pneumonia in children. Most of the published literature on the subject is in the form of case reports, and nearly all have used serologic tests, for which sensitivity and specificity are uncertain. Awareness of Legionella as a potential cause of pediatric pneumonia is important because the disease doesn't respond to standard empiric therapy and may be quite severe and life-threatening, said Dr. Greenberg of Soroka University Medical Center, Beer-Sheva, Israel.

A Medline search identified 76 reported cases of legionnaires' disease in children. Of those, 33 (43%) came from the United States, possibly because of a higher index of suspicion for the disease among U.S. physicians and the availability of specific diagnostic tests for Legionella. Spain was second, with 10 cases, followed by Italy with 7. Another 13 countries reported five or fewer cases each. None were reported from developing countries, probably because diagnostic tests are not available there, the investigators noted at the meeting, sponsored by the American Society for Microbiology.

Patients ranged in age from 5 days to 19 years, with a mean of 24 months.

Symptoms and signs were nonspecific, including fever in nearly all the patients. Cough, tachypnea, and hypoxia also were common.

Results of laboratory tests also were nonspecific and not helpful in making the diagnosis.

Of 63 patients with chest radiographs, pulmonary infiltrates were seen in 97% and pleural effusion in 30%.

Forty-one (54%) of the 76 cases were classified as hospital-acquired. These patients were more likely to be newborns and to have underlying diseases. The 35 patients with community-acquired legionnaires' disease were less likely to be immunosuppressed (37% vs. 90%).

Mortality was 41% in the hospital-acquired cases and 23% in the community-acquired cases. Compared with the 51 who survived, the 25 who died were younger and were more likely to have underlying diseases. Children who received inappropriate antibiotics were three times more likely to die than were those appropriately treated (76% vs. 24%), Dr. Greenberg and his associates said.

Environmental links to Legionella were identified in 23 (88%) of the hospital-acquired cases, compared with just 3 (33%) of those acquired in the community. Tap water, hot water tanks, showerheads, respiratory therapy equipment, and humidifiers were the most common sites of colonization. These findings suggest that all hospitals—including children's hospitals—should routinely culture their water supply for Legionella, they advised.

WASHINGTON — Consider the diagnosis of legionnaires' disease in any child with pneumonia who doesn't respond to β-lactam antibiotic therapy, Dr. David Greenberg and his associates advised in a poster presented at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Legionnaires' disease is considered a rare cause of community-acquired pneumonia in children. Most of the published literature on the subject is in the form of case reports, and nearly all have used serologic tests, for which sensitivity and specificity are uncertain. Awareness of Legionella as a potential cause of pediatric pneumonia is important because the disease doesn't respond to standard empiric therapy and may be quite severe and life-threatening, said Dr. Greenberg of Soroka University Medical Center, Beer-Sheva, Israel.

A Medline search identified 76 reported cases of legionnaires' disease in children. Of those, 33 (43%) came from the United States, possibly because of a higher index of suspicion for the disease among U.S. physicians and the availability of specific diagnostic tests for Legionella. Spain was second, with 10 cases, followed by Italy with 7. Another 13 countries reported five or fewer cases each. None were reported from developing countries, probably because diagnostic tests are not available there, the investigators noted at the meeting, sponsored by the American Society for Microbiology.

Patients ranged in age from 5 days to 19 years, with a mean of 24 months.

Symptoms and signs were nonspecific, including fever in nearly all the patients. Cough, tachypnea, and hypoxia also were common.

Results of laboratory tests also were nonspecific and not helpful in making the diagnosis.

Of 63 patients with chest radiographs, pulmonary infiltrates were seen in 97% and pleural effusion in 30%.

Forty-one (54%) of the 76 cases were classified as hospital-acquired. These patients were more likely to be newborns and to have underlying diseases. The 35 patients with community-acquired legionnaires' disease were less likely to be immunosuppressed (37% vs. 90%).

Mortality was 41% in the hospital-acquired cases and 23% in the community-acquired cases. Compared with the 51 who survived, the 25 who died were younger and were more likely to have underlying diseases. Children who received inappropriate antibiotics were three times more likely to die than were those appropriately treated (76% vs. 24%), Dr. Greenberg and his associates said.

Environmental links to Legionella were identified in 23 (88%) of the hospital-acquired cases, compared with just 3 (33%) of those acquired in the community. Tap water, hot water tanks, showerheads, respiratory therapy equipment, and humidifiers were the most common sites of colonization. These findings suggest that all hospitals—including children's hospitals—should routinely culture their water supply for Legionella, they advised.

WASHINGTON — Cefdinir is superior to penicillin in eradicating group A streptococci in children with tonsillitis, Dr. Itzhak Brook and Dr. Perry A. Foote reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The failure of penicillin to eradicate group A β-hemolytic streptococci (GABHS) from inflamed tonsils, currently exceeding 40%, is of great concern. While penicillin remains effective against GABHS in vitro, several theories have been put forth to explain the high failure rate in patients, said Dr. Brook, professor of pediatrics at Georgetown University, Washington, and Dr. Foote, of the department of otorhinolaryngology at the University of Florida, Gainesville.

Data from a non-industry-funded study of 40 children aged 4–12 years who underwent elective tonsillectomy suggest that two simultaneous mechanisms may be at work: the inactivation of penicillin by β-lactamase-producing bacteria, coupled with penicillin's elimination of the “good” α-hemolytic streptococci, which interfere with the growth of GABHS, they said.

Of the children, 20 received penicillin V (17 mg/kg or 250 mg every 8 hours) while the other 20 were given cefdinir (14 mg/kg or 600 mg/day) for the 10 days prior to surgery.

After removal, GABHS was isolated from core tonsillar cultures in 11 patients in the penicillin group (55%), compared with just 3 given cefdinir (15%).

Thirty-three β-lactamase-producing bacterial organisms—predominantly Staphylococcus aureus, Haemophilus influenzae, and Moraxella catarrhalis—were recovered from 17 (85%) of those treated with penicillin vs. 4 organisms isolated from 3 patients (15%) treated with cefdinir.

However, the penicillin patients had significantly lower numbers of α-hemolytic streptococcus, including those with the capacity to inhibit GABHS, Dr. Brook and Dr. Foote noted at the meeting, also sponsored by the American Society for Microbiology.

Adverse effects were noted in six patients, including diarrhea in two patients on penicillin and three on cefdinir, and vomiting in one of the penicillin patients.

Elsevier Global Medical News

WASHINGTON — Cefdinir is superior to penicillin in eradicating group A streptococci in children with tonsillitis, Dr. Itzhak Brook and Dr. Perry A. Foote reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The failure of penicillin to eradicate group A β-hemolytic streptococci (GABHS) from inflamed tonsils, currently exceeding 40%, is of great concern. While penicillin remains effective against GABHS in vitro, several theories have been put forth to explain the high failure rate in patients, said Dr. Brook, professor of pediatrics at Georgetown University, Washington, and Dr. Foote, of the department of otorhinolaryngology at the University of Florida, Gainesville.

Data from a non-industry-funded study of 40 children aged 4–12 years who underwent elective tonsillectomy suggest that two simultaneous mechanisms may be at work: the inactivation of penicillin by β-lactamase-producing bacteria, coupled with penicillin's elimination of the “good” α-hemolytic streptococci, which interfere with the growth of GABHS, they said.

Of the children, 20 received penicillin V (17 mg/kg or 250 mg every 8 hours) while the other 20 were given cefdinir (14 mg/kg or 600 mg/day) for the 10 days prior to surgery.

After removal, GABHS was isolated from core tonsillar cultures in 11 patients in the penicillin group (55%), compared with just 3 given cefdinir (15%).

Thirty-three β-lactamase-producing bacterial organisms—predominantly Staphylococcus aureus, Haemophilus influenzae, and Moraxella catarrhalis—were recovered from 17 (85%) of those treated with penicillin vs. 4 organisms isolated from 3 patients (15%) treated with cefdinir.

However, the penicillin patients had significantly lower numbers of α-hemolytic streptococcus, including those with the capacity to inhibit GABHS, Dr. Brook and Dr. Foote noted at the meeting, also sponsored by the American Society for Microbiology.

Adverse effects were noted in six patients, including diarrhea in two patients on penicillin and three on cefdinir, and vomiting in one of the penicillin patients.

Elsevier Global Medical News

WASHINGTON — Cefdinir is superior to penicillin in eradicating group A streptococci in children with tonsillitis, Dr. Itzhak Brook and Dr. Perry A. Foote reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

The failure of penicillin to eradicate group A β-hemolytic streptococci (GABHS) from inflamed tonsils, currently exceeding 40%, is of great concern. While penicillin remains effective against GABHS in vitro, several theories have been put forth to explain the high failure rate in patients, said Dr. Brook, professor of pediatrics at Georgetown University, Washington, and Dr. Foote, of the department of otorhinolaryngology at the University of Florida, Gainesville.

Data from a non-industry-funded study of 40 children aged 4–12 years who underwent elective tonsillectomy suggest that two simultaneous mechanisms may be at work: the inactivation of penicillin by β-lactamase-producing bacteria, coupled with penicillin's elimination of the “good” α-hemolytic streptococci, which interfere with the growth of GABHS, they said.

Of the children, 20 received penicillin V (17 mg/kg or 250 mg every 8 hours) while the other 20 were given cefdinir (14 mg/kg or 600 mg/day) for the 10 days prior to surgery.

After removal, GABHS was isolated from core tonsillar cultures in 11 patients in the penicillin group (55%), compared with just 3 given cefdinir (15%).

Thirty-three β-lactamase-producing bacterial organisms—predominantly Staphylococcus aureus, Haemophilus influenzae, and Moraxella catarrhalis—were recovered from 17 (85%) of those treated with penicillin vs. 4 organisms isolated from 3 patients (15%) treated with cefdinir.

However, the penicillin patients had significantly lower numbers of α-hemolytic streptococcus, including those with the capacity to inhibit GABHS, Dr. Brook and Dr. Foote noted at the meeting, also sponsored by the American Society for Microbiology.

Adverse effects were noted in six patients, including diarrhea in two patients on penicillin and three on cefdinir, and vomiting in one of the penicillin patients.

Elsevier Global Medical News

WASHINGTON — Mechanical ventilation significantly increases the risk that a hospitalized patient will develop Clostridium difficile-associated diarrhea, Dr. Chad A. Spangler and Dr. George F. Risi reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

This novel finding “has the potential to support new, additional prevention and control strategies in high-risk patient populations,” said Dr. Spangler and Dr. Risi, of St. Patrick Hospital, Missoula, Mont.

The incidence of C. difficile-associated diarrhea (CDAD) increased from 1.6 to 8.0 cases per 1,000 discharges between 2001 and 2004 at the investigators' 200-bed hospital, with most cases occurring in the intensive care unit. There was no change in the rate of CDAD cases between 2003 and 2004 despite a reduction in the use of both antipseudomonal penicillins and fluoroquinolones during that period.

Among 3,247 patients who received antibiotics and had a length of stay greater than 3 days between January 2004 and March 2005, a total of 19% required ventilation. Of those 614, CDAD developed in 47 (7.6%). With the ventilated population excluded, the infection rate was just 1.2%, the investigators reported at the meeting, which was sponsored by the American Society for Microbiology.

Other significant risk factors for CDAD included ICU stay; use of either proton pump inhibitor or H₂-blocker antacids; and exposure to carbapenems, third-generation cephalosporins, or antipseudomonal penicillins. In the mechanically ventilated population, those requiring more than 2 days on the ventilator were 11 times more likely to develop CDAD than were those requiring less ventilation, they reported.

WASHINGTON — Mechanical ventilation significantly increases the risk that a hospitalized patient will develop Clostridium difficile-associated diarrhea, Dr. Chad A. Spangler and Dr. George F. Risi reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

This novel finding “has the potential to support new, additional prevention and control strategies in high-risk patient populations,” said Dr. Spangler and Dr. Risi, of St. Patrick Hospital, Missoula, Mont.

The incidence of C. difficile-associated diarrhea (CDAD) increased from 1.6 to 8.0 cases per 1,000 discharges between 2001 and 2004 at the investigators' 200-bed hospital, with most cases occurring in the intensive care unit. There was no change in the rate of CDAD cases between 2003 and 2004 despite a reduction in the use of both antipseudomonal penicillins and fluoroquinolones during that period.

Among 3,247 patients who received antibiotics and had a length of stay greater than 3 days between January 2004 and March 2005, a total of 19% required ventilation. Of those 614, CDAD developed in 47 (7.6%). With the ventilated population excluded, the infection rate was just 1.2%, the investigators reported at the meeting, which was sponsored by the American Society for Microbiology.

Other significant risk factors for CDAD included ICU stay; use of either proton pump inhibitor or H₂-blocker antacids; and exposure to carbapenems, third-generation cephalosporins, or antipseudomonal penicillins. In the mechanically ventilated population, those requiring more than 2 days on the ventilator were 11 times more likely to develop CDAD than were those requiring less ventilation, they reported.

WASHINGTON — Mechanical ventilation significantly increases the risk that a hospitalized patient will develop Clostridium difficile-associated diarrhea, Dr. Chad A. Spangler and Dr. George F. Risi reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

This novel finding “has the potential to support new, additional prevention and control strategies in high-risk patient populations,” said Dr. Spangler and Dr. Risi, of St. Patrick Hospital, Missoula, Mont.

The incidence of C. difficile-associated diarrhea (CDAD) increased from 1.6 to 8.0 cases per 1,000 discharges between 2001 and 2004 at the investigators' 200-bed hospital, with most cases occurring in the intensive care unit. There was no change in the rate of CDAD cases between 2003 and 2004 despite a reduction in the use of both antipseudomonal penicillins and fluoroquinolones during that period.

Among 3,247 patients who received antibiotics and had a length of stay greater than 3 days between January 2004 and March 2005, a total of 19% required ventilation. Of those 614, CDAD developed in 47 (7.6%). With the ventilated population excluded, the infection rate was just 1.2%, the investigators reported at the meeting, which was sponsored by the American Society for Microbiology.

Other significant risk factors for CDAD included ICU stay; use of either proton pump inhibitor or H₂-blocker antacids; and exposure to carbapenems, third-generation cephalosporins, or antipseudomonal penicillins. In the mechanically ventilated population, those requiring more than 2 days on the ventilator were 11 times more likely to develop CDAD than were those requiring less ventilation, they reported.

WASHINGTON — In hospitalized patients taking antibiotics, coadministration of the probiotic Saccharomyces boulardii can reduce costs, shorten hospital stays, and may save lives, Allyson L. Rovetto and her associates reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Antibiotic-associated diarrhea (AAD) occurs in up to 30% of all hospitalized patients given antibiotics. Clostridium difficile-associated diarrhea (CDAD) is both the most common and the most severe manifestation, with potential complications including colitis, ileitis, toxic megacolon, and death, noted Ms. Rovetto and associates, of Mount Sinai School of Medicine, New York.

Growing evidence suggests that probiotics such as the live, nonpathogenic yeast S. boulardii may be effective in preventing AAD and recurrent CDAD, although that organism is associated with an increased risk for fungemia, which may also lead to severe complications including death (Clin. Infect. Dis. 2005;40:1625–34).

In a study funded in part by the National Center for Complementary and Alternative Medicine of the National Institutes of Health, the investigators used data from published literature to perform a cost-effectiveness analysis of administering vs. not administering S. boulardii along with antibiotics to hospitalized patients.

The probability of CDAD was estimated to be 2% among those given the probiotic along with antibiotics vs. 5% given antibiotics alone. The increase in hospital cost per patient with CDAD was $4,129, and the probability of CDAD complications was 3%. Compared with antibiotics alone, treatment with antibiotics plus the probiotic yielded a cost saving of $81.60 per patient in addition to shortening hospital stays by about 3 days.

Patients older than 65 and those with hospital stays longer than 2 weeks stand to benefit the most. The analysis revealed that even if the protective effect of S. boulardii was halved, it would remain the preferred strategy. In fact, the only way the probiotic's benefit would be offset is if the incidence of fungemia exceeded 2 per 100 patients, “which seems highly unlikely,” they remarked.

But since the rate and potential severity of S. boulardii-associated fungemia is still not clearly defined, “We believe further studies are needed to confirm safety and effectiveness, especially in elderly and other high-risk populations” before issuing any recommendations, coauthor Dr. Henry Sacks said at the meeting sponsored by the American Society for Microbiology.

WASHINGTON — In hospitalized patients taking antibiotics, coadministration of the probiotic Saccharomyces boulardii can reduce costs, shorten hospital stays, and may save lives, Allyson L. Rovetto and her associates reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Antibiotic-associated diarrhea (AAD) occurs in up to 30% of all hospitalized patients given antibiotics. Clostridium difficile-associated diarrhea (CDAD) is both the most common and the most severe manifestation, with potential complications including colitis, ileitis, toxic megacolon, and death, noted Ms. Rovetto and associates, of Mount Sinai School of Medicine, New York.

Growing evidence suggests that probiotics such as the live, nonpathogenic yeast S. boulardii may be effective in preventing AAD and recurrent CDAD, although that organism is associated with an increased risk for fungemia, which may also lead to severe complications including death (Clin. Infect. Dis. 2005;40:1625–34).

In a study funded in part by the National Center for Complementary and Alternative Medicine of the National Institutes of Health, the investigators used data from published literature to perform a cost-effectiveness analysis of administering vs. not administering S. boulardii along with antibiotics to hospitalized patients.

The probability of CDAD was estimated to be 2% among those given the probiotic along with antibiotics vs. 5% given antibiotics alone. The increase in hospital cost per patient with CDAD was $4,129, and the probability of CDAD complications was 3%. Compared with antibiotics alone, treatment with antibiotics plus the probiotic yielded a cost saving of $81.60 per patient in addition to shortening hospital stays by about 3 days.

Patients older than 65 and those with hospital stays longer than 2 weeks stand to benefit the most. The analysis revealed that even if the protective effect of S. boulardii was halved, it would remain the preferred strategy. In fact, the only way the probiotic's benefit would be offset is if the incidence of fungemia exceeded 2 per 100 patients, “which seems highly unlikely,” they remarked.

But since the rate and potential severity of S. boulardii-associated fungemia is still not clearly defined, “We believe further studies are needed to confirm safety and effectiveness, especially in elderly and other high-risk populations” before issuing any recommendations, coauthor Dr. Henry Sacks said at the meeting sponsored by the American Society for Microbiology.

WASHINGTON — In hospitalized patients taking antibiotics, coadministration of the probiotic Saccharomyces boulardii can reduce costs, shorten hospital stays, and may save lives, Allyson L. Rovetto and her associates reported in a poster at the annual Interscience Conference on Antimicrobial Agents and Chemotherapy.

Antibiotic-associated diarrhea (AAD) occurs in up to 30% of all hospitalized patients given antibiotics. Clostridium difficile-associated diarrhea (CDAD) is both the most common and the most severe manifestation, with potential complications including colitis, ileitis, toxic megacolon, and death, noted Ms. Rovetto and associates, of Mount Sinai School of Medicine, New York.

Growing evidence suggests that probiotics such as the live, nonpathogenic yeast S. boulardii may be effective in preventing AAD and recurrent CDAD, although that organism is associated with an increased risk for fungemia, which may also lead to severe complications including death (Clin. Infect. Dis. 2005;40:1625–34).

In a study funded in part by the National Center for Complementary and Alternative Medicine of the National Institutes of Health, the investigators used data from published literature to perform a cost-effectiveness analysis of administering vs. not administering S. boulardii along with antibiotics to hospitalized patients.

The probability of CDAD was estimated to be 2% among those given the probiotic along with antibiotics vs. 5% given antibiotics alone. The increase in hospital cost per patient with CDAD was $4,129, and the probability of CDAD complications was 3%. Compared with antibiotics alone, treatment with antibiotics plus the probiotic yielded a cost saving of $81.60 per patient in addition to shortening hospital stays by about 3 days.

Patients older than 65 and those with hospital stays longer than 2 weeks stand to benefit the most. The analysis revealed that even if the protective effect of S. boulardii was halved, it would remain the preferred strategy. In fact, the only way the probiotic's benefit would be offset is if the incidence of fungemia exceeded 2 per 100 patients, “which seems highly unlikely,” they remarked.

But since the rate and potential severity of S. boulardii-associated fungemia is still not clearly defined, “We believe further studies are needed to confirm safety and effectiveness, especially in elderly and other high-risk populations” before issuing any recommendations, coauthor Dr. Henry Sacks said at the meeting sponsored by the American Society for Microbiology.