Paediatric Nosocomial Urinary Tract Infection at a Regional Hospital

From a total of 26,603 admissions to the paediatric wards, 1360 paediatric nosocomial urinary tract infections (PNUTI) were identified during a 5-year retrospective chart review at the SFGH. The ages ranged from 3 days to 13 years, with 46% boys and 54% girls. The highest rates of PNUTI per service per 100 admissions were seen in the nursery (11.28) followed by paediatric surgery (2.89) and paediatric medicine (2.86). Although the greatest number of PNUTI occurred in the nursery, comparison between the years was not statistically significant. About 90% (1218 of 1360) of PNUTI occurred in catheterized patients. No documentation was found specifying the type of catheterization (intermittent or continuous). About 90% (1210 of 1360) of isolates were single organisms with Escherichia coli, Proteus mirabilis, Klebsiella spp. and Group B streptococci accounting for a total of 70% of all pathogens. However, the composition of the most common isolate in each service differed. The most common isolate in the nursery was E. coli, in the paediatric medical and surgical services the most common isolates were Klebsiella spp. and Proteus mirabilis, respectively. Proteus mirabilis was isolated predominantly from boys with structural abnormality of the urethral tract. No PNUTIs were complicated by bacteraemia. The antibiotics with least effectiveness (in increasing order) for UTIs were cephalexin, ampicillin, trimethoprim, co-trimoxazole and tetracycline. The most effective antibiotics were nalidixic acid, gentamicin and amoxicillin-clavulanic acid.     

Physiological perspectives of therapy in bronchial hyperreactivity

Purpose

This paper reviews the literature on the aetiology and therapy of bronchial hyperreactivity to describe the underlying pathophysiology, identify patients at risk and update knowledge on new and existing therapies.

Source

Information was obtained from monograms on New Drugs for Asthma, Respiratory Medicine: recent advances, Agents and Actions Supplements, Pulmonary Pharmacology, Anesth Analg, the European Journal of Respiration and a Medline literature search.

Principal findings

Reduced airway calibre, increased bronchial contractility, altered permeability of the bronchial mucosa, humoral and cellular mediators, and dysfunctional neural regulation are critical factors for bronchial hyperreactivity, a characteristic feature of hyperreactive airways which results in bronchoconstriction after exposure to varied stimuli. Preoperative anaesthetic considerations in these patients include FEV₁ and PEFR testing to assess the severity and for optimal control of the condition. Bronchospasm causing hypoxaemia is the major intraoperative problem anticipated in these patients. Current therapeutic management of bronchoconstriction focusses on the β₂ agonists, theophylline and steroids. Besides relaxing the airway smooth muscle these agents are all capable of altering bronchial inflammatory responses. Future developments of therapy are directed towards the inflammatory components of the disease.

Conclusion

This review has presented background information on physiological mechanisms of smooth muscle contractility, pathophysiological alterations of bronchial contractility and the pharmacological basis of therapy in bronchoconstrictive disease. Information is presented to enable the prompt arrest and reversal of airway constriction, and to maintain prophylactic treatment during the perioperative period. Intraopera’tive bronchospasm is managed by adequate oxygenation and reversal of bronchoconstriction     

Methicillin resistance among Trinidadian isolates of community and hospital strains of Staphylococcus aureus and their patterns of resistance to non-beta-lactam antibiotics

The prevalence of methicillin-resistant Staphylococcus aureus (MRSA) strains in Trinidad and the extent of their resistance to other antimicrobial agents in hospital-acquired and community-acquired infections were evaluated over a 2-year period. A total of 450 S. aureus strains were isolated from different patients. The prevalence of methicillin resistance among S. aureus strains was 9.8% (44/450). The proportion of MRSA isolated from hospital sources and community sources was 12.5% (38/305) and 4.1% (6/145), respectively (P < 0.05). The resistant rates of MRSA to the non-beta-lactam antibiotics were as follows: 93.2% resistance to tetracycline, 68.2% to erythromycin, 61.4% to gentamicin, 45.5% to co-trimoxazole, and 20.5% to ciprofloxacin. No MRSA resistant to vancomycin was observed in this study. Study results showed significant increases in MRSA in hospital, 2% in 1995 to 12.5% in 1998 (P < 0.05), and community, 0% in 1995 to 4.1% in 1998 (P < 0.05). It has become apparent that infection control and surveillance initiatives must be focused now on the community in order to monitor and limit the spread of this new and expanding reservoir of MRSA.     

Antimicrobial susceptibility survey of Pseudomonas aeruginosa strains isolated from clinical sources

A two-year prospective study of 554 Pseudomonas aeruginosa isolates was recovered from various clinical sources throughout Trinidad, and their resistance patterns to antipseudomonal antimicrobial agents were determined. Of the 554 P. aeruginosa isolates, 20.6% (114/554) were community isolates, 17.3% (96/554) from the intensive care unit (ICU), 10.1% (56/554) from the nursery, and the remaining 52% (288/554) were from other hospital inpatient services. Respiratory tract infections were the predominant source of P. aeruginosa isolates from the ICU--46.9% (45/96)--and nursery--21.4% (12/56), whereas wounds were the principal source of P. aeruginosa from the surgical services--77.0% (141/183). Community isolates of P. aeruginosa were predominantly from ear--100% (51/51)--and urinary tract infections--35.5%, (33/93). The overall prevalence of resistance was low for both hospital isolates (13.9%) and community isolates (3.8%). All community isolates were fully sensitive to four of the nine antimicrobials tested. Resistance rates among community strains ranged from 2.6% (ciprofloxacin and ceftazidime) to 12.3% for piperacillin. All isolates from hospital were fully sensitive to imipenem, but resistance rates for the other drugs ranged between 2.5% and 27.3%. The study showed that the overall resistance pattern of P. aeruginosa was relatively low. This is an encouraging observation but invites caution since resistance to the newly introduced drug, cefepime, has now emerged within the hospital environment and may present serious therapeutic problems within the near future. Policies governing the use of antimicrobials in many institutions are lacking. Such policies must be instituted in order to limit the spread of resistance and also to reduce the emergence of resistance to newly commissioned drugs within the country.     

Neonatal sepsis and mortality in a regional hospital in Trinidad: aetiology and risk factors

A total of 132 neonatal deaths among 627 infants admitted to the neonatal ward of the San Fernando General Hospital, Trinidad over a 2-year period were reviewed. The most common cause of death was prematurity (43.9%). Infection was the second most common cause (21.2%). Pseudomonas aeruginosa and Staphylococcus aureus were the most frequently isolated organisms (43%). The major drugs used empirically in suspected cases of sepsis were ampicillin or ceftazidime plus gentamicin. About 85% of S. aureus were resistant to ampicillin, and P. aeruginosa resistance to ceftazidime and gentamicin was 76.7% and 72.1%, respectively. Significant risk factors in maternal history were infrequent antenatal care and prolonged rupture of membranes. The incidence of infection among low birthweight infants was 85.6%. Early-onset sepsis (86.4%) seemed to have a nosocomial origin because of the type of pathogens seen. There is an urgent need to improve the staff-to-patient ratio in the neonatal unit and for staff to be constantly reminded to employ simple infection control practices such as proper hand-washing to reduce cross-infections.     

Knowledge and Awareness of Tuberculosis Among Pre-University Students in Trinidad

The purpose of the study was to determine the level of knowledge and attitudes among pre-university students in Trinidad and Tobago on the pre-disposing factors and prevention of tuberculosis and the management of persons with the disease. More than 90% (542 of 600) of participating students from nine secondary schools duly completed the self-administered questionnaires. Two-thirds of the students were girls (336) and the rest were boys (206). The ages of the participants ranged from 16–19 years and more than 82% of them belonged to the 17–18 year old age group. The least represented was the 19 year olds. The study showed that although 92.8% had heard of tuberculosis, overall knowledge about the disease was generally poor. The majority of students (77.5%) believed the disease could be prevented, but 10.3% knew of the BCG vaccine and only 11.1% knew about the Mantoux skin test. The study also demonstrated the need for renewed efforts in health education for the public, clarifying areas of misunderstandings about important and common diseases like tuberculosis, in developing countries.     

Bacteremia in children at a regional hospital in Trinidad.

OBJECTIVE: The objective of this study was to provide a Trinidadian perspective on pediatric community-acquired and hospital-acquired bacteremia via the documentation of common etiologic agents, antimicrobial profiles of the isolated pathogens, and patient outcome. METHODS: This was a six-year retrospective study of children with bacteremia admitted to the pediatric wards of the San Fernando General Hospital, Trinidad. RESULTS: Seven hundred and four episodes of pediatric bacteremia were reviewed during the six-year study period. The predominant isolate was Staphylococcus aureus (23.9%), followed by Pseudomonas aeruginosa (15.5%), Klebsiella pneumoniae (12.5%), and Enterobacter spp (11.1%). The remaining isolates each accounted for less than 10% of total isolates. The mortality rate was highest for P. aeruginosa (39.4%), Streptococcus pneumoniae (22.5%), and Escherichia coli (19.2%). Of the six cases due to Neisseria meningitidis, only two survived. The overall mortality rate for the study period was 15.1%, but varied considerably according to age. All deaths due to P. aeruginosa and E. coli occurred in neonates. Almost 90% and about half of all S. aureus were resistant to ampicillin and erythromycin, respectively; nineteen (11.3%) were methicillin-resistant. More than 95% of K. pneumoniae and more than 87% of Haemophilus influenzae were resistant to ampicillin. Group B streptococci were fully susceptible to ampicillin and amoxicillin-clavulanic acid, but showed >90% and >70% resistance to tetracycline and trimethoprim-sulfamethoxazole, respectively. Of the 40 strains of S. pneumoniae isolated, 10.0% had a minimum inhibitory concentration (MIC) >or=4 microg/mL (resistance) and 12.5% had a MIC=2.0 microg/mL (intermediate resistance) to ceftriaxone, while 7.5% showed intermediate resistance (MIC between 0.12 and 1 microg/mL) and 25.0% showed resistance (MIC >or=2 microg/mL) to penicillin. CONCLUSION: The bacteremia rate was found to be 8.4% among hospitalized children suspected of having sepsis and from whom a blood culture was positive. Bacteremia was also associated with a high mortality rate of 15.1%. An unusually high level of bacteremia with Gram-negative enteric bacteria was seen, which might indicate cross infection and reflect a breakdown in infection control measures. Relatively high-level resistance of S. pneumoniae to penicillin and ceftriaxone was not seen, even though the overall prevalence of resistance to other antibiotics among other pathogens was relatively low. The drugs that showed the greatest efficacy were imipenem, gentamicin, ciprofloxacin, and the cephalosporins ceftazidime and ceftriaxone.     

Gastrointestinal diseases and considerations in the perioperative management of oral surgical patients

This article presents commonly encountered and clinically significant entities affecting the gastrointestinal (GI) system with emphasis on assisting the clinician in developing management strategies to reduce the associated risks. Xerostomia, osteoradionecrosis, gastroesophageal reflux disease, and ulcerative diseases occurring in the proximal portion of the GI system and antibiotic-associated diarrhea, pseudomembranous colitis, adynamic ileus, and malabsorption problems occurring in the distal portion are presented. Lastly, suggestions for managing patients who have splenomegaly and splenectomy are addressed.