TREATMENT OF GONORRHEA
Pediatricians treat gonorrhea infrequently so they might not be up to date on changing therapeutic recommendations. About 6 months ago the CDC recommended that oral cefixime should no longer be used to treat gonorrhea because resistance rates to that drug had increased to 1.5% in the U. S. (MMWR 2012; 61:590). Resistance to ceftriaxone is low enough (less than 0.5% of strains) so that drug is still recommended (a single I.M. dose of 250 mg.) as the preferred treatment. It must be given with a 1 gm dose of azithromycin taken orally. If the patient objects to having a “shot” of ceftriaxone, one can give 2 gm (double the usual dose) of azithromycin but a test of cure must be done a week later. Test of cure is not needed if ceftriaxone is given. The test of cure is preferably a culture, but NAAT (nucleic acid amplification testing) is acceptable. There are alternative regimens but they require taking doxycycline twice daily for a week, which introduces the problem of compliance.
THIOMERSOL IN THE NEWS AGAIN
For almost 70 years during the past century, thiomersol (an ethyl mercury compound) was added to multidose vials of vaccine to prevent bacterial and fungal contamination of the vials. Shortly after the year 2000 the FDA banned its use in the United States because of pressure from people who were concerned that thiomersol might cause autism. There was no scientific evidence for that and the fear turned out to be unfounded when studies were done, but the FDA has not reversed its ban. The Coalition for Mercury-free Drugs, which supports the ban, is petitioning the United Nations and the World Health Organization to ban the use of thiomersol in all countries. A problem is that they offer no alternative to make multidose vials safe. Vaccine experts agree that multidose vials are essential to vaccination efforts in developing countries. Representatives from many countries are to meet in Geneva to discuss a global treaty to ban products that release mercury into the environment. If that document bans thiomersol, the results could be devastating to vaccine use in the developing world.
A SETBACK FOR POLIO ERADICATION
During the past 25 years the worldwide effort to rid the world of polio has reduced the number of polio endemic countries from 120 to 3: Afghanistan, Nigeria and Pakistan. Various types of turmoil and unrest in those countries have hindered the efforts of health workers. Pakistan was making great strides and had thousands of workers in the field administering the oral polio vaccine when tragedy struck in December. Several health workers were shot and killed by persons who oppose the vaccine program. Most of the health workers were young women. The Taliban has not claimed responsibility for the murders, but it is widely assumed that that is the case. As of this writing (early January) the Pakistan government is providing armed guards to accompany the workers as they distribute the polio vaccine. Some days one despairs at the state the world has reached, but then one realizes that there have always been crazy zealots who oppose progress. There is truly nothing new under the sun. Polio will eventually go the way of smallpox.
QUADRIVALENT FLU VACCINE
On December 17, 2012 the US Food and Drug Administration (FDA) approved a new intramuscular quadrivalent influenza vaccine (Fluarix Quadrivalent, GlaxoSmithKline) for adults and children who are 3 years and older to help prevent disease caused by the seasonal influenza virus types A and B contained in the vaccine. Currently-administered trivalent influenza vaccines contain 2 A virus strains most commonly occurring in humans and the B strain expected to be predominant in a given year. One problem has been that the B strain in the vaccine has not matched the circulating strain in 6 of the last 13 years. To counter that, the new vaccine, to be released in time for the 2013-2014 influenza season, will contain a second B strain.
CAROLINE BREESE HALL 1939-2012
We were saddened to learn that Dr Caroline Breese Hall died on December 10, 2012. She was a beloved colleague of ours and of so many pediatricians worldwide. She was appreciated for her wisdom, warmth, and humor. She was a superb and caring clinician, teacher and role model for medical students and residents and a role model for young women interested in a career in medicine. Her research on respiratory viruses was invaluable for practicing physicians and clinical investigators alike and her yearly summary of circulating viruses in the Rochester, NY area provided clear evidence of the seasonal variations for the common respiratory viruses. Her seminal studies of RSV and later HHV6 were groundbreaking. Caren’s entire academic career was in Rochester, NY where she was Professor of Pediatrics and Internal Medicine in Infectious Diseases at the University of Rochester School of Medicine and Dentistry. Caren was a founding member of the Pediatric Infectious Diseases Society, served as its 5th President, and was the Society’s Historian. She served as Chairman of the AAP Committee on Infectious Diseases (Red Book Committee), and the 2006 edition of the Red Book was dedicated to her. She received numerous honors and awards, most notably to us were the Distinguished Physician and Distinguished Service Awards from the Pediatric Infectious Diseases Society and the Robert M. Chanock Lifetime Achievement Award. For so many years she assisted us with the journal as an author of original studies, a reviewer of numerous manuscripts and from the first issue in 1982, as a long standing member of the Editorial Board. We will miss her keen wit, her warm smile and her generosity.
We recently managed a child with a subdural shunt infection caused by a coagulase negative Staphylococcus susceptible to oxacillin. The team managing the child used vancomycin therapy because it is the agent for which we have had most experience either alone or with rifampin in treating these infections. The isolate was confirmed as oxacillin susceptible by cefoxitin disk diffusion that produced a zone size of 30 mm (cut off is 25 mm for susceptible). The shunt fluid cultures were positive for 3 days. The Director of Microbiology at Children’s Medical Center Dallas, Dr Cristopher Doern, was able to enlighten us about susceptibility testing of coagulase negative Staphylococcus. Of 270 isolates tested in the last 2 years 84 (31%) were susceptible to oxacillin. He explained that when they isolate these organisms in cultures from normally sterile sites they do a primary screen for susceptibility to oxacillin. Isolates that have a MIC of ≤ 0.25 mcg/ml are considered susceptible to oxacillin which the laboratory confirms by cefoxitin disc susceptibility. Some non-S. epidermidis strains can have oxcillin MIC’s between 0.5 and 2 mcg/ml and lack mecA. In those cases the cefoxitin result overrules the oxacillin finding. Because of lack of experience we rarely use oxacillin or nafcillin for therapy of shunt infections. We would love to hear whether any of you have used these beta-lactams for treatment for these susceptible S epidermidis infections. Many years ago Dr Carla Odio, one of our fellows at the time, reviewed our experience with CSF infections in 297 patients with shunts (Amer J Dis Child 1984; 138:1103). There were 59 shunt infections in 50 patients and coagulase negative staphylococci were the principal pathogens. To us the most important observation from this study was that antibiotic therapy, usually vancomycin with or without rifampin, coupled with prompt removal of the shunt was the best management resulting in defervescence within 24 hours and very few reinfections.