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Rifampin for CSF shunt infections
Volume 96 Number 4
Editorial correspondence
study were probably not due to their withdrawal per se. On the other hand, our study does demonstrate that a significant number of infants who died from SIDS showed moderate-to-severe drug withdrawal symptoms in the postnatal period. Since our report on the direct relationship of severity of withdrawal to the maternal methadone dosage, we have speculated on the possible relationship of fetal exposure to high concentrations of drugs, including methadone, and the subsequent development of SIDS? Cleofe J. Chavez, M.D. Assistant Professor Department of Pediatrics Research Associate Department of Gynecology and Obstetrics Wayne State University School of Medicine Hutzel Hospital 4707 St. Antoine Blvd. Detroit, MI 48201 REFERENCES
1. Finnegan LP, and Reeser DS: The incidence of sudden death in infants born to women maintained on methadone, Pediatr Res 12:405, 1978 (abstr 248). 2. Rajegowda, BK, Kandall SR, and Falciglia H: Sudden unexpected death in infants of narcotic-dependent mothers, Early Hum Dev 2/3:219, 1978. 3. Ostrea EM Jr, Chavez CJ, and Strauss ME: A study o f factors that influence the severity of neonatal narcotic withdrawal, Addict Dis 2:187, 1975.
785
a prescription for amitriptyline had been filled two days before the first episode. Investigation by child welfare officials suggested that the mother had given the drug to the infant. The baby is now in the custody of the maternal grandmother and has been asymptomatic for four months. COMMENT
Nonaccidental poisoning is an expansion of the syndrome of child abuse and neglect. ~ The diagnosis of a toxin exposure, especially in a child less than 9 months of age, 3 requires an intuitive physician. The episodic nature of this illness, the availability o f the offending agent, and the occurrence of symptoms consistent with the known effects of the drug support the final diagnosis. Frank A. Simon, M.D. Department of Pediatrics The University of Texas Medical School at Houston P.O. Box 20708 Houston, TX 77025 REFERENCES
1. Berger D: Child abuse simulating "near-miss" sudden infant death syndrome, J P~t3~ATg95:554, I979. 2. Watson JBG, Davies JM, and Hunter JLP: Nonaccidental poisoning in childhood, Arch Dis Child 54:143, 1979. 3. Rauber A: Poisoning in children under 12 months of age, Clin Toxicol 8:381, 1975.
Rifampin for CSF shunt infections Uncommon type of child abuse To the Editor: The two examples of child abuse mimicking "near-miss" sudden infant death syndrome reported by Dr. Berger ~stress the need to obtain appropriate information in evaluating such cases. I would like to emphasize the need for toxicologic screening under similar circumstances as demonstrated in the following case report. CASE REPORT
The infant was the product of an uncomplicated pregnancy, labor and delivery in an unmarried 15-year-old mother. The baby was apparently well until 18 days of age, when he was seen in the emergency room because of lethargy and abdominal distension, accompanied by tachycardia and the absence of bowel sounds. He was normothermic. An extensive evaluation on admission, including a full work-up for sepsis, was negative. The child recovered and was discharged without determining an etiology for the episode. He returned to the emergency room at 7 weeks of age with identical findings. At this time the urine and gastric aspirate revealed amitriptyline and nortriptyline. On careful questioning
To the Editor: The title of the article by Ring et al, 1 "Rifampin for CSF shunt infections caused by coagulase-negative staphylococci," is misleading in that, in the two cases reported, the colonized shunts "already had been removed before the treatment described was instituted. Though the residual infections were undoubtedly secondary to, or associated with, shunt colonization, they consisted of ventriculitis and peritonitis, respectively. Vancomycin, presumably in these cases administered intravenously, could be expected to give therapeutic levels in peritoneal exudate and in ventricular cerebrospinal fluid in the presence of inflammation.~ Rifampicin tissue levels usually exceed serum levels, and this drug reaches therapeutic concentrations even in normal cerebrospinal fluid? Consequently, these two drugs may be expected to be effective in cases such as those described, but although rifampicin also may be useful in true shunt colonization, the authors have not shown this. R. Bayston The Hospital for Sick Children Great Ormond St. London, WCIN 3JH England
'7 8 6
Editorial correspondence
REFERENCES 1. Ring JC, Cates KL, Belani KK, Gaston TL, Sveum RJ, and Marker SC: Rifampicin for CSF shunt infections caused by coagulase-negative staphylococci, J PEDIATR 95:317, 1979. 2. Riley HD: Vancomycin and novobiocin, Med Clin North Am 8:1073, 1961. 3. Sensi P, Maggi N, Ft~resz S, and Maffii ,G: Chemical modifications and biological properties of rifampicins, Antimicrob Agents Chemother 6:699, 1966.
Reply To the Editor: Perhaps the title of our observation should have been rearranged to read "Rifampin for coagulase-negative stffphylococcal infections caused by CSF shunts." The point that we wished to make remains unchanged, i.e., rifampin is the most active antibiotic available for the treatment of coagulase-negative staphylococcal infections and should be considered especially when response to other therapy has been poor. Stephen C. Marker, M.D. Department of Laboratory Medicine and Pathology Box 198 Mayo Memorial Building 420 Delaware St. SE Minneapolis, M N 55455
Latex agglutination test and countercurrent immunoelectrophoresis for detection of group B streptococcal antigen To the Editor: Edwards, Kasper, and Baker1 recently reported the sensitivity of latex particle agglutination (LA) test over countercurrent immunoelectrophoresis (CIE) for the detection of group B streptococcal (GBS) antigen. We evaluated the sensitivity of LA and CIE using two group B streptococcal antisera for the detectiOn of GBS antigen. GBS antisera obtained from the Center For Disease Control (CDC) and Burroughs Wellcome & Co, (commercial) were used. Latex particles 0.8 micron in diameter were sensitized with antisera diluted 1:10 with glycine-buffered saline. ~ LA test and CIE were carried out by the standard techniques.~. 3 Each of six CSF specimens and four sera obtained at the time of diagnosis from infants with culture proven GBS meningitis were positive by LA test using CDC antisera. Only three CSF and two sera were positive by LA using commercial antisera. Antigen was detected in only two CSF specimens using CIE (either antiserum).
The Journal of Pediatrics April 1980
Table. N o 5 o f GBS broth cultures positive at different dilutions by latex and CIE (total specimens 20)
Broth dilution Undiluted 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 Geometric mean titers of positive broths
Latex Latex CIE CDC commercial CDC antisera antisera antisera 20 20 20 20 20 20 20 18 10 159.2"
20 20 20 19 11 4 0 0 0 12.91t
20 20 17 4 0 0 0 0 0 4.12
CIE commercial antisera 20' 20 19 4 0 0 0 0 0 4.41:~
P values: * vs "~ <0.001; t vs ~ <0.001. Because of this discrepancy with patients' specimens, we evaluated the sensitivity and specificity of these two antisera with LA and CIE tests. Twofold serial dilutions of four-hour broth cultures of streptococci previously isolated and identified from patients and stored in skim milk at - 7 0 ~ were studied. The number of strains and their groups tested for GBS antigen by CIE and LA were: 30 group A, 20 group B, 5 group C, 10 group D, and 2 group G. None of the 30 group A, 5 group C, 10 group D, and 2 group G streptococci gave a positive reaction with CIE or LA test using either of the group B antisera. Undiluted broth culture of each of the 20 group B streptococci gave positive results by CIE and LA using either of the GBS antisera. In each instance LA test performed using latex particles sensitized with antisera obtained from CDC was at least eightfold sensitive (Table). Geometric mean titers of positive broth dilutions using CDC antisera sensitized latex were 159.2 as compared to 12.9 with commercial antisera (P < 0.001). Geometric mean titers of positive broth by CIE were 4.1 and 4.4 using CDC and commercial antisera, respectively. LA test using either of the antisera was significantly superior to CIE (P < 0.001). The value of LA and CIE for the diagnosis of bacterial infections is well recognized.2-" Sensitivity and specificity of these antigen detection tests depend upon the quality of antisera. We found a significant difference in the sensitivity of LA test depending upon the antiserum used. LA is a sensitive and simple test for the rapid diagnosis of GBS disease, however, laboratories should closely monitor and evaluate the sensitivity of the test whenever the source or lot of antiserum is changed. Ashir Kumar, M.D. Department of Pediatrics Case Western Reserve University St. Luke's Hospital 11311 Shaker Blvd. Cleveland, OH 44104 George A. Nankervis, M.D., Ph.D. Medical College of Ohio at Toledo Toledo, OH 43699
Editorial correspondence
study were probably not due to their withdrawal per se. On the other hand, our study does demonstrate that a significant number of infants who died from SIDS showed moderate-to-severe drug withdrawal symptoms in the postnatal period. Since our report on the direct relationship of severity of withdrawal to the maternal methadone dosage, we have speculated on the possible relationship of fetal exposure to high concentrations of drugs, including methadone, and the subsequent development of SIDS? Cleofe J. Chavez, M.D. Assistant Professor Department of Pediatrics Research Associate Department of Gynecology and Obstetrics Wayne State University School of Medicine Hutzel Hospital 4707 St. Antoine Blvd. Detroit, MI 48201 REFERENCES
1. Finnegan LP, and Reeser DS: The incidence of sudden death in infants born to women maintained on methadone, Pediatr Res 12:405, 1978 (abstr 248). 2. Rajegowda, BK, Kandall SR, and Falciglia H: Sudden unexpected death in infants of narcotic-dependent mothers, Early Hum Dev 2/3:219, 1978. 3. Ostrea EM Jr, Chavez CJ, and Strauss ME: A study o f factors that influence the severity of neonatal narcotic withdrawal, Addict Dis 2:187, 1975.
785
a prescription for amitriptyline had been filled two days before the first episode. Investigation by child welfare officials suggested that the mother had given the drug to the infant. The baby is now in the custody of the maternal grandmother and has been asymptomatic for four months. COMMENT
Nonaccidental poisoning is an expansion of the syndrome of child abuse and neglect. ~ The diagnosis of a toxin exposure, especially in a child less than 9 months of age, 3 requires an intuitive physician. The episodic nature of this illness, the availability o f the offending agent, and the occurrence of symptoms consistent with the known effects of the drug support the final diagnosis. Frank A. Simon, M.D. Department of Pediatrics The University of Texas Medical School at Houston P.O. Box 20708 Houston, TX 77025 REFERENCES
1. Berger D: Child abuse simulating "near-miss" sudden infant death syndrome, J P~t3~ATg95:554, I979. 2. Watson JBG, Davies JM, and Hunter JLP: Nonaccidental poisoning in childhood, Arch Dis Child 54:143, 1979. 3. Rauber A: Poisoning in children under 12 months of age, Clin Toxicol 8:381, 1975.
Rifampin for CSF shunt infections Uncommon type of child abuse To the Editor: The two examples of child abuse mimicking "near-miss" sudden infant death syndrome reported by Dr. Berger ~stress the need to obtain appropriate information in evaluating such cases. I would like to emphasize the need for toxicologic screening under similar circumstances as demonstrated in the following case report. CASE REPORT
The infant was the product of an uncomplicated pregnancy, labor and delivery in an unmarried 15-year-old mother. The baby was apparently well until 18 days of age, when he was seen in the emergency room because of lethargy and abdominal distension, accompanied by tachycardia and the absence of bowel sounds. He was normothermic. An extensive evaluation on admission, including a full work-up for sepsis, was negative. The child recovered and was discharged without determining an etiology for the episode. He returned to the emergency room at 7 weeks of age with identical findings. At this time the urine and gastric aspirate revealed amitriptyline and nortriptyline. On careful questioning
To the Editor: The title of the article by Ring et al, 1 "Rifampin for CSF shunt infections caused by coagulase-negative staphylococci," is misleading in that, in the two cases reported, the colonized shunts "already had been removed before the treatment described was instituted. Though the residual infections were undoubtedly secondary to, or associated with, shunt colonization, they consisted of ventriculitis and peritonitis, respectively. Vancomycin, presumably in these cases administered intravenously, could be expected to give therapeutic levels in peritoneal exudate and in ventricular cerebrospinal fluid in the presence of inflammation.~ Rifampicin tissue levels usually exceed serum levels, and this drug reaches therapeutic concentrations even in normal cerebrospinal fluid? Consequently, these two drugs may be expected to be effective in cases such as those described, but although rifampicin also may be useful in true shunt colonization, the authors have not shown this. R. Bayston The Hospital for Sick Children Great Ormond St. London, WCIN 3JH England
'7 8 6
Editorial correspondence
REFERENCES 1. Ring JC, Cates KL, Belani KK, Gaston TL, Sveum RJ, and Marker SC: Rifampicin for CSF shunt infections caused by coagulase-negative staphylococci, J PEDIATR 95:317, 1979. 2. Riley HD: Vancomycin and novobiocin, Med Clin North Am 8:1073, 1961. 3. Sensi P, Maggi N, Ft~resz S, and Maffii ,G: Chemical modifications and biological properties of rifampicins, Antimicrob Agents Chemother 6:699, 1966.
Reply To the Editor: Perhaps the title of our observation should have been rearranged to read "Rifampin for coagulase-negative stffphylococcal infections caused by CSF shunts." The point that we wished to make remains unchanged, i.e., rifampin is the most active antibiotic available for the treatment of coagulase-negative staphylococcal infections and should be considered especially when response to other therapy has been poor. Stephen C. Marker, M.D. Department of Laboratory Medicine and Pathology Box 198 Mayo Memorial Building 420 Delaware St. SE Minneapolis, M N 55455
Latex agglutination test and countercurrent immunoelectrophoresis for detection of group B streptococcal antigen To the Editor: Edwards, Kasper, and Baker1 recently reported the sensitivity of latex particle agglutination (LA) test over countercurrent immunoelectrophoresis (CIE) for the detection of group B streptococcal (GBS) antigen. We evaluated the sensitivity of LA and CIE using two group B streptococcal antisera for the detectiOn of GBS antigen. GBS antisera obtained from the Center For Disease Control (CDC) and Burroughs Wellcome & Co, (commercial) were used. Latex particles 0.8 micron in diameter were sensitized with antisera diluted 1:10 with glycine-buffered saline. ~ LA test and CIE were carried out by the standard techniques.~. 3 Each of six CSF specimens and four sera obtained at the time of diagnosis from infants with culture proven GBS meningitis were positive by LA test using CDC antisera. Only three CSF and two sera were positive by LA using commercial antisera. Antigen was detected in only two CSF specimens using CIE (either antiserum).
The Journal of Pediatrics April 1980
Table. N o 5 o f GBS broth cultures positive at different dilutions by latex and CIE (total specimens 20)
Broth dilution Undiluted 1:2 1:4 1:8 1:16 1:32 1:64 1:128 1:256 Geometric mean titers of positive broths
Latex Latex CIE CDC commercial CDC antisera antisera antisera 20 20 20 20 20 20 20 18 10 159.2"
20 20 20 19 11 4 0 0 0 12.91t
20 20 17 4 0 0 0 0 0 4.12
CIE commercial antisera 20' 20 19 4 0 0 0 0 0 4.41:~
P values: * vs "~ <0.001; t vs ~ <0.001. Because of this discrepancy with patients' specimens, we evaluated the sensitivity and specificity of these two antisera with LA and CIE tests. Twofold serial dilutions of four-hour broth cultures of streptococci previously isolated and identified from patients and stored in skim milk at - 7 0 ~ were studied. The number of strains and their groups tested for GBS antigen by CIE and LA were: 30 group A, 20 group B, 5 group C, 10 group D, and 2 group G. None of the 30 group A, 5 group C, 10 group D, and 2 group G streptococci gave a positive reaction with CIE or LA test using either of the group B antisera. Undiluted broth culture of each of the 20 group B streptococci gave positive results by CIE and LA using either of the GBS antisera. In each instance LA test performed using latex particles sensitized with antisera obtained from CDC was at least eightfold sensitive (Table). Geometric mean titers of positive broth dilutions using CDC antisera sensitized latex were 159.2 as compared to 12.9 with commercial antisera (P < 0.001). Geometric mean titers of positive broth by CIE were 4.1 and 4.4 using CDC and commercial antisera, respectively. LA test using either of the antisera was significantly superior to CIE (P < 0.001). The value of LA and CIE for the diagnosis of bacterial infections is well recognized.2-" Sensitivity and specificity of these antigen detection tests depend upon the quality of antisera. We found a significant difference in the sensitivity of LA test depending upon the antiserum used. LA is a sensitive and simple test for the rapid diagnosis of GBS disease, however, laboratories should closely monitor and evaluate the sensitivity of the test whenever the source or lot of antiserum is changed. Ashir Kumar, M.D. Department of Pediatrics Case Western Reserve University St. Luke's Hospital 11311 Shaker Blvd. Cleveland, OH 44104 George A. Nankervis, M.D., Ph.D. Medical College of Ohio at Toledo Toledo, OH 43699