Pediatric Anaerobic Infections: Diagnosis and Management (Infectious Disease and Therapy)

619 Pages·2001·2.71 MB·English

by  Itzhak Brook

To my wife, Joyce, and my children, Dafna, Dan, Tamar, Yoni, and Sara
The last edition of the book was published as Pediatric Anaerobic Infection: Diagnosis and
Management, Second Edition, ©The C. V. Mosby Company (St. Louis, 1989).
ISBN: 0-8247-0615-3
This book is printed on acid-free paper.
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Preface
Since the publication of the second edition of the book in 1989, much has changed in our
understanding and knowledge of the role of anaerobic bacteria in infections in children.
More clinical studies have been performed, describing the activity of these bacteria in a
variety of infections, which include splenic and liver abscesses, infections after trauma,
and head and neck and abdominal infections. With increased awareness, patient care has
improved in those infected by these organisms.
With the passage of time, there has been an increase in the resistance of anaerobic
bacteria to many of the antimicrobials used against them. During this period, newer an-
timicrobial agents effective against these organisms have been introduced. Methods for
their identification have been improved and simplified, as their taxonomy has changed.
The third edition of the book updates our knowledge of the role of anaerobic bacte-
ria in pediatric infections. All the chapters have been revised to provide current informa-
tion about diagnosis and therapy, resistance to antimicrobials, the newer agents,
indications and contraindications for surgery, and the therapy of complications. Newer di-
agnostic tests have been included, the nomenclature of the organisms has been updated,
and newer and updated references have been provided.
Each chapter presents the information in the most user-friendly way, and emphasis
has been given to treatment of various infections for ready use by pediatricians and family
practitioners, as well as teaching institutions. I believe that practicing physicians will con-
tinue to find this reference useful in delivering care for their patients.
Itzhak Brook
iii

Acknowledgments
I am most grateful to those who have made this book possible.
I would like to express my deepest gratitude to my parents, Haya and Baruch, who
worked so hard to ensure that I would have a proper education. They have always encour-
aged the development of my scientific curiosity and capabilities. I would also like to
thank my children and especially my wife, Joyce, for their patience, assistance, and un-
derstanding.
I am indebted to many of my teachers in the Hareali Haivri High School of Haifa,
Israel, for their devotion and enthusiastic teaching, which were instrumental in promoting
my scientific, professional, and ethical development. I am especially grateful to my biol-
ogy teacher, Z. Zilberstein, for his enthusiastic recognition of nature’s role in human life,
and to my physics teacher, L. Green, for teaching me an analytical and scientific approach
to my studies. I am grateful to many of my teachers in the Hebrew University Hadassah
School of Medicine in Jerusalem and especially to the late Professor H. Berenkoff, who
introduced me to the wonders of microbiology; to Dr. T. Sacks, who taught me clinical
microbiology; and to Dr. S. Levine from Kaplan Hospital, Rehovot, Israel, who taught me
general pediatrics.
I owe special gratitude to my teacher and mentor at University of California, Los An-
geles, Dr. S. M. Finegold, for sharing his knowledge of anaerobic microbiology and clini-
cal infectious diseases. Dr. Finegold has served over the years as a constant source of
support and encouragement. Other teachers who provided invaluable help are Drs. W. J.
Martin and V. L. Sutter from University of California, Los Angeles, and Drs. C. V. Sumaya,
G. D. Overturf, and P. Wherle, who taught me about pediatric infectious diseases.
I am also grateful to my friends and collaborators who assisted in many of the clini-
cal and laboratory studies: K. S. Bricknel for his excellent gas liquid chromatography
work, and L. Calhoun and P. Yocum for their dedication and laboratory support.
Finally, I would like to thank the many medical students, house officers, infectious
diseases fellows, and faculty and staff members at the Medical Centers of the University
of California, Los Angeles; University of California, Irvine; George Washington Univer-
sity and Georgetown University, Washington, D.C.; and the Naval Hospital in Bethesda,
Maryland, for their collaboration in clinical studies.
v

Contents
Preface iii
Acknowledgments v
Part I Introduction to Anaerobes
1 Anaerobes as Pathogens in Childhood 1
2 The Indigenous Microbial Flora in Children 25
3 Collection, Transportation, and Processing of Specimens for Culture 41
4 Clinical Clues to the Diagnosis of Anaerobic Infections 55
5 Virulence of Anaerobic Bacteria and the Role of the Capsule 63
Part II Neonatal Infections
6 Introduction to Neonatal Infections 75
7 Colonization of Anaerobic Flora in Newborns 79
8 Conjunctivitis and Dacryocystitis 87
9 Pneumonia 91
10 Ascending Cholangitis Following Portoenterostomy 95
11 Cutaneous Infections 99
12 Bacteremia and Septicemia 109
13 Necrotizing Enterocolitis 119
14 Infant Botulism 129
15 Scalp Infection Following Intrauterine Fetal Monitoring 139
Part III Anaerobic Infections of the Specific Organ Sites
16 Infections of the Central Nervous System 145
17 Eye Infections 169
vii
viii Contents
18 Odontogenic Infections 187
19 Ear, Nose, and Throat Infections 205
20 Infections of the Head and Neck 279
21 Chest Infections 311
22 Intra-Abdominal Infections 339
23 Urinary Tract and Genitourinary Suppurative Infections 365
24 Female Genital Tract Infections 379
25 Cutaneous and Soft Tissue Abscesses and Cysts 393
26 Soft-Tissue and Muscular Infections 415
27 Burn Infections 431
28 Decubitus Ulcers 439
29 Surgical Wound Infections 445
30 Human and Animal Bite Wounds 455
31 Infected Solid Tumors 465
32 Infections of Bones and Joints 471
33 Clostridial Diarrhea and Pseudomembranous Enterocolitis 489
34 Endocarditis 499
35 Pericarditis 505
Part IV OtherTypes of Anaerobic Infections
36 Anaerobic Bacteremia 509
37 Botulism 523
38 Tetanus 531
Part V Principles of Management
39 Treatment of Anaerobic Infections 545
40 Beta-Lactamase–Producing Bacteria in Mixed Infections in Children 569
Index 595
1
Anaerobes as
Pathogens in Childhood
Anaerobic bacteria differ in their pathogenicity. Not all of them are believed to be clin-
ically significant, while others are known to be highly pathogenic. Table 1.1 lists the
major anaerobes that are most frequently encountered clinically. The species of anaer-
obes most often isolated from clinical infections are, in decreasing frequency, gram-
negative rods (Bacteroides, Prevotella, Porphyromonas, Fusobacterium, Bilophila,
and Sutterella), gram-positive cocci (primarily Peptostreptococcus), gram-positive
spore-forming (Clostridium) and non-spore-forming bacilli (Actinomyces, Propioni-
bacterium, Eubacterium, Lactobacillus, and Bifidobacterium), and gram-negative
cocci (mainly Veillonella).1About 95% of the anaerobes isolated from clinical infec-
tions are members of these genera (Table 1.2). The remaining isolates belong to
species not yet described, but these can usually be assigned to the appropriate genus
on the basis of morphologic characteristics and fermentation products. The frequency
of recovery of the different anaerobic strains differs in various infectious sites. We
have summarized our experience in recovering anaerobic bacteria over a period of 12
years from both adults and children.2 Anaerobic gram-negative bacilli (Bacteroides,
Prevotella, and Porphyromonas) accounted for 43% of anaerobic isolates (Table 1.2).
They were predominant in genitourinary infections (56% of all anaerobic isolates), ab-
dominal infections (55%), abscesses (51%), obstetric and gynecologic infections
(49%), infected cysts (44%), wounds (43%), and tumors (42%). They were less often
recovered in infections of the central nervous system (7%), eye (12%), joint (13%),
and lymph glands (15%).
Anaerobic gram-positive cocci accounted for 26% of all isolates. The infected sites
where they predominated were ears (53%), cysts (40%), bones (39%), and obstetric and
gynecologic (35%). They were uncommonly found in the eye (6%), bile (12%), abdomen
and lymph gland (13% each), and central nervous system (17%).
Clostridiumspp. were 7% of all isolates. They predominated in infection of the bile
(36%), abdomen and wound (13% each), joint (12%), and blood (11%). They were less
commonly found in tumors and sinuses (1% each) or the genitourinary tract, ears, and
cysts (2% each).
1
2 Chapter 1
Table 1.1 Anaerobic Bacteria Most Frequently Encountered in Clinical Specimens from
Children
Organism Infection Site
Gram-Positive cocci
Peptostreptococcussp. Respiratory tract, intra-abdominal and subcutaneous infections
Microaerophilic streptococcia Sinusitis, brain abscesses
Gram-positive bacilli
Non-spore-forming
Actinomycessp. Intracranial abscesses, chronic mastoiditis, aspiration
pneumonia, head and neck infections
Propionibacterium acnes Shunt infections (cardiac, intracranial)
Bifidobacteriumsp. Chronic otitis media, cervical lymphadenitis
Spore-forming
Clostridiumsp.
C. perfringens Wounds and abscesses, sepsis
C. septicum Sepsis
C. difficile Diarrheal disease, colitis
C. botulinum Infantile botulism
C. tetani Tetanus
Gram-negative bacilli
B. fragilisgroup (B. fragilis, Intraabdominal and female genital tract infections, sepsis,
B. thetaiotamicron) neonatal infection
Pigmented Prevotellaand Orofacial infections, aspiration pneumonia, periodontitis
Porphyromonas sp.
Prevotella oralis Orofacial infections
Prevotella oris-buccae Orofacial infections, intraabdominal infections
Prevotella bivia, Female genital tract infections
Prevotella disiens
Fusobacteriumsp.
F. nucleatum Orofacial and respiratory tract infections, brain abscesses,
bacteremia
F. necrophorum Aspiration pneumonia, bacteremia
aNot obligate anaerobes.
Fusobacteriumsp. accounted for 5% of all isolates. They were often found in infec-
tions of the chest (11%), abdomen (8%), and sinuses (7%). They were infrequently recov-
ered in tumors, cysts, the central nervous system, and bile (1% each); ears and wounds
(2% each); and obstetric and gynecologic infections (3%).
This chapter provides a discussion of each of the important anaerobic species re-
covered from children and the role of these organisms in infectious processes.
CLASSIFICATION OF ANAEROBES
Anaerobes do not multiply in oxygen. However, they possess different susceptibilities to
oxygen. Most normal-flora anaerobes are extremely oxygen-sensitive, while those that