Report of Five Children
with
Hemophilus
Influenzae Pneumonia Resistance to
Ampicillin
Must
Always
Be Looked For
Emilio Soto, M.D.,* John
Silverio,
M.D.**
Five cases of Hemophilus influenzae pneumonia were observed in a 13month period at Fairfax Hospital, Fairfax, Va. More aggressive diagnostic procedures may be required in order to diagnose this disease with greater frequency. This has become especially important in view of the growing recovery of ampicillin-resistant H. influenzae strains.
Although
FALTHOUGH the current pediatric medical literature contains relatively few reports of pneumonia caused by Hemophilus influenzae, Honig and colleagues~ described five patients who had been seen in a 15-month period at Children’s Hospital of Philadelphia. These investigators also surveyed 18 other cases that had been reported. During the 13 months between January, 1973 and February, 1974, we encountered five young children with H.
influenza pneumonia at Hospital, Fairfax, Virginia. These
Fairfax five pa-
tients are here described. Several reports’--’ cite the ,
H. in
influenzae pneumonia
as
frequency of varying from 1
2,000 to 1 in less than 500 pneumonia patients. It is difficult to establish this etiologic diagnosis because bronchial sputum is not readily obtainable from small over
* Professor of Pediatrics, Georgetown University Medical School, Washington, D.C. ** Associate in Pediatrics, University of Pennsylvania School of Medicine, Philadelphia, Pa. Correspondence to John Silverio, M.D., Box 8299, Philadelphia, Pa. 19101.
children and because I-~. irfluenzae can be isolated from pharyngeal cultures of many normal subjects who clearly are carriers.6,7 H. influenza infections are observed most frequently in children from three months to three years of age, but older children and adults are also susceptible.
Cases Observed Five patients, aged 3 months, 11 months, 2 years, 3 years, and 4Y2 years, were diagnosed as suffering from H. influenzae pneumonia in a 13-month period. All were females, although this disorder does not usually exhibit any sex preference. Two of the patients also had acute otitis media, a complication not rare in the course of H. influenzae pneumonia. One patient had acute gastroenteritis possibly related to the primary illness. Another had a probably unrelated
right torticollis. The radiologic patterns ranged from those of lobar pneumonia (two cases) to bronchopneumonia (two cases) to interstitial pneumonia (one case). All patients recovered.
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TABLE 1. Treatment
H. influenzas was isolated from blood cultures, tracheal aspirates, and/or pleural fluid in all five cases. Four of the isolated strains were Type B; one was nontypable. Four of the bacterial isolates were sensitive to ampicillin, but one was resistant in vitro to more than 100 mcg/ml of the agent. Table 1 lists the therapy. Three patients were treated with ampicillin intravenously, one who was allergic to penicillin was treated with chloramphenicol, and the one with the resistant H. influenzae strain was treated with carbenicillin in relatively large doses. Carbenicillin was given because laboratory studies showed this strain to be sensitive to it.
Discussion
ral fluid, tracheobronchial
secretions,
or
coughed-up sputum. The diagnosis of this disease could be established more frequently if intensive investigational diligence (such as lung puncture) were employed. Studies of lung fluid obtained by tap suggest that H. influenza pneumonia may be more widespread than generally realized.14 Lung tap may be both specifically informative and relatively safe.~ Clinically acute H. influenzae pneumonia is often indistinguishable from pneumococcal pneumonia. In its subacute form, the onset 7
It is clear from the literature that this disease may be acute, subacute, or chronic.’ Among the most common complications are pleural effusions, empyema, and otitis media. We have added our five cases to the 23 collected by Honig, Pasquariello, and Stool, and the summary of the 28 reviewed (inTABLE 2. Clinical Characteristics
cluding the five reported in this paper) is presented in Table 2. Inasmuch as H. influenzae can be isolated from the nasopharynx of 3 to 40 per cent of normal subjects,6,13 it is practically useless to base the clinical diagnosis on nasopharynx cultures. Positive diagnosis requires isolation of the organism from blood, pleu-
of H. influenzaePneumonid
is often insidious, in contrast to that of pneumococcal pneumonia. The chronic form may be confused with severe systemic respiratory disorders such as may be seen in cystic fibrosis.
Ampicillin Resistance
Although for a decade H. influenzae only rarely demonstrated resistance to ampicillin this is now occurring and has been reported from different geographic locations. 16-19 Hence, it is now mandatory that whenever this microorganism is isolated, careful sensitivity testing be performed .2&dquo; Recently, a quick qualitative method for susceptibility testing has been described 20 but strains which show equivocal sensitivity or evident resistance should undergo quantitative sensitivity determinations by tube dilution or agar diffusion * See reference 1.
techniques.
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Haemophilus of bacteremic influenzae pneumonia in adults with typable strains. Am. J. Med. 50:
References P. J., Pasquariello, P. S., Jr., and Stool, S. E.: H. influenzae pneumonia in infants and children. J. Pediatr. 83: 215, 1973. 2. Fisher, A. J., and Shaw, E. B.: Streptomycin treatment of empyema caused by H. influenzae. Am. J. Dis. Child. 74: 468, 1947. 3. Crowell, J., and Loube, S. D.: Primary Hemophilus influenzae pneumonia. Arch. Intern. Med. 93: 1.
4.
781, 1971.
Honig,
921, 1954. W. L., Rectanus,
Nyhan,
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M. D.:
6.
7.
8.
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changing
picture of pneumonia and empyema in infants and children. JAMA 175: 1039, 1961. Willard, C. Y., and Hansen, A. E.: Bacterial flora of the nasopharynx in children. Am. J. Dis. Child. 97: 318, 1959. Klein, J. O., and Gellis, S. S.: Diagnostic needle aspiration in pediatric practice. Pediatr. Clin. North Am. 18: 219, 1971. Graber, C. D., Gershanik, J. J., Levkoff, A. H., and Westphal, M.: Changing pattern of neonatal susceptibility to Hemophilus influenzae. J. Pediatr. 78: 948, 1971. Norden, C. W., Callerame, M. L., and Baum, J.: Haemophilus influenzae meningitis in an adult. N. Engl. J. Med. 282: 190, 1970. Weinstein,
L.:
Type
B
Haemophilus influenzae
in-
fections in adults. N. Engl. J. Med. 282: 221, 1970 (Editorial). 11. Quintiliani, R., and Hymans, P. J.: The association
Hughes, J. R., Sinha,
D. P., Cooper, M. R., Shah, V., and Bose, S. K.: Lung tap in childhood: bacteria, viruses, and mycoplasmas in acute lower respiratory tract infections. Pediatrics 44: 477, K.
Hemophilus influenzae type B pneumonia. Pediatrics 16: 31, 1955. 5. Ravitch, M. M., and Fein, R.: The
Johnson, W. D., Kaye, D., and Hook, E. W.: Hemophilus influenzae pneumonia in adults. Am. Rev. Resp. Dis. 97: 1112, 1968. Turk, D. C. : Nasopharyngeal carriage of Haemophilus influenzae type B. J. Hyg. (Camb.) 61:
1969. D.: Ampicillin in the treatment of menintis due to Hemophilus influenzae: an appraisal J. Pediatr. 74: 848, 1969. 16. Thomas, W. J., McReynolds, J. W., Mock, C. R., and Bailey, D. W.: Ampicillin-resistant Haemophilus influenzae meningitis. Lancet 1: 313, 1974 (Letter). 17. Center for Disease Control: Ampicillin-resistant 15.
Yow, M.
Hemophilus influenzae meningitis—Maryland, Georgia. Morbidity and Mortality Weekly Report 23 (9): 77, 1974. 18. Tomeh, M. O., Starr, S. E., McGowan, J. E., Jr., Terry, P. M., and Nahmias, A. J.: Ampicillinresistant Haemophilus influenzae type B infection. JAMA 229: 295, 1974. 19. Khan, W., Ross, S., Rodriguez, W., Controni, G., and Saz, A. K.: Haemophilus influenzae type B resistant to ampicillin. A report of two cases. JAMA 229: 298, 1974. 20. Center for Disease Control: Ampicillin-resistant Hemophilus influenzae -Texas. Morbidity and Mortality Weekly Report 23 (11): 99, 1974.
In some cultures crying is relatively rare, whereas in most Western countries crying is common and is regarded as normal child behavior are often advised to let the baby ’cry it out.’ I am not aware of any scientific basis for the different attitudes, but the cry certainly is a signal. There is an old adage of medicine that the doctor should listen to what a patient is saying to him: doctors should listen to the infant cry and construct dictionaries and phrase-books which will enable them to understand what babies are telling them. A baby in a cot who cries usually succeeds in drawing attention to himself and, in response to his signal, often gets his needs dealt with. But when babies in incubators cry, ambient noise within the immediate area frequently masks the cries and the attendants may not be aware that the baby is signalling distress. An amplifier to make these cries more audible to the outside world
-parents
There Is Much To Learn About the Infant Cry
should be a routine part of all incubators. A small laryngeal microphone can be attached with minimal inconvenience. There may be less crying in babies who talk late. It has often been reported that mentally retarded children cry less than normal children. This may relate to general lessened activity but may be of clinical importance. There are numerous situations, apart from pain, hunger, and some anomalous syndromes, in which the baby may be able to signal specific problems. For example, there may be specific cries for the hyperexcitable baby, the apathetic baby, the baby who is understimulated or overstimulated, or the baby who has some difficulty forming an affectional bond with his caretaker. All such matters should be the subject of systematic clinical studies. -Martin Bax of London irz Developmental Medicine and Child Neurology. December 1975.
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