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Context: The incidence of urinary tract infection (UTI) varies with age, but there is limited evidence on the role of other risk factors., Objective: The aim of this meta-analysis was to investigate the risk factors for UTIs in children., Data Sources: PubMed from 1966 to May 2019., Study Selection: All studies assessing at least 1 possible risk factor for occurrence or recurrence of UTI with a clear definition of symptomatic UTI in children were eligible. We excluded studies with UTIs related to hospital treatment or severe congenital renal abnormalities., Data Extraction: After the quality assessment we extracted data on the given risk factor in children with and without UTI. The data were extracted separately for the occurrence and recurrence of UTIs., Results: We included 24 studies in the meta-analysis. Circumcision decreased the occurrence of UTIs with an odds ratio (OR) of 0.1 [95% confidence interval (CI): 0.06-0.17) and breast-feeding with an OR of 0.4 (CI: 0.19-0.86), both with low heterogeneity. Being overweight or obese increased the risk of UTI (OR: 2.23; CI: 1.37-3.63). Both poor fluid intake (OR: 6.39; CI: 3.07-13.39) and infrequent voiding (OR: 3.54; CI: 1.68-7.46) were associated with recurrent UTIs., Limitations: The design, populations and definitions varied between the studies., Conclusions: Being overweight or obese and having poor fluid intake are modifiable risk factors that increase the risk for UTIs in children. Breast-feeding and circumcision are associated with a decreased occurrence of UTIs., Competing Interests: The authors have no funding or conflicts of interest to disclose., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc.)

Background: Although Chlamydia trachomatis infection is common in pregnant women, such infections are rarely encountered in infants. To clarify the recognition of C. trachomatis infections in infants, we analyzed symptoms and signs of perinatally acquired chlamydial infection, together with its long-term prognosis in a large population-based patient series., Methods: A search through 2 national health registries covering 1996-2011, a cohort of 933,823 births, yielded 124 children with a microbiologically confirmed C. trachomatis infection. We then reviewed copies of the children's medical records up to 16 years of age., Results: One-third of the infants with chlamydial conjunctivitis (33/110) had spontaneous blood-stained discharge from the infected eye. The infants with C. trachomatis lower respiratory tract infection were mostly afebrile (30/32), and 15/32 of them had wheezing. Staccato cough was not recorded in any of the infants. The median diagnostic delay from the onset of the symptoms was 13 (range 4-374) days for conjunctivitis and 25 (range 10-149) days for lower respiratory tract infection. One neglected child developed bilateral corneal scars because of an untreated C. trachomatis infection., Conclusions: Blood-stained discharge was a typical finding in C. trachomatis conjunctivitis. The C. trachomatis-infected infants had severe and prolonged symptoms, but long-term consequences were rare. The diagnostic delay was long, especially among the infants with a C. trachomatis lower respiratory tract infection.

Background: The incidence of invasive group A streptococcus (iGAS) infections varies in time and geographically for unknown reasons. We performed a nationwide survey to assess the population-based incidence rates and outcomes of children with iGAS infections., Methods: We collected data on patients from hospital discharge registries and the electronic databases of microbiological laboratories in Finland for the period 1996-2010. We then recorded the emm types or serotypes of the strains. The study physician visited all university clinics and collected the clinical data using the same data entry sheet., Results: We identified 151 children with iGAS infection. Varicella preceded iGAS infection in 20% of cases and fasciitis infection in 83% of cases. The annual incidence rate of iGAS infection was 0.93 per 100,000 in 1996-2000, 1.80 in 2001-2005 and 2.50 in 2006-2010. The proportion of emm 1.0 or T1M1 strains peaked in 1996-2000 and again in 2006-2010, to 44% and 37% of all typed isolates. The main clinical diagnoses of the patients were severe soft-tissue infection (46%), sepsis (28%), empyema (10%), osteoarticular infection (9%) and primary peritonitis (5%). Severe pain was the most typical symptom for soft-tissue infections. More than half of the patients underwent surgery and received clindamycin. The readmission rate was 7%, and the case fatality rate was 2%., Conclusions: The incidence rate of pediatric iGAS infections tripled during our study. The increase was not, however, the result of a change in the strain types causing iGAS. Varicella immunization would likely have prevented a significant number of the cases.

Background: Tympanostomy with or without adenoidectomy is effective in preventing recurrences of acute otitis media (RAOM), but little is known about the effect of these operations on the quality of life (QOL). We evaluated the efficacy of insertion of tympanostomy tubes with and without adenoidectomy for improving QOL in young children in a controlled, randomized trial., Methods: QOL was evaluated in the 159 children aged 10 months to 2 years participating in our larger study in which children with RAOM were randomly assigned to receive tympanostomy tubes, tympanostomy tubes with adenoidectomy or neither. The caregiver of the child completed otitis media-specific QOL questionnaires (Otitis Media-6) at entry and after 4 months and 12 months of follow up., Results: Scores on the global ear-related QOL and the subsets of caregiver concern, emotional distress and physical suffering in the questionnaires improved with time during the follow up, but the groups did not differ from each other., Conclusions: QOL in children with RAOM improves with time when the subjects are closely followed. Tympanostomy with adenoidectomy does not provide any additional QOL benefit for children with RAOM, even though these operations are effective in preventing further otitis media episodes.

Background: Finland introduced universal rotavirus (RV) vaccination in September 2009, with exclusive use of the pentavalent human-bovine reassortant RV vaccine RotaTeq® and following a vaccination schedule at 2, 3 and 5 months of age. This study monitored the impact of RV vaccination on hospitalizations due to RV acute gastroenteritis (RVGE). The results following the first 3 RV seasons after implementation of universal RV vaccination are presented., Methods: Prospective hospital-based surveillance identified children with acute gastroenteritis admitted to 2 University Hospitals (Tampere and Oulu, Finland), from December 2009 to August 2012. The surveillance covered a population of approximately 173,000 children from the 2 hospitals' catchment areas. Stool samples were taken and analyzed centrally for RV by enzyme-linked immunosorbent assay, with genotyping by reverse transcription polymerase chain reaction. International Classification of Diseases discharge codes were collected retrospectively pre- and postvaccination., Results: During the 3-year prospective surveillance, 127 RVGE episodes were identified. Of these, 117 were in unvaccinated children and 6 were in fully vaccinated children (RotaTeq, n = 3; Rotarix, n = 3). The vaccine effectiveness against hospitalized RVGE for fully vaccinated children was 92.1% [95% confidence interval (CI): 50.0-98.7] among children eligible for the National Immunization Program. When analyzing retrospectively the Tampere and Oulu hospital databases for all children aged <16 years, hospitalizations for RVGE had decreased by 78% in the postvaccination period (2009-2012) compared with the prevaccination data (2001-2006)., Conclusions: Severe RVGE requiring hospitalization was virtually eliminated in vaccine-eligible children in the 3 years following implementation of universal RotaTeq vaccination in Finland.

Background: Our aim was to evaluate changes in infectious disease mortality in children in Finland from 1969 to 2004. We especially wanted to find out whether infection mortality could be further reduced by means of existing vaccines not included in national vaccination program., Methods: We analyzed infectious disease mortality in Finland using data obtained from the official Cause of Death statistics for 1969 to 2004. Annual mortality rates were calculated in proportion to those at risk of dying. Infection mortality rates were calculated separately for neonates and children who were 1 month to 15 years., Results: Childhood mortality due to infectious diseases decreased by 89%, from 0.12% in 1969 to 0.013% in 2004, and neonatal mortality by 69%, from 0.50% to 0.16%. Pneumonia, central nervous system infections and septicemia were the most common fatal infections in childhood. There were slightly more deaths due to all infections and respiratory tract infections in years marked by epidemics of respiratory syncytial virus. We estimated that pneumococcal conjugate vaccines would have prevented 2 deaths annually in our population, rotavirus vaccines 1 to 2 deaths, influenza vaccine 1 death and varicella vaccine 0.7 death., Conclusions: We found that even though mortality from infectious diseases in childhood decreased markedly during the period concerned, it could have been further reduced by means of existing vaccines. Even though the number of deaths prevented would have been small, the number of years of life saved would have been great because the life expectancy of children is long.

In a population-based observational study of 285 patients with positive blood culture for pneumococci, we found that the course and outcome of invasive pneumococcal infections differ considerably between adults and children. None of the children died, whereas the infection was fatal for 15% (35/229) of the adults (P<0.001). The differences are only partly explained by the underlying conditions.

Background: The prevention of otitis media, particularly among infants, remains a controversial issue. We evaluated the efficacy of insertion of tympanostomy tubes with and without adenoidectomy for preventing recurrent acute otitis media (AOM) in young children., Methods: We randomly assigned 300 children aged 10 months to 2 years who had recurrent AOM to groups receiving tympanostomy tubes (Tymp) (n = 100), tympanostomy tubes with adenoidectomy (TympAde) (n = 100) or neither (Contr) (n = 100). All the children were followed up for 12 months., Results: The primary outcome was intervention failure (2 AOM episodes in 2 months, 3 in 6 months or persistent effusion lasting for 2 months). Intervention failed in 21% of cases (21/100) in the Tymp group, 16% (16/100) in the TympAde group and 34% (34/100) in the Contr group. The absolute differences were -13% [95% confidence interval (CI) -25% to -1%, P = 0.04] between the Tymp and Contr groups and -18% (95% CI -30 to -6%, P =0.004) between the TympAde and Contr groups., Conclusions: Insertion of tympanostomy tubes alone or with adenoidectomy was effective in preventing recurrent AOM episodes in children younger than 2 years of age.

Background: Holarctica-type tularemia is endemic in the Northern Hemisphere. Despite recurrent epidemics tularemia is not well known in children and the pediatric cases are often misdiagnosed., Methods: An outbreak of holarctica-type tularemia occurred in the Oulu region of Northern Finland in late summer/early August 2007. We collected prospectively data on all the cases of children diagnosed and treated for tularemia at the Department of Pediatrics, Oulu University Hospital, during the epidemic from July through September 2007., Results: Fifty patients were confirmed as having tularemia. All the cases appeared in a relatively small part of the Oulu region and almost all came from an area about 40 km in diameter where the annual incidence rate was high (342/100,000). Ulceroglandular tularemia was recorded in 47 of the 50 cases and secondary skin manifestations in half of the cases., Conclusions: Tularemia caused by holarctica-type bacteria is a relatively mild infection, but symptoms are protracted in children and an epidemic consumes considerable health care resources.

Background: Acute rhinosinusitis in a child with signs and symptoms of a cold that persist beyond 10 days is recommended to be treated with antimicrobials. One reason for this recommendation is to prevent the complications of sinus infection. We wanted to find out whether there is any evidence to support this., Methods: We reviewed retrospectively all the medical records of children treated in our hospital from February 1996 to March 2006 for complications related to rhinosinusitis., Results: Twenty children had such complications. Their symptoms of uncomplicated acute respiratory infection had lasted for an average of 5.1 days before the appearance of the complication, and only 3 children had respiratory symptoms lasting longer than 10 days., Conclusions: Complications of rhinosinusitis in children appear during the first few days of acute upper respiratory infection. This finding does not support the recommendation that antibiotics should be started if upper respiratory symptoms have lasted longer than 10 days in children. Even though patients with findings suggesting invasive periorbital infection require immediate antimicrobial treatment, we should be critical in our recommendations as to when antibiotics need to be given to patients with only prolonged upper respiratory infections.

Background: Respiratory viruses occur frequently in the community and are a common cause of fever in children. Data on respiratory viral infections in children with cancer are limited., Methods: A long-term, prospective, multicenter study was carried out in Finland searching for respiratory viruses in febrile children with leukemia. For this purpose, 138 febrile episodes in 51 children with leukemia were analyzed. Twelve types of respiratory viruses were searched for by viral culture, antigen detection, and polymerase chain reaction tests., Results: Evidence of a respiratory viral infection was found in 61 of 138 febrile episodes (44%), accounting for an incidence of 0.8 (range, 0-2.4) per person year at risk during the treatment of leukemia. The most common viruses detected were rhinovirus (22%), respiratory syncytial virus (11%), human bocavirus (5%), and influenza A virus (4%). Dual viral infections were detected in 12 cases (9%). Half of the children had respiratory symptoms with cough being the most common symptom. Two children developed pneumonia. The mean duration of fever was 2.6 (SD 1.7) days in children with respiratory viral infection and 2.1 (SD 1.3) days in children without evidence of viral infection (P = 0.44)., Conclusions: Respiratory viruses are found commonly during febrile episodes in children with leukemia. The detection of viruses permits the use of available antiviral agents, may explain a poor response to antimicrobial agents, and minimizes the proportion of febrile episodes without possible etiologic agents in children with leukemia.

Background: Febrile infections in children with leukemia are common. The occurrence of possible mixed bacterial-viral infections is unknown., Methods: We searched for viruses in leukemic children with blood culture-positive bacterial infections. The prospective multicenter survey included 156 febrile episodes in 51 children with acute leukemia. The mean follow-up time was 1.5 years per patient (27,743 patient-days at risk). Sixteen viruses were searched for from nasal swab and stool samples using virus culture, virus antigen detection, and polymerase chain reaction tests., Results: Bacterial blood cultures were positive in 19 (11%) febrile episodes among 17 children. In half of the septic episodes (11 of 19), a virus was also found. Rhinovirus and respiratory syncytial virus were the most common viruses detected., Conclusions: Our findings suggest that invasive bacterial infections are commonly associated with viral infections in children with leukemia.

Background: Xylitol administered regularly 5 times a day after each meal is successful in preventing acute otitis media (AOM) in children, but if given only during respiratory infections it is ineffective against AOM. To find a more convenient dosing regimen, we tested whether xylitol administered 3 times a day reduces the occurrence of AOM., Methods: In this 3-month randomized, double-blind trial, 663 healthy day care children were randomized to receive either a control product (n = 331) or xylitol (n = 332). Xylitol was given in chewing gum or in a mixture 3 times a day, the daily dose being 0.5 g in the control group and 9.6 g in the xylitol group. The occurrence of the first AOM diagnosed during any period of respiratory symptoms during the follow-up was the main outcome measure., Results: At least one AOM episode was diagnosed in 98 of the 331 children who received control products (30%) and in 94 of the 332 who received xylitol products (28%). A total of 142 episodes of AOM were diagnosed in the control group compared with 156 in the xylitol group. The differences were not statistically significant., Conclusions: Xylitol given regularly 3 times a day for 3 months during the respiratory infection season failed to prevent AOM.

Aims: To test our hypothesis that children with potentially pathogenic bacteria (Streptococcus pneumoniae, Haemophilus influenzae or Moraxella catarrhalis) in the nasal middle meatus might have more prolonged symptoms of acute respiratory infection than children without such bacteria, we conducted a prospective cohort study of such children., Materials and Methods: We recruited prospectively child volunteers between 6 and 13 years of age with acute respiratory infections present for fewer than 10 days. Nasal middle meatal bacterial culture was taken with a rigid endoscope at enrollment and again after 3 weeks and evaluated for presence or absence of 3 potential pathogens: S. pneumoniae, H. influenzae and M. catarrhalis. The subsequent persistence of acute symptoms (nasal discharge: clear/colored, nasal obstruction and cough) was determined by means of a diary. Viral etiology was studied with polymerase chain reaction methods., Results: The 82 children had had symptoms for an average of 4 days (range, 1-10) at entry, and viruses were detected in 54% (39 of 72). The endoscopic procedure and bacteriologic sampling succeeded in all cases. Thirty-eight children (46%) had at least 1 of the 3 pathogens in the middle meatus specimen. The children with nasal pathogens present at entry had a significantly longer mean duration of symptoms than those with nonpathogenic bacteria (difference, 3.6 days; 95% confidence interval, 0.7-6.5; P = 0.025). The effect remained significant after adjustment for age, sex, allergic symptoms and the presence of virus (adjusted relative hazard of delayed recovery, 2.0; 95% confidence interval, 1.1-3.6)., Conclusions: We found that the use of endoscopic swab culture sampling from the nasal middle meatus is well-tolerated by children older than 6 years of age and that it can be useful in selected situations to determine pathogenic bacteria in the culture of these specimens.

In adults, HLA haplotype B8-DRB1*03 is clearly associated with a severe clinical course of nephropathia epidemica caused by Puumala hantavirus. We investigated whether the same applies in pediatric patients. This HLA haplotype was found in 20 of 39 (51%) of the patients, a significantly higher figure than in the Finnish population (19%). There were, however, no significant differences in the clinical picture between patients with and without HLA B8-DRB1*03.

Objective: Child care outside the home increases children's infections substantially. We have to evaluate the possibilities for reducing the transmission of infections by an infection prevention program., Design and Methods: A 15-month randomized controlled trial involving 20 day-care centers was conducted to evaluate the efficacy of an infection prevention program. The program was introduced in 10 centers and the other matched 10 centers served as controls. Records were made of the occurrence of infections and absences from care or work because of infections among the children, their parents and the personnel of the day-care centers., Results: Both the children and the personnel in the program centers had significantly fewer infections than those in the control centers, the reduction being 9% [95% confidence interval (95% CI), 4 to 16%, P < 0.002] among 3-year-old children and 8% (95% CI 0 to 14%, P = 0.049) among the older children. The children at the program centers received 24% fewer prescriptions of antimicrobials (95% CI 22 to 27%, P < 0.001). Likewise there were 2.5 man-year fewer absences from work on the part of parents because of a child's illness during 1 year in the program centers, a 24% difference (95% CI 18 to 29%, P < 0.001)., Conclusions: Effective prevention of infections is possible in child day-care centers, and this can benefit both the families and the personnel. Such a program is cost-effective even if a specialist nurse implements it.

Background: The decision to seek medical advise for children during upper respiratory infections is largely based on the parental assumption that the child's symptoms are related to acute otitis media. The symptoms related to acute otitis media, however, are considered nonspecific., Methods: Altogether 857 healthy day-care children (mean age, 3.7 years) were followed up for 3 months, and the symptoms of each child were compared during upper respiratory infections with and without acute otitis media., Results: A total of 138 children had upper respiratory infections with and without acute otitis media. The symptom with the strongest association with acute otitis media was earache [relative risk (RR), 21.3; 95% confidence intervals (CI), 7.0 to 106, P < 0.0001] but sore throat (RR = 3.2; CI = 1.1 to 11; P = 0.027), night restlessness (RR = 2.6; CI = 1.1 to 6.9; P = 0.024) and fever (RR = 1.8; CI = 1.1 to 3.2; P = 0.025) also had significant associations. Logistic regression analysis showed 71% of the cases to be correctly diagnosed on the basis of the symptoms of earache and night restlessness. The parents were able to predict the presence of acute otitis media with a sensitivity and specificity of 71 and 80%, respectively (positive predictive value, 51%; negative predictive value, 90%)., Conclusions: Despite the limited value of symptoms in differentiating acute otitis media from upper respiratory infection, the parents are able to predict acute otitis media somewhat reliably. More symptoms than have been reported earlier appeared to be associated with acute otitis media.

Objective: To determine the efficacy of intranasally administered immunoglobulin in preventing symptoms of rhinitis in children., Methods: Forty children ages 1 to 4 years who attended day-care centers in Turku, Finland, were enrolled in the double blind, placebo-controlled study. The children were randomly assigned to receive treatment with immunoglobulin, composed mainly of immunoglobulin A, or placebo, both administered as nasal sprays twice daily for 8 weeks. During this medication period and an additional 8-week follow-up period, the parents recorded the symptoms of the children daily in the diaries provided. One child who met an exclusion criterion was withdrawn from the study after a few days of medication., Results: During the 8-week medication period the 19 children in the immunoglobulin group had 42% fewer days with rhinitis than the 20 children receiving placebo (mean, 10.8 vs. 18.7 days; P=0.004). The total numbers of episodes of rhinitis in the immunoglobulin and placebo groups were 33 and 51, respectively. No significant differences were observed between the groups during the postmedication follow-up period., Conclusions: Intranasal administration of immunoglobulin appears to be an effective method to prevent symptoms of rhinitis in children, and further studies of this approach are needed.

Objective: To assess the effects of early recurrent otitis media on linguistic development in children. We especially wanted to determine the possible significant consequences of early recurrent otitis media at school age., Methods: We collected data retrospectively on recurrent otitis media episodes from the parents of 394 children in 18 school classes selected at random in a middle-sized city in Finland. Auditory comprehension was tested with a subtest of the Illinois Test of Psycholinguistic Ability, picture vocabulary with the Peabody Picture Vocabulary Test (revised test version), morphologic competence with a Finnish Morphological Test and reading comprehension with a test designed for this purpose., Results: Children with more than four otitis episodes before the age of 3 years performed less well in the reading comprehension test (P = 0.01 to 0.02) than children with fewer otitis media episodes. Multiple regression analysis adjusted for the confounding variables showed early otitis media to be associated with impaired reading comprehension test scores (regression coefficient -0.1245, 95% confidence interval -0.2245 to -0.0245, P = 0.01), which also correlated significantly with the teachers' evaluation of the student's reading comprehension (Spearman rank correlation r = 0.5, P < 0.01). Otitis episodes after the age of 3 years were not associated with abnormal test results., Conclusion: Middle ear disease in infancy had a significant adverse effect on reading comprehension as late as 9 years of age, even among children whose acute episodes were effectively treated.

Background: It is difficult to obtain reliable date on the rate of adverse reactions caused by drugs in general use. Yet it would be important to compile data on adverse reactions to long-term antimicrobial therapy., Methods: A sample of 1607 girls and 218 boys from 16 409 children younger than 16 years who had received long term antimicrobial therapy for recurrent urinary tract infections during 1976 to 1985 was analyzed with regard to adverse reactions., Results: Altogether 5066 courses of treatment were given to female patients and 607 to male patients. Adverse reactions were reported in 589 courses of the 5673 (10.4%), and 463 courses (8.2%) were discontinued because of adverse reactions. None of the patients had serious life-threatening reactions, and none of those receiving nitrofurantoin had pulmonary problems. The most common adverse reactions associated with the use of nitrofurantoin were nausea and vomiting (rate, 4.4/100 person years at risk; 95% confidence interval, 3.4 to 5.4), whereas sulfonamides caused most commonly allergic skin reactions (rate, 4.6; 95% confidence interval, 3.2 to 6.5). Patients younger than the age of 2 years receiving nitrofurantoin had adverse reactions more often than those who received sulfonamides, but in the age group 2 to 15 years sulfonamides caused adverse reactions leading to discontinuation of treatment more often than did nitrofurantoin of treatment the adverse reactions occurred during the first 6 months of treatment., Conclusions: We found nitrofurantoin and sulfonamides to be safe drugs for use in long term preventive antimicrobial therapy.

To analyze the effects of quinolones on growth and joints in children we identified 78 patients who had been receiving nalidixic acid for 116 days on the average (range, 3 to 570 days) from a random sample of 3094 of 16,409 children treated with long term medication because of recurrent urinary tract infection. Two controls per each index case, matched for sex and the age at which the first medication for recurrent urinary tract infection occurred, were chosen. Frequency of joint symptoms and examinations or possible treatments for arthropathies were similar in the index (n = 44) and control (n = 62) cases. Detailed growth data were analyzed from 39 case-control pairs after the mean follow-up time of 19.6 years (range, 14.8 to 24.7 years), and no growth disturbances were found. The final heights (age, > 18 years) of the index and control cases were similar (n = 31 case-control pairs). We conclude that nalidixic acid does not cause arthropathies or hamper growth in children, which supports the suggestion that at least short treatment periods with quinolones are safe.

Although the symptoms of the acutely ill child are important both in the diagnosis and follow-up of acute otitis media (AOM), data about them are quite limited. We carried out a prospective survey by collecting information on 354 consecutive children visiting a pediatrician, otolaryngologist or general practitioner because of any kind of acute symptoms to compare symptoms of children with acute otitis media with those of children with other acute infectious diseases. The symptoms and signs observed at home were recorded by the parents before the visit and the findings in the physical examination were recorded later by the physician. AOM was diagnosed in 191 patients (54.0%). The most important symptoms increasing the likelihood of AOM significantly were ear-related symptoms, such as earache (relative risk (RR) 5.4; P < 0.001), rubbing of the ear (RR 5.0; P < 0.001) and feeling of blocked ear (RR 4.5; P < 0.05). However, only 67.7% of children younger than 2 years of age with AOM had any ear-related symptoms. The children with tympanostomy tubes had earache (47.8%) and rubbing of the ear (58.8%) of the same magnitude as did children without tubes. Rhinitis increased the likelihood of AOM (RR 2.3; P < 0.001) as did excessive crying in children older than 2 years of age (RR 3.0; P < 0.001). Fever, earache or excessive crying was present in 90.1% of patients with AOM but also in 72.4% of patients without AOM.(ABSTRACT TRUNCATED AT 250 WORDS)

The efficacy of imipenem-cilastatin was compared with that of tobramycin and metronidazole for the treatment of appendicitis-associated abdominal infections in children in an open, randomized trial. Two hundred eighteen patients between 2.5 and 16.8 years of age hospitalized for appendectomy because of suspected acute appendicitis were allocated to 5 treatment groups. The appendix was perforated in 54 (33.8%) of the 160 cases with appendicitis. All patients responded favorably to treatment. Infection in the wound occurred in 15 of 125 (12.0%) of those without preoperative antibiotic therapy and in 5 of 83 (6.0%) of those given imipenem preoperatively (P = 0.12; 95% confidence interval, -2.2 to 14.2%). C-reactive protein decreased significantly faster in those with perforated appendix treated with imipenem than in those treated with tobramycin and metronidazole (58.2 mg/liter vs. 89.4 mg/liter, P less than 0.05 on the third postoperative day). Imipenem-cilastatin was at least as effective and economically comparable as tobramycin and metronidazole for the treatment of appendicitis-associated infections in children.

Existing data on tularemia infections in children caused by the biovar Francisella tularensis palaearctica (type B) are limited. The case histories of all patients younger than the age of 16 years in northern Finland who had tularemia, based on the antibody response, during the years 1967 to 1986 are reviewed. A total of 67 children, 28 girls and 39 boys, were identified as having had tularemia. The occurrence of the disease varied greatly among years. Most of the cases occurred in July, August and September. The epidemiology differed significantly from that reported for F. tularensis biovar tularensis (type A). This is most probably attributable to the different vector, which was the mosquito in our series, but the tick in areas where type A is common. There were also clear differences in the clinical picture. The ulceroglandular clinical type was the most common. The clinical symptoms and signs were usually quite benign, but the symptoms lasted for a median duration of 26 days. The patients were treated with different antibiotics and there were no differences in the outcome related to the treatment given. Prospective comparative investigations of antibiotic therapy given for tularemia are needed. It is also important to try to identify which strain is causing the disease in each case.

The occurrence of childhood encephalitis was evaluated in a population-based study in an area with no arboviral infections. Ninety-five children were treated for encephalitis during 1973 to 1987, giving an annual incidence of 8.8/100,000 children younger than 16 years of age (95% confidence interval, 6.7 to 10.1). Based on virologic and serologic studies the most common etiologic agents were varicella (24 cases), mumps (8), herpes simplex (7) and measles (4). The etiology remained unknown in 37 children. No cases of encephalitis caused by mumps, measles or rubella were found in the population after 1982, when vaccination against these viruses was introduced.

Acute phase and convalescent sera from 51 pediatric patients who had a documented viral infection and no obvious culture-confirmed bacterial infection such as meningitis, otitis media or urinary tract infection were tested by enzyme immunoassay for antibodies to Haemophilus influenzae and Branhamella catarrhalis and by the latex agglutination test for pneumococcal antigens to evaluate the frequency of mixed bacterial and viral infections. A mixed bacterial and viral infection was documented in 19 patients (37%). Seven patients (14%) showed a diagnostic rise in antibodies to H. influenzae and 8 patients (16%) showed an antibody elevation to B. catarrhalis in their paired sera; pneumococcal antigen was detected in acute phase serum from 4 patients (8%). The rate of mixed infections in patients having respiratory symptoms was 52%. High serum C-reactive protein values and white blood cell counts were found significantly more often in those with mixed infections than in those who had viral infections. The results indicate that mixed bacterial and viral infections occur more frequently in children than one could anticipate on the basis of the earlier reports. Mixed bacterial and viral etiology is highly probable in a child who has a defined viral infection with high C-reactive protein and white blood cell count values, especially in the presence of respiratory symptoms.