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A Bacteria
30 to 40 mg/kg per day (which can be reduced by half after 3 days of therapy), and gentamicin is given every 8 hours and can be administered intramuscularly or intravenously. A JarischHerxheimer reaction has been described at the outset of streptomycin treatment of tularemia.9 Ciprofloxacin given for 10 to 14 days (or possibly imipenem-cilastatin) is the best alternative to aminoglycosides or is used after relapse with aminoglycoside therapy.32,33 Although ciprofloxacin is not approved for treatment of children with tularemia, it has been used successfully to treat 12 infected children.33 Treatment with tetracycline or chloramphenicol results in a prompt clinical response, but these agents are not bactericidal and relapse occurs in at least half of patients after cessation of therapy. A limited number of cases of pneumonia have been treated successfully with erythromycin.9 In vitro susceptibility does not necessarily predict clinical efcacy. F. tularensis is susceptible to third-generation cephalosporins in vitro, but all of 8 children treated with ceftriaxone failed to improve, indicating that this therapy is ineffective.34 In one pediatric series, late suppuration after antibiotic therapy was noted in 33% of children. In these cases, the aspirate or excised material was sterile.8 The mortality rate for tularemia is less than 3%.8,9 In Finnish patients infected with F. tularensis subsp. holarctica (type B) organisms, the impact of antibiotics on the clinical course was uncertain.10 By in vitro susceptibility testing, strains are susceptible to tetracyclines, aminoglycosides, quinolones, chloramphenicol, and rifampin. Strains are generally resistant to b-lactam antibiotics, carbapenems, aztreonam, and macrolide antibiotics.35,36

typhoidal (30% to 80% of cases) or ulceroglandular (10% to 15% of cases) infections. A case of fever and a pulmonary nodule secondary to F. tularensis has been reported in a stem cell transplant recipient.

Occasional Sites
Rare manifestations of infection have included subcutaneous nodules resembling sporotrichosis, meningitis with a mononuclear cell predominance and hypoglycorrhachia,23 encephalitis, pericarditis, endocarditis, peritonitis, and osteomyelitis.9 A variety of rashes, including maculopapular, pustular, and erythema nodosum, have been seen.

LABORATORY FINDINGS AND DIAGNOSIS

Gram-stain smears prepared from exudate or tissue sections rarely show weakly staining gram-negative coccobacilli in an extracellular or intracellular location. An indirect immunofluorescent antibody test can be performed with commercially available antisera. The histopathology of affected lymph nodes shows follicular hyperplasia with conglomerates of macrophages, epithelioid cell granulomas, and caseating necrosis, ndings similar to those seen in tuberculosis15 or Bartonella infection. A polymerase chain reaction assay to detect bacterial DNA in clinical specimens such as swabs of ulcers showed good sensitivity and excellent specicity.24,25 Culture of F. tularensis is not routinely performed in clinical laboratories because of the potential for aerosol inhalation and infection of laboratory personnel. Additionally, specimens should be collected cautiously and the laboratory notied when specimens suspected of harboring F. tularensis are submitted. Biosafety level 2 is recommended for clinical laboratory work and transfer of cultures to biosafety level 3 as soon as F. tularensis is suspected.26 An enriched medium such as cystine-glucose blood agar, chocolate agar, or buffered charcoal yeast extract agar (used for culture of Legionella ) incubated aerobically is required for isolation of F. tularensis from clinical specimens.26 F. tularensis has been isolated using radiometric or nonradiometric blood culture techniques.27 Colonies are blue-gray, round, smooth, and slightly mucoid, and they usually exhibit a small surrounding zone of a-hemolysis. Direct isolation can be achieved from ulcer scrapings, lymph node biopsy specimens, gastric washings, sputum, and occasionally, culture of blood with a radiometric technique. Inoculation of laboratory animals such as mice or rabbits is a sensitive means of isolation of F. tularensis but is no longer used routinely for diagnosis. The laboratory diagnosis of tularemia is most often conrmed by serologic testing. Antibodies are generally detectable at the end of the second or during the third week of illness. A fourfold increase or decrease in titer using a serum agglutination test is diagnostic; a single titer of > 1:160 by tube agglutination or > 1:128 by microagglutination is a presumptive positive result.26 Infected patients can have convalescent titers > 1:1000 and a prozone phenomenon can be observed. Nonspecic cross-reactions can occur in patients infected with bacteria from the genus Brucella. The microagglutination assay is more sensitive than the tube agglutination test.28 An enzyme immunoassay using lipopolysaccharide antigens and immunoblot conrmation29 or outer-membrane proteins30 is highly sensitive. Assay for immunoglobulin M (IgM) antibodies is not useful because IgM antibodies are not present earlier than IgG antibodies and can persist for years.26,30 Empiric antimicrobial therapy must often be initiated before serologic conrmation of infection is possible.

PREVENTION
The key to preventing tularemia is interruption of transmission, which can be achieved by prevention or timely detection of tick bites, avoidance of handling sick or dead rabbits or rodents, use of rubber gloves to handle game meat, and thorough cooking of meat. An investigational live-attenuated vaccine given pre-exposure using a multiple puncture technique partially protects against inhalation tularemia, but its use in the United States has been limited to research personnel with exposure to F. tularensis. This vaccine prevents respiratory tract infection in laboratory personnel but has not prevented ulceroglandular infection.2,16,37 A 14-day course of doxycycline or ciprofloxacin has been recommended for prophylaxis of exposed persons following an intentional aerosol release of organisms or exposure in a laboratory.22

CHAPTER

17 2

Haemophilus Influenzae
Joseph W. St. Geme III

TREATMENT
A 7-day course of streptomycin, gentamicin,31 or amikacin is the treatment of choice for tularemia and is expected to produce defervescence within a few days and is associated with a low relapse rate.5 Streptomycin is given intramuscularly twice daily at a dose of

Haemophilus influenzae was rst isolated by Peffer during the 1889 influenza pandemic.1 For a time, H. influenzae was believed to be the causative agent of influenza and was originally called the influenza bacillus. However, subsequent studies demonstrated the fallacy of this notion, and the organism was ultimately given the genus name Haemophilus, meaning blood loving. The species name was chosen to reflect the historical association with influenza. In 1995, the nucleotide sequence of the entire genome of H. influenzae strain Rd KW20 was published, representing the rst organism to be sequenced completely. The annotated sequence of this strain is available at http://www.tigr.org. More recently, a number of additional clinical isolates have been sequenced.2

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THE PATHOGEN
H. influenzae is a nonmotile, nonspore-forming, gram-negative bacterium and typically appears as small coccobacilli, roughly 1 0.3 mm in size. On occasion, however, organisms grow as long laments. H. influenzae can grow aerobically or anaerobically. Aerobic growth requires two supplements known as factors X and V, whereas anaerobic growth requires only factor X. Factor X can be supplied by heatstable iron-containing pigments, including hemin and hemoglobin, both of which represent a source of protoporphyrin IX. Factor V can be supplied by nicotinamide adenine dinucleotide, nicotinamide adenine dinucleotide phosphate, or nicotinamide nucleoside. Factor V is present in erythrocytes but must be released to sustain growth; as a consequence, standard blood agar is an unsatisfactory medium for propagating H. influenzae. Optimal growth is achieved on media enriched with erythrocytes that have been disrupted by heating (e.g., chocolate agar) or by peptic digestion (e.g., Fildes medium). Incubation in the presence of 5% to 10% carbon dioxide has a benecial effect on the growth of some strains and is thus recommended for primary isolation. Isolates of H. influenzae are classied according to their polysaccharide capsule.3 As detailed in Table 172-1, six structurally and antigenically distinct capsular types (serotypes) designated a through f exist. In addition, strains can be nonencapsulated; these strains are dened on the basis of their failure to react with typing antisera against capsular serotypes a through f and are referred to as nontypable. Worldwide, most clinical isolates are either type b or nontypable.4,5 Isolates also can be separated into subgroups called biotypes by using biochemical tests that determine the production of indole and the presence of ornithine decarboxylase and urease.6 These reactions dene eight biotypes designated I through VIII (Table 172-2). Data generated from biotyping studies indicate that type b isolates are predominantly biotype I.7 Nontypable strains also can be biotype I but in most collections are more often biotype II or III.8 Clinical isolates

that are biotypes IV through VIII are relatively uncommon and almost always nontypable. In recent years multilocus enzyme electrophoresis and a variety of other molecular techniques have been used to examine isolates of H. influenzae. Studies using multilocus enzyme electrophoresis demonstrate that the population structure of encapsulated H. influenzae is clonal, with most isolates falling into a few common clonal groups.9 Nontypable strains are genetically distinct and more heterogeneous than encapsulated H. influenzae and appear to lack clonality.10

EPIDEMIOLOGY
In the past, H. influenzae type b (Hib) strains were found in the upper respiratory tract of 3% to 5% of children and a small percentage of adults. In general, colonization rates with type b strains are even lower now because of routine immunization of infants with conjugate Hib vaccines, although exceptions exist.11 Non-type b encapsulated H. influenzae stains are present in the nasopharynx of < 2% of individuals, whereas nontypable strains colonize the respiratory tract of 40% to 80% of children and adults.12 Until approximately 1990, Hib was the leading cause of bacterial meningitis in children younger than 5 years in the United States, accounting for 8000 to 10,000 cases per year.13 Hib also was the predominant etiology of epiglottitis and a major cause of pyogenic arthritis, pneumonia, pericarditis, and facial cellulitis in young children. Approximately 1 in 200 children in the United States experienced invasive (bacteremic) disease with this organism before the age of 5 years, with a peak incidence at 6 to 7 months of age. Invasive disease was more frequent in boys, African Americans, Alaskan Eskimos, Apache and Navajo Indians, childcare center attendees, and children living in overcrowded conditions.1418 Medical conditions predisposing to invasive Hib disease included sickle cell disease, asplenia, human immunodeciency virus (HIV) infection, certain immunodeciency syndromes, and malignancies. Since 1990, the incidence of invasive Hib disease in the United States has fallen by over 95%, with a minority of cases now occurring in young children.1922 Of note, in some developed countries there has been a modest resurgence of cases in recent years.23,24 Despite the overall successful reduction in invasive Hib disease in the United States and other industrialized countries, Hib remains an important pathogen in developing countries, where routine vaccines still are not available to most of the population. In these countries, Hib remains the leading cause of bacterial meningitis and the second leading cause of bacterial pneumonia, with up to 500,000 deaths per year in children younger than 5 years.25 A recent meta-analysis of Hib-related medical reports from 75 countries estimated that vaccine use by a total of 38 countries has resulted in only a 5.7% decrease worldwide in Hib meningitis and roughly a 2% decrease worldwide in all Hib-related diseases, including pneumonia.5 These gures reflect the current lack of availability of vaccine in approximately 90 countries, most notably populous nations in Asia and Africa, where more than 118 million children remain unimmunized. Nontypable strains of H. influenzae are a common cause of localized respiratory tract disease in both children and adults.26,27 In children, these organisms are the most common cause of purulent conjunctivitis, the most common or second most common cause of otitis media, and a frequent etiology of sinusitis. In children in developing countries, they are a frequent cause of pneumonia and an important source of mortality. In adults, nontypable H. influenzae is an especially common etiologic agent of community-associated pneumonia and exacerbations of underlying lung disease and also accounts for a substantial fraction of cases of otitis media and sinusitis. Beyond producing localized disease, nontypable H. influenzae is an occasional cause of serious systemic disease such as septicemia, meningitis, and pyogenic arthritis, especially in neonates and individuals with compromised immunity.28,29 Disease by non-type b encapsulated strains occurs occasionally, particularly in underdeveloped countries. For example, among children in Papua New Guinea, roughly one quarter of H. influenzae

TABLE 172-1. Chemical Composition of the Capsule of Haemophilus influenzae

Type a b c d e f Sugar Glucose Ribose, ribiol Galactose Hexose Hexosamine Galactosamine

N-Acetyl
+ +

Phosphate + + + + + +

TABLE 172-2. Haemophilus influenzae Biotypes

Biotype I II III IV V VI VII VIII Indole + + + + Urease + + + + Ornithine Decarboxylase + + + +

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and facilitates phagocytosis by opsonization.59 Based on studies performed in the pre-Hib vaccine era, during the rst 3 to 6 months of life, most infants have protective levels of maternally acquired anticapsular antibody. These levels gradually decline, reach a nadir by 6 to 12 months of age, and remain low for the next few years. By the age of 5 years, virtually all individuals have acquired anticapsular antibody,60,61 in some cases as a result of colonization with Hib and in others probably from exposure to commensals (e.g., Escherichia coli K100) or ingested food possessing cross-reactive epitopes.62 Antibodies to noncapsular antigens such as LPS and outer membrane proteins also contribute to serum bactericidal and opsonic activity.63,64 A number of investigators have examined the immune response to infection with Hib. At the time of infection, serum antibodies against the serotype b capsule are low or absent. In children younger than 2 years, levels remain low during convalescence65 because of an agerelated deciency in the ability to respond to polysaccharide antigens (T-lymphocyte-independent antigens). In older children, infection stimulates a brisk increase in the level of anticapsular antibody. Natural infection also is associated with the formation of antibodies to LPS and surface-associated proteins, and these antibodies contribute to protection against recurrent Hib disease. The complement system is critical in host defense against Hib disease, and patients with congenital deciencies of certain complement components, including C2, C3, and C4, have increased susceptibility to Hib disease.66 Type b organisms are capable of activating both the classic and the alternate complement pathways.66, 67 Early in the course of infection in nonimmune hosts, the alternate pathway probably is more important, whereas at later stages, the antibodydependent classic pathway is more likely to predominate. Clearance of bacteremia with type b organisms also requires an intact mononuclear phagocytic system, thus explaining the higher incidence of Hib bacteremia in patients with splenic dysfunction. Immunity to nontypable organisms involves both systemic and local antibody responses. Moreover, evidence suggests that systemic priming functions to enhance the local response. Based on studies of patients with otitis media and bronchitis, it appears that the immune response to nontypable H. influenzae often is strain specic. For example, Faden and colleagues observed a population of children prospectively for 2 years and identied 8 subjects who experienced 2 separate episodes of acute otitis media from nontypable H. influenzae.68 In all 8 patients, the second episode was caused by a different strain. Serum was collected from 6 of these patients at the time of the second episode and was found uniformly to contain bactericidal antibody against the rst strain. However, only 3 of these 6 samples possessed measurable bactericidal antibody against the second strain, thus indicating the absence of cross-reacting bactericidal activity. Consistent with these ndings, Musher and associates found that adsorption of normal human serum with nontypable H. influenzae removed bactericidal activity against the adsorbing isolate but not necessarily against other nontypable strains.69 Major targets of the antibody response to infection include the P2 major outer membrane protein, the high-molecular-weight (HMW) and Hia adhesins, and LPS. Recent evidence indicates that the P6 outer membrane protein is a potent and selective inducer of macrophages and proinflammatory cytokines.70

isolates associated with acute lower respiratory tract infection and approximately 15% of isolates associated with meningitis are nontype b encapsulated strains.30,31 Based on recent reports, in the United States systemic disease attributable to H. influenzae type f is increasing in frequency and is fatal in roughly 20% of children and 30% of adults.32,33 Two hospital-based studies reinforce this point and suggest an increase in the number of serotype e isolates as well.34,35 The annual incidence of invasive H. influenzae type a disease among Navajo and White Mountain Apache children also is appreciable, with approximately 20 cases per 100,000 population under 5 years of age.36

PATHOGENESIS
Generally, H. influenzae is transmitted by airborne droplets or by direct contact with respiratory tract secretions. Colonization with a particular strain can persist for weeks to months, and most individuals remain asymptomatic throughout this period.37 A variety of bacterial factors appear to influence the process of respiratory tract colonization. For example, the lipid A component of H. influenzae lipopolysaccharide (LPS), peptidoglycan fragments, and a surface-associated glycerophosphodiester phosphodiesterase called protein D or GlpQ (which allows choline to be transferred from the host to the bacterial surface) cause ciliostasis and thereby interfere with mucociliary clearance.3841 In addition, both pilus and nonpilus adherence factors exist and are known to mediate binding to mucus and to respiratory epithelium.4245 Like other mucosal pathogens, H. influenzae produces IgA1 protease, an enzyme that cleaves human IgA1 and presumably facilitates evasion of the local immune response.46 Bacterial antigenic variation, entry into host cells, penetration between host cells (paracytosis), and biolm formation may also promote evasion of local immunity.4754 In certain circumstances, colonization is followed by contiguous spread within the respiratory tract, resulting in local disease in the middle ear, sinuses, conjunctiva, or lungs (Figure 172-1). Anatomic factors, deciencies in local immune function, viral respiratory infection, exposure to cigarette smoke, and allergies predispose to localized respiratory tract disease.26 On occasion, bacteria penetrate the nasopharyngeal epithelial barrier and enter the bloodstream (see Figure 172-1). The determinants of this event remain poorly dened but may include bacterial LPS.55 Of note, penetration of the epithelial barrier appears to involve the separation of tight junctions, which allows bacteria to migrate between cells and into the subepithelial space.56 In most cases, the bacteremia is probably transient. However, in nonimmune hosts, intravascular bacteria that express the type b capsule are sometimes able to survive, replicate, and disseminate to distant sites. In the absence of specic antibody, the type b polysaccharide capsule promotes resistance to serum bactericidal activity and to phagocytosis.

IMMUNITY
The age-associated susceptibility to Hib disease is inversely related to the presence of serum bactericidal antibody,57 much of which is directed against the type b polysaccharide capsule.58 Antibody against the type b capsule activates complement-mediated bacterial killing
Acquisition

CLINICAL MANIFESTATIONS

Haemophilus influenzae Type b Infection

Nasopharynx Contiguous spread Respiratory tract disease Clearance Translocation into blood Systemic disease

Meningitis
Meningitis is the most common and most serious form of Hib disease. Symptoms typically include fever, irritability, lethargy, and vomiting. Antecedent symptoms of an upper respiratory tract infection are common. Occasionally, the course is fulminant, with rapid neurologic deterioration leading to respiratory arrest.71 Shock is present in 20% of cases of meningitis and can be associated with coagulopathy and purpura.72 An association of Hib meningitis and anemia is clear and

Figure 172-1. Pathogenic sequence for disease caused by Haemophilus influenzae.

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appears to be related, at least partly, to adsorption of capsular antigen to the red cell surface with secondary immune-mediated hemolysis.73 Complications of Hib meningitis include subdural effusion or empyema, ischemic or hemorrhagic cortical infarction, cerebritis, ventriculitis, intracerebral abscess, and hydrocephalus. The overall mortality rate is approximately 5%. Among survivors, between 5% and 10% have permanent sensorineural hearing loss, and about 30% have some other signicant handicap. If subtle neurologic decits are sought, up to one half of survivors have sequelae.7476

Epiglottitis
Epiglottitis is a life-threatening infection involving cellulitis of the epiglottis and the aryepiglottic folds. Complete obliteration of the vallecular and piriform sinuses is typical, and acute airway obstruction can occur. Most affected children are between 2 and 7 years of age. Symptoms often are sudden in onset and classically include high fever,

sore throat, stridor, and dyspnea progressing rapidly to dysphagia, pooling of secretions, and drooling. In children younger than 2 years, the fever can be low grade and a croup-like cough can be present; in addition, dysphagia and drooling sometimes are lacking. Regardless of age, the patient usually is restless and anxious and adopts a sitting position with the neck extended and the chin protruding to reduce airway obstruction. Abrupt deterioration can occur within a few hours and result in death unless an articial airway is established. Direct laryngoscopy at the time of controlled placement of an endotracheal tube reveals a red and swollen epiglottis and swollen aryepiglottic folds (Figure 172-2A,B). On a lateral neck radiograph, the swollen epiglottis produces the so-called thumb sign (see Figure 172-2C).

Pneumonia
Patients with Hib pneumonia typically have a consolidative pulmonary inltrate. In 50% of cases, evidence of pleural involvement can be

B
Figure 172-2. Clinical ndings in conrmed cases of Haemophilus influenzae type b epiglottitis. Direct laryngoscopic ndings of erythema and edema of the epiglottis in a 4-year-old child (A). Gross specimen from a fatal case shows erythema and edema predominantly of arytenoids structures (arrows) and aryepiglottic folds (B). Lateral neck examination. Lateral neck radiograph in another case shows thumb-print appearance (arrow) of the swollen epiglottis (C). (Courtesy of S. S. Long.)

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seen on the initial chest radiograph, and up to 90% of these patients have pleural fluid recoverable by thoracentesis. Generally, Hib pneumonia is more insidious in onset than is pneumonia from Staphylococcus aureus or Streptococcus pneumoniae. Nearly one quarter of patients have concomitant meningitis or epiglottitis. An important complication is contiguous spread to the pericardium and subsequent purulent pericarditis, which is manifest as severe dyspnea (grunting in infants), tachycardia, and cardiac failure. Although patients with Hib pneumonia often have a persistent pleural reaction with secondary restrictive lung function at the time of hospital discharge, long-term abnormalities are rare.

INFECTION DUE TO NONTYPABLE HAEMOPHILUS INFLUENZAE Respiratory Tract Infection

Studies examining the bacteriology of acute otitis media (AOM) consistently demonstrate H. influenzae as the most common or second most common pathogen.8183 Among H. influenzae isolates, > 90% are nontypable. According to studies reported from the United States and Scandinavia, the peak age-specic incidence of H. influenzae AOM occurs between the ages of 6 and 15 months.84,85 Characteristic manifestations include ear pain, fever, irritability, sleep disturbance, and otorrhea. On examination, the tympanic membrane is usually red or yellow and bulging, with distorted landmarks. Pneumatic otoscopy reveals decreased mobility, indicative of middle ear fluid. In addition to producing AOM, nontypable H. influenzae is the pathogen implicated most commonly in otitis media with effusion and accounts for > 40% of cases with positive tympanocentesis cultures.86,87 Nontypable H. influenzae also has been associated with dual infection of the conjunctiva and the middle ear.88 These infections occur primarily during the winter months and have been termed the conjunctivitisotitis syndrome. Nontypable strains also are an important cause of isolated conjunctivitis (see Chapter 173, Other Haemophilus Species). Among individuals with acute sinusitis, S. pneumoniae and H. influenzae account for nearly three quarters of all bacterial isolates recovered,89 with most H. influenzae strains being nontypable. The majority of patients with sinusitis have persistent nasal discharge or cough that lasts longer than 10 days without improvement. Others present acutely with high fever and purulent nasal discharge. Physical examination often reveals tenderness over the involved paranasal sinuses. Data on the microbiology of chronic sinusitis are limited but suggest that nontypable H. influenzae is a prominent pathogen.90 Several studies have examined the predictive value of surface cultures of the nose, throat, or nasopharynx in patients with acute or chronic sinusitis. Although the organisms isolated from direct aspiration of infected sinuses generally are recovered from surface cultures, they are not consistently the predominant organisms. As a result, surface cultures are of minimal value in establishing an etiologic agent. Because sputum frequently is contaminated by pharyngeal bacterial flora, interpretation of the growth of H. influenzae from sputum culture is difcult. However, substantial evidence exists that nontypable H. influenzae causes bacterial pneumonia, especially in children in developing countries, the elderly, and patients with underlying lung disease. Among children in developing countries with clinical evidence of pneumonia, lung aspiration studies demonstrate that bacteria can be recovered more than 60% of the time; up to half of these isolates are nontypable H. influenzae.91

Osteoarticular Infection
Historically, Hib was the most common cause of pyogenic arthritis in children younger than 2 years,77 with a single large weight-bearing joint (hip, knee, or ankle) involved usually. In 10% to 20% of cases, contiguous osteomyelitis is present. Osteomyelitis alone is unusual. The response to systemic antibiotics combined with prompt drainage of the joint is dramatic, but long-term follow-up is important because residual joint dysfunction can occur. On occasion, culture-negative arthritis develops during treatment of H. influenzae meningitis, presumably as a result of immune complex deposition in the joint.78 In 75% of patients with reactive arthritis, signs of joint inflammation begin 1 week or more after therapy is begun.

Bacteremic Cellulitis
Cellulitis is the result of a metastatic focus of bacteremia and is seen predominantly in young children. Typically, the patient is febrile and has a warm, tender area of erythema or violaceous discoloration on the cheek or in the periorbital area. Facial (buccal) cellulitis almost invariably occurs in children younger than 1 year. The age of the child, the location of the cellulitis, and the occasional distinctive violaceous color should suggest the etiology (Figure 172-3). Aspirate cultures, either from the center of the lesion or the leading edge, usually yield the organism. Concomitant bloodstream infection (BSI) generally is present, and another focus of infection, for example, meningitis, develops in approximately 10% of children.79,80 Cellulitis that occurs as a complication of trauma to the skin is not caused by H. influenzae.

Other
Other manifestations of Hib disease include occult BSI (which infrequently is self-limited or benign), otitis media, orbital cellulitis, endophthalmitis, urinary tract infection, and peritonitis. In addition, purulent pericarditis can result from direct seeding from BSI.

Meningitis
Nontypable H. influenzae is an occasional cause of meningitis and, unlike Hib, usually spreads by direct extension from a contiguous focus of infection. Most individuals with nontypable H. influenzae meningitis have a predisposing factor, such as sinusitis, otitis media, or head trauma, or another anomaly resulting in cerebrospinal fluid (CSF) leak. In patients with recurrent bacterial meningitis, nontypable H. influenzae is the second most common cause, after S. pneumoniae; patients commonly have communication between a parameningeal site and the subarachnoid space.92

Neonatal Infection
Nontypable H. influenzae is a well-recognized neonatal pathogen.9397 (Non-type b encapsulated strains occasionally also have been implicated in this setting.) In most cases, H. influenzae produces an early-onset neonatal syndrome similar to that caused by group B streptococci. Disease occurs primarily in premature neonates and is associated with a mortality rate of nearly 50%. Symptoms develop in most infants within the rst few hours of life, with pneumonia and

Figure 172-3. Buccal cellulitis in a 14-month-old girl whose blood culture yielded Haemophilus influenzae type b. Note distinctive site of cellulitis on the lower cheek and violaceous color. (Courtesy of S. S. Long.)

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respiratory distress dominating the clinical picture. Meningitis occurs infrequently. H. influenzae usually can be isolated from the genitourinary tract of mothers of infected infants, often in association with maternal postpartum endometritis. Paired maternal-infant isolates have been conrmed to be the same strain by a variety of methods.98,99 Studies have indicated that a large percentage of these isolates are biotype IV, a subgroup of nontypable H. influenzae found uncommonly at other sites of infection.95 Analysis of these biotype IV strains by multilocus enzyme electrophoresis indicates divergence from other H. influenzae, and chromosomal DNA hybridization studies and 16S rRNA gene sequencing suggest that these strains represent a distinct Haemophilus species most similar to H. haemolyticus,100,101 leading to the designation genospecies of Hemophilus.

Other
Nontypable H. influenzae has been reported rarely as a cause of endocarditis, pericarditis, pyogenic arthritis, osteomyelitis, epiglottitis, cellulitis, urinary tract infection, intra-abdominal infection, and occult BSI.26

DIAGNOSIS
Consideration of the diagnosis of meningitis, epiglottitis, pneumonia, pyogenic arthritis, or cellulitis is usually prompted by the history and physical examination. In most cases of invasive Hib disease, blood cultures are positive. When meningitis is present, bacteria almost always can be recovered from CSF. In patients with epiglottitis, culture of the epiglottis usually is positive, but specimens should be obtained only after establishment of an articial airway. H. influenzae is often cultivated from samples of pleural fluid, joint fluid, or pericardial fluid in affected patients. In roughly 70% of patients with H. influenzae meningitis, Gram stain of the CSF is positive for gram-negative coccobacilli. The sensitivity of CSF Gram stain correlates with bacterial density and ranges from 0% in the presence of < 103 colonyforming units per milliliter to nearly 100% when the density is > 105 or more colony-forming units per milliliter.102 (The sensitivity of Gram stain is higher when CSF is cytocentrifuged.) Type b capsular polysaccharide is secreted during bacterial growth, and detection of capsular antigen can aid in diagnosis. Methods available for this purpose include latex particle agglutination, coagglutination, countercurrent immunoelectrophoresis, and enzyme immunoassay. Serum, CSF, urine, and other normally sterile body fluids are suitable for examination for capsular antigen. Antigen detection techniques are most valuable in patients who have previously received antibiotic therapy and have sterile cultures. In addition, they may be useful to conrm a diagnosis before bacterial growth is appreciated in the clinical laboratory, thus allowing for earlier chemoprophylaxis of contacts. In cases of culture-proven meningitis, capsular antigen is detected roughly 90% of the time in CSF and even more frequently in concentrated urine. False-positive reactions occur occasionally as a result of cross-reactivity with E. coli, S. pneumoniae, staphylococci, or meningococci. Of note, Hib conjugate vaccines can produce positive reactions in urine and CSF for days to weeks after vaccination.103107 Because H. influenzae is a common commensal organism in the upper respiratory tract, establishing H. influenzae as an etiology of localized respiratory tract disease is challenging. Procedures such as tympanocentesis, sinus aspiration, tracheal or lung aspiration, bronchoscopy, and bronchoalveolar lavage can provide a denitive diagnosis, but these procedures generally are reserved for circumstances in which a specic microbiologic diagnosis is required, as in patients with persistent or recurrent infection or underlying immunodeciency.

some communities.108 Ampicillin should never be used alone as empiric therapy of invasive disease. Ampicillin resistance usually is related to plasmid-mediated production of b-lactamase, but occasionally it is due to decreased afnity of certain penicillin binding proteins. To detect both forms of resistance, a b-lactamase assay should be performed along with disk or broth-dilution susceptibility tests. The third-generation cephalosporins are the therapy of choice for H. influenzae meningitis. Both cefotaxime and ceftriaxone have potent activity against H. influenzae (including isolates that produce blactamase and those with altered penicillin-binding proteins) and achieve high levels in CSF. For infections outside the central nervous system, cefuroxime or ampicillin-sulbactam are effective as suitable alternatives. In patients with invasive H. influenzae disease, antibiotic therapy represents only one component of management. For patients with meningitis, optimal ventilation and judicious administration of fluid are important (see Chapter 42, Acute Bacterial Meningitis beyond the Neonatal Period). In addition, dexamethasone therapy in a dose of 0.15 mg/kg every 6 hours for the rst 2 or 4 days of treatment appears to decrease the risk of neurologic sequelae, including hearing decit.109111 Dexamethasone should be initiated before the rst dose of antibiotic whenever possible. Patients with epiglottitis require placement of an articial airway, and children with pneumonia often need treatment with supplemental oxygen. When pleural empyema, purulent pericarditis, or pyogenic arthritis is present, prompt drainage is essential to a good outcome. Otitis media and sinusitis are treated effectively with oral agents to which the organisms are susceptible. Table 172-3 shows comparative minimal concentrations inhibitory to 90% of organisms for selected oral antibiotics.

PREVENTION Vaccination
First-generation vaccines against Hib were puried type b capsular material, polyribosylribitol phosphate (PRP). These vaccines were not effective in children younger than 24 months and had variable efcacy in children 24 months and older.112,113 Second-generation vaccines, in which PRP or a derivative is conjugated to an immunogenic protein, have replaced the earlier vaccines and are effective in infants. Currently, three conjugate vaccines are licensed, all differing to some extent in the size of the polysaccharide, chemical linkage between the polysaccharide and the carrier, and the type of protein carrier114 (Table

TABLE 172-3. In Vitro Activity of Selected Oral Agents against Haemophilus influenzae
Antibiotic Cephalexin Cefaclor Cefprozil Cefuroxime Loracarbef Cefpodoxime Cexime Amoxicillin-clavulanate Trimethoprim-sulfamethoxazole MIC90 (mg/mL) 8 8 8 0.5 2 0.06 0.06 16 0.5 8 1

TREATMENT
Historically, ampicillin was effective therapy for invasive H. influenzae disease. However, resistance to ampicillin now is common in isolates of H. influenzae, with the incidence approaching 40% in

Clarithromycin Azithromycin
MIC, minimal inhibitory concentration.

898

SECTION

A Bacteria
on the age and immunization status of the attendees and the duration of daily contact between attendees and the index patient. In-home group childcare settings are managed like families. Treatment of the index case with cefotaxime or ceftriaxone eradicates Hib colonization, eliminating the need for prophylaxis in this individual. However, index patients who are treated with other agents (e.g., ampicillin or meropenem) and who are younger than 2 years of age or have a susceptible household contact should receive rifampin prophylaxis at the end of systemic treatment for invasive disease. Chemoprophylaxis also is a consideration in children who have recurrent otitis media from nontypable H. influenzae (or other typical pathogens). In this situation, chronic prophylaxis with either amoxicillin or sulsoxazole may be effective in reducing infectious episodes.

TABLE 172-4. Haemophilus influenzae Type b Conjugate Vaccines

Vaccine Trade Name Polysaccharide Linkage Thioether Protein Carrier Neisseria meningitidis outer membrane protein CRM197 mutant Corynebacterium diphtheriae toxin Tetanus toxoid

PRP-OMPa PedvaxHIB Medium

HbOC

HibTITER

Small

None

PRP-Ta

ActHIB

Large

6-Carbon

HbOC, oligosaccharide-CRM197 conjugate Haemophilus influenzae type b vaccine; OMP, outer membrane protein; PRP, polyribosylribitol phosphate. a Additional combination vaccines have been licensed that include these conjugate vaccines.

Passive Immunization
Although active immunization is the cornerstone of prevention of Hib disease, passive prophylaxis with anti-type b capsular antibody has potential use in the following high-risk settings: (1) to prevent secondary disease in households, childcare centers, or institutions; (2) for selected racial groups who are at high risk for disease during early infancy (e.g., Eskimos and Native Americans); and (3) for immunocompromised patients who fail to respond to active immunization. A human hyperimmunoglobulin called bacterial polysaccharide immunoglobulin (BPIG) has been prepared from the plasma of adult donors immunized with Hib, meningococcal, and pneumococcal polysaccharide vaccines. Pharmacologic studies show that high serum levels of anti-type b capsular antibody are achieved after intramuscular injection (0.5 mL/kg) of BPIG and that levels considered protective against Hib disease persist for as long as 4 months.116 A clinical trial corroborated these ndings and demonstrated signicant protective efcacy against invasive Hib disease in Apache children given three doses during the rst year of life.117

172-4). As a result of differences in immunogenicity, the primary series in infancy consists of three doses (at 2, 4, and 6 months of age) for HbOC (oligosaccharide-CRM197 conjugate Hib vaccine) and PRPT (PRP-tetanus toxoid) and two doses (at 2 and 4 months) for PRPOMP (PRP-Neisseria meningitidis outer membrane protein). Regardless of the particular vaccine used during the rst year of life, a booster dose should be administered between 12 and 15 months of age. Combination vaccines that contain a Hib conjugate formulation are licensed in the United States, namely DTaP/PRP-T (TriHIBit) and PRP-OMP/HepB (Comvax), DTaP-IPV/PRP-T (Pentacel) is under FDA review in mid 2007. Children with sickle cell disease, anatomic or functional asplenia, HIV infection, or IgG2 subclass deciency, patients receiving chemotherapy for malignancies, and patients who have undergone bone marrow transplantation have an increased risk of invasive Hib disease. Conjugate vaccine should be considered for those who are unvaccinated. Two doses (at least 1 month apart) are recommended for children 12 to 59 months of age and one dose for those 60 months or older. (For further consideration, see the 2006 Red Book by the American Academy of Pediatrics Committee on Infectious Diseases114 and Chapter 7, Active Immunization.) All the conjugate vaccines are well tolerated, with the most common adverse effect being short-lived redness and swelling at the site of injection. Postlicensing studies indicate that the existing conjugate vaccines are highly effective against Hib disease and reduce rates of nasopharyngeal colonization. These vaccines confer no protection against non-type b or nontypable strains. No vaccine currently is available for prevention of disease caused by nontypable H. influenzae. However, work is under way to identify surface-exposed antigens that elicit protective antibodies, and several proteins appear promising.115 Similarly, a number of investigators are studying routes and vehicles for immunization to maximally stimulate mucosal immunity. Clinical trials of candidate vaccines have been initiated.

CHAPTER

17 3

Other Haemophilus Species

Steven C. Buckingham

Chemoprophylaxis
Chemoprophylaxis is an important intervention for preventing invasive Hib disease.114 The intent is to eradicate nasopharyngeal colonization and thereby interrupt transmission. In households with one or more infants younger than 12 months who have not received the complete Hib primary vaccine series, all household contacts should receive rifampin prophylaxis. The same applies in households with children younger than 4 years who are incompletely vaccinated and in families with a fully vaccinated but immunocompromised child. In addition, when two or more cases of invasive disease occur within a 60-day period in attendees of a group childcare facility and incompletely vaccinated children attend the facility, rifampin is recommended for all attendees and supervisory personnel. Management after a single case at a childcare facility is controversial and depends

Of the Haemophilus species, H. influenzae causes by far the most human disease. Several other members of this genus, however, are capable of causing clinical illness. These include H. aegyptius (now termed H. influenzae biogroup aegyptius), H. ducreyi, H. parainfluenzae, H. aphrophilus, H. paraphrophilus, H. haemolyticus, H. parahaemolyticus, H. segnis and the ill-dened species H. paraphrohaemolyticus.1 The genus Haemophilus is classied in the family Pasteurellaceae. Members of this genus are small, pleomorphic, facultatively anaerobic, gram-negative coccobacilli. The various Haemophilus species can be distinguished from one another based on their need for X factor (hemin) and/or V factor nicotinamide for in vitro growth, their ability to lyse horse erythrocytes and their production of catalase (Table 173-1). H. parainfluenzae, H. paraphrophilus, and H. segnis are differentiated based on their carbohydrate fermentation. H. paraphrophilus ferments both lactose and mannose; H. parainfluenzae, only mannose; and H. segnis, neither. With the sole exception of H. ducreyi, all Haemophilus species ferment glucose. H. ducreyi grows optimally at 33C, whereas other species do so between 35C and 37C. In general, haemophili grow best in a humid environment enriched with 5 to 10% carbon dioxide.1

PART III Etiologic Agents of Infectious Diseases