Pediatric Pulmonology 13133-135 (1992)
Original Articles Branhamella catarrhalis Colonization in Preschool Asthmatics Paul C. Seddon, MRCP,’ Deborah Sunderland, BSC,* Susan M. O’Halloran, MRCP,’ C. Anthony Hart, MD,* and David P. Heaf’ Summary. Branhamella cafarrhalis has been associated with exacerbations of chronic bronchitis and asthma in adults. To investigate the possible role of 13.cafarrhalis in asthma of early childhood, we took posterior pharyngeal swabs from 24 normal children, 20 well asthmatics, and 20 acutely wheezy asthmatics, all between 1 and 4 years of age. On culture, 33% of the normal children were colonized with B. catarrhalis; colonization rates in the well asthmatics (70%) and in the wheezy asthmatics (75%) were significantly higher than in normals. The nature of this association requires further study. Pediatr Pulmonol. 1992; 13:133-135. (o iwzWiley-Liss. Inc. Key words: Posterior pharyngeal swabs; selective agar medium; semiquantitative culture assessment.
INTRODUCTION The possible role of infection in the genesis of the asthmatic state, and in exacerbations of asthma, continues to be controversial. Early thinking stressed the importance of bacterial infection in wheezy episodes, and thc concept of “bacterial allergy” continued to be proposed up to the late 1960s to explain the development of asthma in non-atopic individuals. However, several studies failed to show either that bacterial pathogens were more prevalent in asthmatics,2 or that pathogenic bacteria could be cultured from children with asthma during exacerbations.’ Because of this, in more recent years interest has shifted to respiratory viruses, which are frequently cultured during wheezy episodes in such ~ h i l d r e nand ,~ may cause persisting bronchial hyperreactivity . Two developments caused us to re-examine the role of bacteria in children with asthma. One was the emergence of Branhamelfa catarrhalis as a respiratory pathogen. Previously called Micrococcus cutarrhalis, then Neisseria catarrhalis (more recently it has again been renamed Moroxella catarrhalis), this gram-negative coccus was isolated by Osler from his own sputum during his terminal i l l n e ~ sbut , ~ apart from this finding was regarded until recently as a harmless commensal whose only clinical significance lay in its differentiation from the meningococcus and the gonococcus. Over the past few years, however, B. catarrhalis has been acknowledged as a common cause of acute otitis media and acute sinusitis in children, and of exacerbations of chronic obstructive airway disease in adults.h It has also been implicated in
’
0 1992 Wiley-Liss, Inc.
episodes of pneumonia and tracheitis in infants with preexisting chronic lung disease’ and among intubated children receiving intensive care.8 In one study B. cararrhalis was associated with chronic cough in children, but it is unclear whether these children had other features suggestive of asthma.” The second relevant development has been the demonstration that chemical substances released from bacteria are not only capable of causing bronchoconstriction, but also of inducing bronchial hyperreactivity. I I This occurs because the constituents of some bacteria, including B. catarrhalis, cause release of mediators, by both immune and non-immune mechanisms. To assess whether B. catarrhalis might have a role in paediatric asthma, we compared the incidence of colonization by this organism in normal and asthmatic preschool children, and between asthmatic children when they were free of wheezing and during wheezy episodes. We also examined the incidence of other pathogenic bacteria in these groups.
From the Respiratory Unit, Alder Hey Children’s Hospital,’ and the Departmentof Medical Microbiology, University of Liverpool, Livcrpool.’ Unitcd Kingdom. Received May 9, 1990; (revision) accepted for publication January 8 , 1992. Address correspondenceand reprint requests to Dr. P. Scddon. Dcpartinent of Child Health, Bristol Children’s Hospital, Bristol BS2 8BJ. UK.
134
Seddon et al.
MATERIALS AND METHODS
The patients studied were as follows: Normal controls: 24 consecutive attenders, aged 1 to 4 years, at a community child health clinic for routine medical examination, with no history of wheezing. Well asthmatics: 20 consecutive patients aged I to 4 years attending the asthma clinic at Alder Hey Children’s Hospital, Liverpool, with asthma (defined as a history of at least three episodes of wheezing, responsive to bronchodilators) but currently not wheezy. Wheezy asthmatics: 20 consecutive children aged 1 to 4 years admitted to Alder Hey Children’s Hospital for acute wheezing, with a history of asthma as defined above. All patients were studied within a 12 week period from September through November, the peak time of year for asthma admissions in the United Kingdom. All lived in urban areas within the Merseyside conurbation. None of the normal controls or well asthmatics had been taking antibiotics within 2 weeks of the study, but five of the wheezy children with asthma were or had recently stopped taking antibiotics (ampicillin or amoxycillin in all cases). A swab was taken from the posterior pharynx by one of the investigators (P.S. or S.O.H.) and kept at 4°C until processing. All swabs were processed in the same laboratory by the same investigator (D.S.) within 24 hours. After preparing a smear for a direct gram film, each swab was then plated out onto four culture media, the three standard media (blood, chocolate, and MacConkey agars) for identification of “traditional” pathogens, and a selective agar containing vancomycin and trimethoprim to identify Branhamella species. l 3 Any gram-negative cocci that grew on this medium were identified as a Branhamella or Neisseria species by a positive oxidase test, and further identified as B. catarrhalis by a positive tributyrin test. l4 For specimens growing B. cararrhalis, a semiquantitative assessment of the heaviness of growth if bacteria were present in the was made as follows: if they grew after one dilution initial inoculum only, on the plate, and + + + if they grew after two dilutions. Statistical analysis of the data was by chi-squared test with Yates’ correction when it concerned categories (Table 1) and by Mann-Whitney U test for the semiquantitative data (Table 2).
+ ++
RESULTS
The findings on direct gram staining of posterior pharyngeal swabs showed no differences between the three groups. On culture (Table I ) , very few children yielded bacterial pathogens other than B. caturrhalis, and the numbers of these were not significantly different between the groups.
TABLE 1-Potentially Pathogenic Organisms Cultured From Pharyngeal Swabs
Organism Brunhumrllu c.uturrlta1i.v Strepto~oc.c.u.suureus Sireprococcus pvogcwes Enteroiwcus fucjcwlis
Haemophilus influenzuc Coliforms Yeasts
Normal children ( n = 24)
Well asthmatics ( n = 20)
Wheezy asthmatics (n = 20)
8 1 I
14 4
15 2 I 0
I 3 0 8 2
0
0 3
2
I 4 I
TABLE 2-Semi-Quantitative Growth of Branhamella catarrhalis From Pharyngeal Swabs
Growth” 0
+ ++ +++
Normal children ( n = 24)
Well asthmatics (n = 20)
Wheezy asthmatics (n = 20)
16
6 I 4
5
3 3 2
3
8 4 1
‘I+, bacteria present in initial inoculum; + +, bacteria present after one dilution: + + + , hacteria present after two dilutions.
Branhamella cararrhalis was cultured from 33% of the normal children. This figure is comparable to the prcvalence of this organism previously reported in young children. l 5 The isolation rates for the well asthmatics (70%) and the wheezy asthmatics (75%) were both significantly higher than for the normal children (P < 0.05, chisquared test), but not different from each other. Of the five wheezy asthmatics who had been receiving antibiotics, three were positive for B. catarrhulis. Table 2 shows a semiquantitative assessment of the growth of B . cutarrhalis across the three groups. Growth was significantly higher for the two asthmatic groups (P < 0.05, Mann-Whitney test) than for the normals, but again there was no difference between the well and wheezy asthmatics. DISCUSSION
Our main finding was that B . catarrhalis is much more commonly isolated from the nasopharynx of children with asthma (70 to 75%) than of normal controls. This could be because the organism predisposes to the development of asthma because asthma makes an individual more prone to colonization or because a third factor predisposes separately to both. Branhamella catarrhalis might predispose to asthma by releasing substances such as endotoxin, which can induce bronchial hyperreactivity. I Infections of the upper respiratory tract commonly caused by B. carurrhalis, such as sinusitis and otitis media, are known to be more
’
B. catarrhalis in Preschool Asthmatics
common in asthmatic children," and there are (anecdotal) reports of recalcitrant asthma improving when chronic sinusitus is treated. " It is also possible that asthma predisposes in some way to colonization by B. cuturrhulis. For example, asthmatics have areas of epithelial damage in their airways," which might allow potential pathogens to colonize. Also, B. cuturrhulis often produces beta-lactamase, and the repmted courses of antibiotics often received by young children with asthma might select for such resistant organisms. However, this would not explain our findings, since in our population only 1 of the 37 isolates of B. cuturrhulis produced beta-lactamase. (Our unusually low incidence of beta-lactamase was confirmed on retesting with a different method). Furthermore, in normal preschool children colonization rates for B. cuturrhulis are no higher in areas where many antibiotics are prescribed." None of our well asthmatic children had recently received antibiotics. The third possibility is that some underlying factor, perhaps immunological, predisposes separately to colonization with B. cuturrhulis and to asthma. Minor defects in immune function have been reported in association with early onset asthma.*" Our results do not suggest that B. cuturrhulis has any role in causing acute exacerbations of wheezing in children with asthma, since it was found with equal frequency in those who wheeze and those who do not. We have shown that B . cuturrhulis colonizes children with asthma more commonly than those without, but have found no link with acute wheezing episodes. Further work is required to clarify this association between B. cuturrhulis colonization and asthma: a longitudinal study relating B. caturrhulis colonization and bacterial clearance to coughing, wheezing, and bronchial reactivity in young children would be required. REFERENCES I. Eisen AH. The role of infection in allergic disease. Pediatr Clin N Am. 1969; 16:67-83. 2. Sanders S, Norman AP. The bacterial flora of the upper respiratorytract inchildren withsevercasthma. J Allergy. 1968;41:319325.
135
3. Mclntosh K, Ellis EF, Hoffman LS, et al. The association of viral and bacterial respiratory infections with exacerbations of wheezing in young children. J Pediatr. 1973; 82578-590. 4. Mitchell I , lnglis H, Simpson H. Viral infection in wheezy bronchitis and asthma in children. Arch Dis Child. 1976; 51:707-71 I. 5. Cushing H. The Life of Sir William Osler, Vol. 2. Oxford: Clarendon Press, 1925. 6. Van Hare GF, Shurin PA. Thc increasing importance of Rrunhumelku cuturrhulis in respiratory infections. Pcdiatr Infect Dis J. 1987; 6:Y2-94. 7. Bcrg RA, Bartley DL. Pneumonia associated with Brunchumelku cuturrhulis in infants. Pediatr Infect Dis J. 1987; 6569-573. 8. Kasian GF, Shafran SD, Shyleyko EM. Branhumello cururrhulis bronchopulmonary isolates in PlCU patients. Pediatr Pulmonol. 1989; 7:128-132.
9. Brorson JE, Malmvall BE. Brunhumellu cuturrhulis and other bacteria in the nasopharynx of children with longstanding cough. ScandJ InfectDis. 1981; 13:111-113. 10. Berend N, Peters MJ, Armour CL, Black JL, Ward HE. Effect of inhaled formyl-methionyl-leucyl-phenylalanineon airway function. Thorax. 1987; 42:3640. I I . Hutchinson AA, Hinson JM, Brigham KL, Snapper JR. Effect of endotoxin on airway responsiveness to aerosol histamine in sheep. J Appl Physiol: Respirat Environ Exercise Physiol. 1983; 54: 1463- 1468. 12. Norn S, Stahl Skov P, Jensen C. Jarlov JO. Espersen F. Histamine
release induced by bacteria. A new mechanism in asthma'? Agents Actions. 1987; 20:29-34. 13. Corkill JE, Makin T. A selective medium for non-pathogenic aerobic Gram negative cocci from the rspiratory tract with particular reference to Rrunhumellu cuturrhulis. Med Lab Sci. 1982; 3913-10. 14. Rion JY, Guibourdenche J. Brunhumellu cuturrhulis: New methods of bacterial diagnosis. Drugs. 1986; 3I(Suppl. 3): 1-6. 15. Vaneechoutte M, Verschraegen G, Claeys G, van den Abeele AM. Selective medium for Brunhurncllu cufurrhuliswith acetazolamide as a specific inhibitor of Neisseria spp. J Clin Microbiol. 1988; 26:2544-2548. 16. Shapiro GG. Sinusitis in children. J Allergy Clin Immunol. 1988; 8 I : 1025-1027. 17. Juntunen K, Tarkkanen J , Makinen J. Caldwell-Luc operation in the treatment of childhood bronchial asthma. Laryngoscope. 1984; 94:249-25 I . 18. Laitinen LA, Heino M, Laitnine A, Kava T. Haahtela T. Damage of the airway epithelium and bronchial hypcrreactivity in patients with asthma. Am Rev Respir Dis. 1985; 131599-606. 19. Mlstad S , Eliasson I, Hovelius B, Kamme C, Schalen C. Beta-
lactamase production in the upper respiratory tract flora in relation to antibiotic consumption: A study in children attending day nurseries. Scand J Infect Dis. 1988; 20:32%334. 20. Loftus BC. Price JF. Clinical and immunological characteristics of preschool asthma. Clin Allergy. 1986; 16:25 1-257.
Original Articles Branhamella catarrhalis Colonization in Preschool Asthmatics Paul C. Seddon, MRCP,’ Deborah Sunderland, BSC,* Susan M. O’Halloran, MRCP,’ C. Anthony Hart, MD,* and David P. Heaf’ Summary. Branhamella cafarrhalis has been associated with exacerbations of chronic bronchitis and asthma in adults. To investigate the possible role of 13.cafarrhalis in asthma of early childhood, we took posterior pharyngeal swabs from 24 normal children, 20 well asthmatics, and 20 acutely wheezy asthmatics, all between 1 and 4 years of age. On culture, 33% of the normal children were colonized with B. catarrhalis; colonization rates in the well asthmatics (70%) and in the wheezy asthmatics (75%) were significantly higher than in normals. The nature of this association requires further study. Pediatr Pulmonol. 1992; 13:133-135. (o iwzWiley-Liss. Inc. Key words: Posterior pharyngeal swabs; selective agar medium; semiquantitative culture assessment.
INTRODUCTION The possible role of infection in the genesis of the asthmatic state, and in exacerbations of asthma, continues to be controversial. Early thinking stressed the importance of bacterial infection in wheezy episodes, and thc concept of “bacterial allergy” continued to be proposed up to the late 1960s to explain the development of asthma in non-atopic individuals. However, several studies failed to show either that bacterial pathogens were more prevalent in asthmatics,2 or that pathogenic bacteria could be cultured from children with asthma during exacerbations.’ Because of this, in more recent years interest has shifted to respiratory viruses, which are frequently cultured during wheezy episodes in such ~ h i l d r e nand ,~ may cause persisting bronchial hyperreactivity . Two developments caused us to re-examine the role of bacteria in children with asthma. One was the emergence of Branhamelfa catarrhalis as a respiratory pathogen. Previously called Micrococcus cutarrhalis, then Neisseria catarrhalis (more recently it has again been renamed Moroxella catarrhalis), this gram-negative coccus was isolated by Osler from his own sputum during his terminal i l l n e ~ sbut , ~ apart from this finding was regarded until recently as a harmless commensal whose only clinical significance lay in its differentiation from the meningococcus and the gonococcus. Over the past few years, however, B. catarrhalis has been acknowledged as a common cause of acute otitis media and acute sinusitis in children, and of exacerbations of chronic obstructive airway disease in adults.h It has also been implicated in
’
0 1992 Wiley-Liss, Inc.
episodes of pneumonia and tracheitis in infants with preexisting chronic lung disease’ and among intubated children receiving intensive care.8 In one study B. cararrhalis was associated with chronic cough in children, but it is unclear whether these children had other features suggestive of asthma.” The second relevant development has been the demonstration that chemical substances released from bacteria are not only capable of causing bronchoconstriction, but also of inducing bronchial hyperreactivity. I I This occurs because the constituents of some bacteria, including B. catarrhalis, cause release of mediators, by both immune and non-immune mechanisms. To assess whether B. catarrhalis might have a role in paediatric asthma, we compared the incidence of colonization by this organism in normal and asthmatic preschool children, and between asthmatic children when they were free of wheezing and during wheezy episodes. We also examined the incidence of other pathogenic bacteria in these groups.
From the Respiratory Unit, Alder Hey Children’s Hospital,’ and the Departmentof Medical Microbiology, University of Liverpool, Livcrpool.’ Unitcd Kingdom. Received May 9, 1990; (revision) accepted for publication January 8 , 1992. Address correspondenceand reprint requests to Dr. P. Scddon. Dcpartinent of Child Health, Bristol Children’s Hospital, Bristol BS2 8BJ. UK.
134
Seddon et al.
MATERIALS AND METHODS
The patients studied were as follows: Normal controls: 24 consecutive attenders, aged 1 to 4 years, at a community child health clinic for routine medical examination, with no history of wheezing. Well asthmatics: 20 consecutive patients aged I to 4 years attending the asthma clinic at Alder Hey Children’s Hospital, Liverpool, with asthma (defined as a history of at least three episodes of wheezing, responsive to bronchodilators) but currently not wheezy. Wheezy asthmatics: 20 consecutive children aged 1 to 4 years admitted to Alder Hey Children’s Hospital for acute wheezing, with a history of asthma as defined above. All patients were studied within a 12 week period from September through November, the peak time of year for asthma admissions in the United Kingdom. All lived in urban areas within the Merseyside conurbation. None of the normal controls or well asthmatics had been taking antibiotics within 2 weeks of the study, but five of the wheezy children with asthma were or had recently stopped taking antibiotics (ampicillin or amoxycillin in all cases). A swab was taken from the posterior pharynx by one of the investigators (P.S. or S.O.H.) and kept at 4°C until processing. All swabs were processed in the same laboratory by the same investigator (D.S.) within 24 hours. After preparing a smear for a direct gram film, each swab was then plated out onto four culture media, the three standard media (blood, chocolate, and MacConkey agars) for identification of “traditional” pathogens, and a selective agar containing vancomycin and trimethoprim to identify Branhamella species. l 3 Any gram-negative cocci that grew on this medium were identified as a Branhamella or Neisseria species by a positive oxidase test, and further identified as B. catarrhalis by a positive tributyrin test. l4 For specimens growing B. cararrhalis, a semiquantitative assessment of the heaviness of growth if bacteria were present in the was made as follows: if they grew after one dilution initial inoculum only, on the plate, and + + + if they grew after two dilutions. Statistical analysis of the data was by chi-squared test with Yates’ correction when it concerned categories (Table 1) and by Mann-Whitney U test for the semiquantitative data (Table 2).
+ ++
RESULTS
The findings on direct gram staining of posterior pharyngeal swabs showed no differences between the three groups. On culture (Table I ) , very few children yielded bacterial pathogens other than B. caturrhalis, and the numbers of these were not significantly different between the groups.
TABLE 1-Potentially Pathogenic Organisms Cultured From Pharyngeal Swabs
Organism Brunhumrllu c.uturrlta1i.v Strepto~oc.c.u.suureus Sireprococcus pvogcwes Enteroiwcus fucjcwlis
Haemophilus influenzuc Coliforms Yeasts
Normal children ( n = 24)
Well asthmatics ( n = 20)
Wheezy asthmatics (n = 20)
8 1 I
14 4
15 2 I 0
I 3 0 8 2
0
0 3
2
I 4 I
TABLE 2-Semi-Quantitative Growth of Branhamella catarrhalis From Pharyngeal Swabs
Growth” 0
+ ++ +++
Normal children ( n = 24)
Well asthmatics (n = 20)
Wheezy asthmatics (n = 20)
16
6 I 4
5
3 3 2
3
8 4 1
‘I+, bacteria present in initial inoculum; + +, bacteria present after one dilution: + + + , hacteria present after two dilutions.
Branhamella cararrhalis was cultured from 33% of the normal children. This figure is comparable to the prcvalence of this organism previously reported in young children. l 5 The isolation rates for the well asthmatics (70%) and the wheezy asthmatics (75%) were both significantly higher than for the normal children (P < 0.05, chisquared test), but not different from each other. Of the five wheezy asthmatics who had been receiving antibiotics, three were positive for B. catarrhulis. Table 2 shows a semiquantitative assessment of the growth of B . cutarrhalis across the three groups. Growth was significantly higher for the two asthmatic groups (P < 0.05, Mann-Whitney test) than for the normals, but again there was no difference between the well and wheezy asthmatics. DISCUSSION
Our main finding was that B . catarrhalis is much more commonly isolated from the nasopharynx of children with asthma (70 to 75%) than of normal controls. This could be because the organism predisposes to the development of asthma because asthma makes an individual more prone to colonization or because a third factor predisposes separately to both. Branhamella catarrhalis might predispose to asthma by releasing substances such as endotoxin, which can induce bronchial hyperreactivity. I Infections of the upper respiratory tract commonly caused by B. carurrhalis, such as sinusitis and otitis media, are known to be more
’
B. catarrhalis in Preschool Asthmatics
common in asthmatic children," and there are (anecdotal) reports of recalcitrant asthma improving when chronic sinusitus is treated. " It is also possible that asthma predisposes in some way to colonization by B. cuturrhulis. For example, asthmatics have areas of epithelial damage in their airways," which might allow potential pathogens to colonize. Also, B. cuturrhulis often produces beta-lactamase, and the repmted courses of antibiotics often received by young children with asthma might select for such resistant organisms. However, this would not explain our findings, since in our population only 1 of the 37 isolates of B. cuturrhulis produced beta-lactamase. (Our unusually low incidence of beta-lactamase was confirmed on retesting with a different method). Furthermore, in normal preschool children colonization rates for B. cuturrhulis are no higher in areas where many antibiotics are prescribed." None of our well asthmatic children had recently received antibiotics. The third possibility is that some underlying factor, perhaps immunological, predisposes separately to colonization with B. cuturrhulis and to asthma. Minor defects in immune function have been reported in association with early onset asthma.*" Our results do not suggest that B. cuturrhulis has any role in causing acute exacerbations of wheezing in children with asthma, since it was found with equal frequency in those who wheeze and those who do not. We have shown that B . cuturrhulis colonizes children with asthma more commonly than those without, but have found no link with acute wheezing episodes. Further work is required to clarify this association between B. cuturrhulis colonization and asthma: a longitudinal study relating B. caturrhulis colonization and bacterial clearance to coughing, wheezing, and bronchial reactivity in young children would be required. REFERENCES I. Eisen AH. The role of infection in allergic disease. Pediatr Clin N Am. 1969; 16:67-83. 2. Sanders S, Norman AP. The bacterial flora of the upper respiratorytract inchildren withsevercasthma. J Allergy. 1968;41:319325.
135
3. Mclntosh K, Ellis EF, Hoffman LS, et al. The association of viral and bacterial respiratory infections with exacerbations of wheezing in young children. J Pediatr. 1973; 82578-590. 4. Mitchell I , lnglis H, Simpson H. Viral infection in wheezy bronchitis and asthma in children. Arch Dis Child. 1976; 51:707-71 I. 5. Cushing H. The Life of Sir William Osler, Vol. 2. Oxford: Clarendon Press, 1925. 6. Van Hare GF, Shurin PA. Thc increasing importance of Rrunhumelku cuturrhulis in respiratory infections. Pcdiatr Infect Dis J. 1987; 6:Y2-94. 7. Bcrg RA, Bartley DL. Pneumonia associated with Brunchumelku cuturrhulis in infants. Pediatr Infect Dis J. 1987; 6569-573. 8. Kasian GF, Shafran SD, Shyleyko EM. Branhumello cururrhulis bronchopulmonary isolates in PlCU patients. Pediatr Pulmonol. 1989; 7:128-132.
9. Brorson JE, Malmvall BE. Brunhumellu cuturrhulis and other bacteria in the nasopharynx of children with longstanding cough. ScandJ InfectDis. 1981; 13:111-113. 10. Berend N, Peters MJ, Armour CL, Black JL, Ward HE. Effect of inhaled formyl-methionyl-leucyl-phenylalanineon airway function. Thorax. 1987; 42:3640. I I . Hutchinson AA, Hinson JM, Brigham KL, Snapper JR. Effect of endotoxin on airway responsiveness to aerosol histamine in sheep. J Appl Physiol: Respirat Environ Exercise Physiol. 1983; 54: 1463- 1468. 12. Norn S, Stahl Skov P, Jensen C. Jarlov JO. Espersen F. Histamine
release induced by bacteria. A new mechanism in asthma'? Agents Actions. 1987; 20:29-34. 13. Corkill JE, Makin T. A selective medium for non-pathogenic aerobic Gram negative cocci from the rspiratory tract with particular reference to Rrunhumellu cuturrhulis. Med Lab Sci. 1982; 3913-10. 14. Rion JY, Guibourdenche J. Brunhumellu cuturrhulis: New methods of bacterial diagnosis. Drugs. 1986; 3I(Suppl. 3): 1-6. 15. Vaneechoutte M, Verschraegen G, Claeys G, van den Abeele AM. Selective medium for Brunhurncllu cufurrhuliswith acetazolamide as a specific inhibitor of Neisseria spp. J Clin Microbiol. 1988; 26:2544-2548. 16. Shapiro GG. Sinusitis in children. J Allergy Clin Immunol. 1988; 8 I : 1025-1027. 17. Juntunen K, Tarkkanen J , Makinen J. Caldwell-Luc operation in the treatment of childhood bronchial asthma. Laryngoscope. 1984; 94:249-25 I . 18. Laitinen LA, Heino M, Laitnine A, Kava T. Haahtela T. Damage of the airway epithelium and bronchial hypcrreactivity in patients with asthma. Am Rev Respir Dis. 1985; 131599-606. 19. Mlstad S , Eliasson I, Hovelius B, Kamme C, Schalen C. Beta-
lactamase production in the upper respiratory tract flora in relation to antibiotic consumption: A study in children attending day nurseries. Scand J Infect Dis. 1988; 20:32%334. 20. Loftus BC. Price JF. Clinical and immunological characteristics of preschool asthma. Clin Allergy. 1986; 16:25 1-257.
