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Re: Sterile Site Infection in Sudden Infant Death – Unanswered Questions

To The Editor,

Goldwater’s paper “Sterile Site Infection At Autopsy In Sudden Unexpected Deaths In Infancy” (ADC Online First. September 15, 2008 as 10.1136/adc.2007.135939) raises several issues. His statement that 132 cases occurring between 1978 and 2004 fulfilled the 2004 San Diego definitional criteria for SIDS1 presumes retrospective assignment of this diagnosis in a very high percentage of the case given the dramatic decline in these deaths since implementation of the Reduce the Risk (Back to Sleep) campaign. Given forensic and/or pediatric pathologists are not co- authors, how was this accomplished? Given also that death scene evaluation was uncommonly undertaken in earlier years of SIDS investigation, how were these cases handled? The second and third sections of the Results have identical subtitles; presumably, the third section title was meant to be “ --- insignificant pathogens---.” How certain is it that all of the cultures were obtained in a standardized “aseptic technique” given the long period of case acquisition during which time there were presumably numerous pathologists performing the autopsies? How are the findings of the author’s present study reconciled with his previous findings2 that “all 92 SIDS E. coli isolates produced curlin protein” thereby leading to his proposal that “SIDS should be renamed ‘infant curlinism’ --- and our conclusion that this association is likely to be causal in nature. Finally, in our study, bacterial cultures were positive in 80% of SIDS cases and 78% were polymicrobial; among control cases composed of infants who died as a result of accidental or inflicted injuries, 89% were positive and 94% were polymicrobial.3 In conclusion, we believe it is important that all aspects of the medical history, circumstances of death and autopsy findings, including results of postmortem cultures, be considered in certifying the cause and manner of death in cases of sudden infant death.

References 1. Krous HF, Beckwith JB, Byard RW, et al. Sudden infant death syndrome and unclassified sudden infant deaths: a definitional and diagnostic approach. Pediatrics. 2004;114:234-238. 2. Goldwater PN, Bettelheim KA. Curliated Escherichia coli, soluble curlin and the sudden infant death syndrome (SIDS). J Med Microbiol. 2002;51:1009 -1012. 3. Krous HF, Nadeau JM, Silva PD, Blackbourne BD. A comparison of respiratory symptoms and inflammation in sudden infant death syndrome and in accidental or inflicted infant death. Am J Forensic Med Pathol. 2003;24:1-8.