Artículos previos organizados por temas (A-Z) hasta enero 2019

Absceso

El absceso retrofaríngeo es una de las infecciones profundas del cuello más graves, por la posibilidad de extensión a zonas adyacentes, y se debe considerar en los niños que se presentan con fiebre, limitación del movimiento del cuello, sobre todo la extensión, torticolis, disfagia, babeo y otros síntomas relacionados con la inflamación u obstrucción del tracto respiratorio y digestivo superior y, en general, no suele ser tan rápidamente progresiva como otras etiologías infecciosas. Se presenta un caso en un lactante de 17 meses.

¿Qué papel tienen los antibióticos en el tratamiento de los abscesos cutáneos no complicados después de la incisión y el drenaje? Un estudio reciente sugirió que, para los abscesos cutáneos pequeños sin complicaciones, los antibióticos después de la incisión y el drenaje mejoran las posibilidades de curación a corto plazo en comparación con el placebo. Basándose en una revisión y utilizando el marco GRADE de acuerdo con el proceso de recomendación rápida de BMJ, un panel de expertos hace una recomendación débil a favor de trimetoprim-sulfametoxazol (TMP-SMX, cotrimoxazol) o clindamicina además de incisión y drenaje frente a incisión y drenaje solo. Para los pacientes que han elegido iniciar antibióticos, el panel emite una recomendación fuerte para TMP-SMX o clindamicina en lugar de una cefalosporina y una recomendación débil para TMP-SMX en lugar de clindamicina.

Aciclovir

Adenitis (ver Temas A-Z y Micobacterias)

Eighty-five children were diagnosed with culture-confirmed nontuberculous mycobacterial cervical lymphadenitis within the MYCOMED surveillance network from 2004 to 2013. The mean incidence sharply increased from 0.57 to 3.7 per 100,000 children per year, after the discontinuation of mandatory bacillus Calmette and Guérin immunization in 2007. Cases were documented as Mycobacterium avium (62.3%), Mycobacterium intracellulare (15.3%) and Mycobacterium lentiflavum (12.9%). Outcome was favorable in all, with or without surgery or antimycobacterial treatment.

Conclusión. M. lentiflavum debe ser considerado como un importante patógeno emergente causante de linfadenitis cervical en población pediátrica.

Las medidas de control del ganado y la pasteurización de los productos lácteos han hecho que la enfermedad tuberculosa por Mycobacterium bovis sea infrecuente en nuestro medio. El diagnóstico de esta entidad requiere un alto índice de sospecha, fundado en una historia clínica detallada y pruebas complementarias oportunas. La presentación más frecuente es extrapulmonar, principalmente como linfadenitis, por lo que ante una adenopatía de mala evolución se recomienda remitir al paciente para estudio y valorar la realización de punción aspiración con aguja fina para examen citológico y cultivo. Presentamos un caso de linfadenitis por M. bovis en una niña de siete años que respondió adecuadamente al tratamiento médico.

Se detectan 27 casos, edad media de presentación 39,9 meses (rango 10 meses-8 años). El tiempo desde inicio de los síntomas hasta la primera consulta especializada es 1,7±1,1 meses. La localización más frecuente es submaxilar en 17/27 casos (63%), lado derecho en el 59,3%, con tamaño de 2,96±1,26cm. Solo 16/27 presentan fistulización. Prueba de tuberculina superior a 10mm en 7/24 (29,1%). El cultivo es positivo para Mycobacterium avium en 14/27 (51,9%), Mycobacterium intracellulare 3/27 (11,1%), Mycobacterium lentiflavum 3/27 (11,1%). El 92,6% (23/27) es tratado inicialmente con amoxicilina-clavulánico. La combinación de antibióticos y cirugía se aplica en 16/27 casos (59,3%), solo antibioterapia 7/27 (25,9%) y únicamente exéresis 4/27 (14,8%). Dos pacientes precisan reintervención y un caso desarrolla neutropenia grave secundaria a rifabutina. Solo un caso (3,7%) presenta parálisis facial transitoria como secuela. La combinación de antibioterapia y cirugía es el tratamiento más frecuente. El retraso en el diagnóstico hace que la exéresis como primera opción terapéutica se realice únicamente en uno de cada 7 pacientes.

La afectación ganglionar por Mycobacterium tuberculosis puede ocurrir tras una diseminación linfohemática a partir de una afectación primaria pulmonar, o por primoinfección extrapulmonar, cuya puerta de entrada son las mucosas o contacto con objetos contaminados. Se presenta el caso de un niño de diez años, nacido en España, afecto de adenitis tuberculosa en la región inguinal, cuya infección se produjo tras una herida en el pie ocurrida en una playa de Brasil. Tras el inicio de la terapia antituberculosa desarrolló una escrófula que requirió desbridamiento quirúrgico, con buena evolución posterior.

Amigdalitis (ver faringoamigdalitis)

Antibiograma

Los métodos más frecuentemente utilizados en Microbiología Clínica para la determinación de la sensibilidad de las bacterias a los antibióticos se basan en un estudio fenotípico, observando el crecimiento bacteriano de la cepa incubada en presencia del antibiótico a estudiar. Estos métodos requieren normalmente un tiempo de unas 24 h para la obtención de resultados. El objetivo de este trabajo es revisar el fundamento y los resultados de las principales técnicas instrumentales que proporcionan un antibiograma rápido. De manera pormenorizada se exponen datos relativos a técnicas moleculares, citometría de flujo, quimioluminiscencia, espectrometría de masas, métodos comerciales utilizados en el trabajo de rutina, métodos colorimétricos, nefelometría, microarrays, microfluidos y métodos de lisis bacteriana

Al aplicar los puntos de corte del EUCAST, la mayoría de los porcentajes de sensibilidad a antimicrobianos no se alteró o lo hizo de forma muy leve; sin embargo, se observó una disminución de la sensibilidad a los aminoglucósidos en bacilos gramnegativos, especialmente a la amicacina en Pseudomonas aeruginosa (23,2%), aunque solo el 5,7% fueron totalmente resistentes; además, disminuyó notablemente el porcentaje de aislados sensibles a aztreonam. Es de destacar el aumento de cepas de Staphylococcus aureusresistentes a clindamicina (51,5%) y a aminoglucósidos (gentamicina 43,1%).

Antibióticos (Ver Temas A-Z y apartado específico)

Conclusions Narrow-, compared with broad-spectrum antibiotics were equally effective and demonstrated a lower rate of adverse events.

Antibióticos alergia (Ver Temas A-Z)

Antibióticos (consumo y adecuación)

Conclusión Hasta en la mitad de los pacientes la prescripción de antimicrobianos puede ser inadecuada. Estos resultados ponen de manifiesto la importancia de introducir un programa de optimización de antimicrobianos para reducir su uso innecesario.

We found substantial differences of up to 7.5-fold in pediatric antimicrobial use across several industrialized countries from Europe, Asia, and North America. These data reinforce the need to develop strategies to decrease the unnecessary use of antimicrobial agents.

Objective: To evaluate variation in antibiotic prescribing between pediatric and nonpediatric providers for common upper respiratory illnesses.

Study design: Patient encounters for children aged <18 years from a regional health care system were identified. Electronic medical records from 2011 to 2016 were extracted for diagnoses of upper respiratory infection, pharyngitis, acute otitis media, and sinusitis. Encounters with competing medical diagnoses, recent hospitalization, and antibiotic prescriptions within 30 days were excluded. Adherence to antibiotic guidelines was assessed by provider training (pediatric, nonpediatric physicians, and advance practice providers). Additional factors assessed were calendar year, and patient's age, sex, insurance status, and number of sick visits in the prior year.

Results: Across 6 years, 141 361 visits were examined: 43 914 for upper respiratory infection, 43 701 for pharyngitis, 43 925 for acute otitis media, and 9821 for sinusitis. Pediatricians were more likely than Advanced practice providers (APP) and nonpediatric providers to have guideline-concordant prescribing for pharyngitis (pediatricians, 66.7% [95% CI, 54.5-77.0]; nonpediatricians, 49.1% [95% CI, 36.3-62.0], APPs, 52.2% [95% CI, 39.4-64.7]; P < .0001) and sinusitis (pediatricians, 70.8% [95% CI, 53.8-83.4], nonpediatricians, 63.3% [95% CI, 46.8-77.2], APPs, 62.1% [95% CI, 45.1-76.5]; P = .48) and to withhold antibiotics for upper respiratory infection than APPs and nonpediatric providers (pediatricians, 86.6% [95% CI, 81.2-90.6], nonpediatricians, 80.8% [95% CI, 73.0-86.8], APPs, 76.8% [95% CI, 68.4-83.5]; P < .0001). Pediatricians were less likely to prescribe antibiotics for pharyngitis without a positive test for group A Streptococcus than APPs and nonpediatric providers (pediatricians, 15.1% [95% CI, 10.4-21.6], nonpediatricians, 29.4% [95% CI, 20.8-39.6], APPs, 27.2% [95% CI, 19.3-36.9]; P < .0001). First-line antibiotic prescribing for acute otitis media did not differ between provider specialties. A trend toward more guideline-concordant prescribing was seen for pharyngitis and sinusitis over the study period.

Conclusions: Pediatricians were more likely to adhere to guidelines for management of pediatric acute respiratory infections. Pediatric antibiotic stewardship efforts should also target nonpediatricians.

Conclusions: The incidence of episodes treated with antibiotics among Danish children 0–4 years of age has decreased considerably since 2011. In contrast to guideline recommendations, amoxicillin is the most frequently used initial treatment. Early switching between antibiotics is uncommon. Initiatives should address the extensive use of amoxicillin.

Concerns about increasing antibiotic resistance will be well-known to all, and policy-makers are busy devising ways to persuade us to use less. But in order to determine the success of any such intervention, a baseline measure of antibiotic usage needs to be established. This has already been done in adults, and in children in some European countries, but until now not in the UK. The NHS in England has launched an initiative to …

Antibióticos dispensación

It is necessary and urgent to improve the training of pharmacists in dispensing antibiotics but also strengthen basic health knowledge among the population.

Antibiotics are commonly prescribed for children with acute respiratory infections (ARIs). This study describes the distribution of ARI diagnoses and specifically quantifies antibiotic dispensing for bronchitis and upper respiratory infection (URI) by treatment setting and specialty.

Methods:This retrospective, observational cross-sectional study used data from the HealthCore Integrated Research Environment containing claims from 14 commercial health plans for 2012 to 2014. Children (2–17 years) with first-episode ARI were identified by diagnosis of acute otitis media (AOM), sinusitis, pharyngitis, bronchitis or URI with no competing infections or chronic illnesses. Treatment setting was where diagnoses were made: primary care offices, urgent care centers (UCC), retail health clinics (RHCs) or emergency departments. Primary outcome measure was antibiotic prescription fills from pharmacies within 2 days of start of ARI episode.

Results: For URI, the highest proportions in antibiotic dispensing were ordered by office-based or UCC family physicians (28% and 30%, respectively) and office-based or UCC nurse practitioners/physician assistants (30% and 29%, respectively). Across all settings and specialties, there was high proportion of antibiotic dispensing for bronchitis (75%). Overall, 48% of 544,531 children diagnosed with ARI filled antibiotics. Nurse practitioners/physician assistants in RHC made the most diagnoses of AOM (24%) and streptococcal pharyngitis (22%).

Conclusions: Outreach efforts to decrease antibiotic dispensing for URI can be focused on office-based and UCC family physicians and nurse practitioners/physician assistants. All specialties need widespread interventions to reduce antibiotic dispensing for bronchitis. RHC nurse practitioners/physician assistants can be targeted to reduce high proportion of AOM and streptococcal pharyngitis diagnoses

Antibióticos (duración tratamientos)

With little evidence that failing to complete a prescribed antibiotic course contributes to antibiotic resistance, it’s time for policy makers, educators, and doctors to drop this message. The “complete the course” message has persisted despite not being supported by evidence and previous arguments that it should be replaced.

En este artículo se comentan y se cuestionan las “pautas” completas de los antibióticos. ¿Deberíamos apresurarnos a reescribir las pautas y decirles a los pacientes que sean arrogantes al no terminar sus pautas de antibióticos? Para infecciones graves con evidencia suficiente de la mejor duración de los antibióticos, no. Pero para las infecciones en las que el uso de antibióticos es discrecional de todos modos, sí, tal vez deberíamos decirles a los pacientes que pueden detener sus antibióticos cuando se sienten mejor con el consejo habitual de regresar para una reevaluación si la recuperación no va según lo planeado.

Few studies are available to inform duration of intravenous antibiotics for children and when it is safe and appropriate to switch to oral antibiotics. We have systematically reviewed antibiotic duration and timing of intravenous to oral switch for 36 paediatric infectious diseases and developed evidence-graded recommendations on the basis of the review, guidelines, and expert consensus. We searched databases and obtained information from references identified and relevant guidelines. All eligible studies were assessed for quality. 4090 articles were identified and 170 studies were included. Evidence relating antibiotic duration to outcomes in children for some infections was supported by meta-analyses orrandomised controlled trials; in other infections data were from retrospective series only. Criteria for intravenous to oral switch commonly included defervescence and clinical improvement with or without improvement in laboratory markers. Evidence suggests that intravenous to oral switch can occur earlier than previously recommended for some infections. We have synthesised recommendations for antibiotic duration and intravenous to oral switch to support clinical decision making and prospective research.

Antibióticos educación

Se está alentando a los escolares de todo el Reino Unido a luchar contra el uso indebido de antibióticos a través de canciones.

El espectáculo es una creación de Meghan Perry, científica clínica de la Universidad de Edimburgo, que reconoció el poder de aprovechar el entusiasmo de los niños para impulsar el cambio. "Hemos visto lo influyentes que han sido los niños con el reciclaje. Llevan estos mensajes a casa, y esperamos que lo hagan con la historia de los antibióticos ".

El musical cuenta la historia de la vida antes y después del descubrimiento de la penicilina por parte de Alexander Fleming, con la condición de que los antibióticos deben usarse con prudencia para preservar su efectividad. Está diseñado para ser aceptado por las escuelas, con apoyo disponible para aquellos sin experiencia en música o drama.

"Todos sabemos que los médicos de familia experimentan una gran presión del público para recetar antibióticos, por lo que si podemos empoderar a los niños con conocimiento, podemos con suerte lograr que influyan en sus padres.

Although based on hypothetical reported future behaviour, the results of this study suggest that public information campaigns to reduce unnecessary antibiotic use may risk a paradoxical consequence of increased, rather than decreased, public demand for antibiotics. This does not negate the potentially important role such campaigns may have; several public information campaigns have proven effective as part of multi-faceted interventions to reduce unnecessary prescribing. However, it underscores the importance of testing public antibiotic stewardship information campaigns on a small scale before rolling them out widely. Choosing the right words may be critical to success, and different strategies may be needed for different population subgroups .

Antibióticos (mejorando la prescripción)

Se solicitaron 921 pruebas correspondientes a 837 pacientes, mayoritariamente urocultivos (416), hemocultivos (175) y coprocultivos (136). El laboratorio informó 246 microorganismos, fundamentalmente bacterias (91%). Se prescribieron antimicrobianos a 333 pacientes. Tras la revisión de los resultados microbiológicos, se modificó el tratamiento en 109 pacientes (13%): 96 interrupciones del antimicrobiano prescrito, tres cambios y diez prescripciones nuevas. Se notificaron los resultados a 381 pacientes, 218 del grupo de los resultados positivos y 163 en el de los negativos. El urocultivo fue la muestra implicada en el 63% de las modificaciones terapéuticas. Conclusiones: el seguimiento de las pruebas microbiológicas de los pacientes que acuden a Urgencias y la modificación de los tratamientos antimicrobianos prescritos pueden ser herramientas útiles en la mejora del uso de antimicrobianos en los Servicios de Urgencias Pediátricas.

Resumen: muy completa revisión sobre el uso adecuado de antibioterapia en atención primaria en Estados Unidos y resistencias a antimicrobianos. Estiman un uso inadecuado de antimicrobianos en un 30%de prescripciones. Hacen propuestas de mejora para todas las partes implicadas en la prescripción

Empiric therapy of the septic patient in the hospital is challenging. Antibiotic stewardship is concerned with optimizing antibiotic use and minimizing resistance. Clinicians should avoid overcovering and overtreating colonizing organisms in respiratory secretions and urinary catheters. Empiric therapy should take into account the prevalence of multidrug-resistant organisms in the hospital setting. The most effective resistance prevention strategies is to preferentially select a low resistance potential antibiotic, which should be administered in the highest possible dose without toxicity for the shortest duration to eliminate the infection

Evidence-based guidelines for implementation and measurement of antibiotic stewardship interventions in inpatient populations including long-term care were prepared by a multidisciplinary expert panel of the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. The panel included clinicians and investigators representing internal medicine, emergency medicine, microbiology, critical care, surgery, epidemiology, pharmacy, and adult and pediatric infectious diseases specialties. These recommendations address the best approaches for antibiotic stewardship programs to influence the optimal use of antibiotics.

El uso inadecuado de antibióticos puede aumentar la probabilidad de resistencia a los antibióticos y eventos adversos. En los Estados Unidos, casi un tercio de las prescripciones de antibióticos en entornos ambulatorios son innecesarias, y la selección de antibióticos y la duración del tratamiento a menudo también son inapropiadas. Diferentes metanálisis y ensayos controlados aleatorios han evaluado las intervenciones para optimizar el uso de antibióticos.  En 2016, los CDC publicaron los Elementos centrales de la administración ambulatoria de antibióticos, que proporciona un marco para implementar estas intervenciones en entornos ambulatorios. Esta revisión resume la variada evidencia sobre los que impulsan a la prescripción inadecuada de antibióticos en entornos ambulatorios y las posibles intervenciones para mejorar su uso en dichos entornos.

Este estudio se suma a otros que muestran que no realizar una prescripción inmediata de antibióticos a las personas con infecciones respiratorias agudas comunes no complicadas, es una estrategia de bajo riesgo. En conjunto, proporcionan una buena evidencia de que la no prescripción de antibióticos en la primera visita para estas infecciones es una opción segura y debería permitir a los médicos mejorar la comunicación con los pacientes afectados, quizás utilizando la prescripción diferida entre otras técnicas para ayudar a lograr el mejor resultado posible para todos.

Background: Although Italian pediatric antimicrobial prescription rates are among the highest in Europe, little action has been taken to improve the appropriateness of antimicrobial prescriptions. The primary aim of this study was to assess changes in antibiotic prescription before and after acute otitis media (AOM) and group A streptococcus (GAS) pharyngitis Clinical Pathway (CP) implementation; secondary aims were to compare treatment failures and to assess change in the total antibiotics costs before and after CP implementation.

Methods: Pre-post quasi-experimental study comparing the 6-month period before CP implementation (baseline period: October 15, 2014, through April 15, 2015) to the 6 months after intervention (postintervention: October 15, 2015, through April 15, 2016).

Results: Two hundred ninety-five pre- and 278 postintervention emergency department visits were associated with AOM. After CP implementation, there was an increase in “wait and see” approach and a decrease in overall prescription of broad-spectrum antibiotics from 53.2% to 32.4% (P < 0.001). One hundred fifty-one pre- and 166 postimplementation clinic visits were associated with GAS pharyngitis, with a decrease in broad-spectrum prescription after CP implementation (46.4% vs. 6.6%; P < 0.001). For both conditions, no difference was found in treatment failure, and total antibiotics cost was significantly reduced after CP implementation, with a decrease especially in broad-spectrum antibiotics costs.

Conclusions: A reduction in broad-spectrum antibiotic prescriptions and a reduction in the total cost of antibiotics for AOM and GAS pharyngitis along with an increase in “wait and see” prescribing for AOM indicate effectiveness of CP for antimicrobial stewardship in this setting.

Se revisan 10 publicaciones sobre 9 estudios, que incluyen más de 1000 médicos de AP y 492000 pacientes. 6 de los estudios incluyen clínicos en prácticas y en 4 de ellos además se les ofrece información a los pacientes sobre el uso de antibióticos en infecciones respiratorias.

Parece que la toma compartida de decisiones disminuye la prescripción de antibióticos en estos casos, sin que disminuya la satisfacción del paciente en la consulta o aumenten las consultas de los pacientes por el mismo motivo.

No se especifica las consecuencias a otros niveles (ingresos) o su repercusión en las resistencias a antibióticos

Se requiere la definición de indicadores básicos de seguimiento de uso de antibióticos adaptados a la realidad local. Los resultados de estos indicadores pueden ser objeto de retroinformación a los profesionales y ser utilizados para evaluar el impacto de la implantación de programas de optimización de uso de antimicrobianos.

The patterns of antibiotic prescribing varied highly with age and country. The pediatric-specific QIs combined with the total prevalence rate of use provide a clear picture of the trends of community childhood antibiotic prescribing, allowing monitoring of the impact of policy interventions

Antibióticos preventivos

Resumen: La resistencia bacteriana a los antibióticos es una consecuencia, cada vez de mayor transcendencia, de la exposición a los antimicrobianos. En el artículo se estudiaron los patrones de resistencia de los urocultivos positivos en niños con espina bífida que realizan cateterización limpia intermitente. En aquellos que cesaban la profilaxis antibiótica se reducían las resistencias bacterianas a los antibióticos.

Se analizan 7 estudios que comparan tto con macrólidos en infecciones del tracto respiratorio inferior causadas por mycoplasma vs otros antibióticos o vs no tratamiento. Sólo uno de los 7 estudios muestra resultados favorable a los macrólidos. En el resto, resultados no concluyentes.

There is inconclusive evidence that antibiotic prophylaxis in certain groups of high-risk children can reduce pneumonia, exacerbations, hospital admission and mortality in certain conditions. However, limitations in the evidence base mean more clinical trials assessing the effectiveness of antibiotics for preventing LRTIs in children at high risk should be conducted. Specifically, clinical trials assessing the effectiveness of antibiotics for preventing LRTIs in congenital heart disease, metabolic disease, endocrine and renal disorders, neurological disease or prematurity should be a priority.

NOTA. Se revisan 10 ensayos clínicos en niños <12 años con riesgo infeccioso: 3 en pacientes con VIH, 4 en pacientes con FQ, 1 en pacientes con drepanocitosis, 1 en niños con cáncer y 1 en RNPT con patología respiratoria

-VIH: Profilaxis con isoniazida. No demuestran disminución significativa en la incidencia de TBC pulmonar. Profilaxis con cotrimoxazol: 1 de los 3 estudios muestra una disminución de la mortalidad; 1 de los 3 estudios muestra una disminución significativa en el número de ingresos. En general, no se demuestran en los 3 estudios un aumento de las reacciones adversas, pero en 1 estudio hablan de un aumento de resistencias.

-       FQ: La profilaxis con ciprofloxacino no disminuye de forma significativa las infecciones por pseudomona. La profilaxis con azitromicina reduce en 2 estudios las exacerbaciones respiratorias en 2 estudios. En 3 de los 4 estudios no se demuestra un aumento de las reacciones adversas y en 2 de los 4 estudios hablan de que no se evidencia un aumento de las resistencias

-       Drepanocitosis: 1 solo estudio en donde se demuestra una disminución significativa de la septicemia por neumococo en los pacientes que reciben profilaxis con penicilina.

-       Cáncer: 1 estudio en el que se demuestra disminución significativa en las infecciones por P. Carinii recibiendo profilaxis con trimetroprim-sulfametoxazol.

-       RNPT: no disminución de infecciones respiratorias con profilaxis con vancomicina.

Penicilina es un tto antibiótico eficaz y sin efectos secundarios en la anemia drepanocítica.

There is insufficient evidence for antibiotic use as a means of reducing the risk of otitis or pneumonia in children up tofive years of age with undifferentiated ARIs. Further high-quality research is needed to provide more definitive evidence of the effectiveness ofantibiotics in this population.

Antibióticos resistencia: el problema

La OMS ha reiterado su advertencia de que existe una grave falta de nuevos antibióticos en desarrollo para combatir la creciente amenaza de resistencia a los antimicrobianos. Sólo ocho de los 51 nuevos antibióticos y biológicos en desarrollo clínico, para tratar a los patógenos resistentes a los antibióticos, son tratamientos innovadores que podrían agregar valor a los medicamentos actuales. La mayoría de los fármacos en desarrollo clínico son modificaciones de las clases de antibióticos existentes y son sólo soluciones a corto plazo.

  • Join Action on Antimicrobial Resistance and Healthcare-Associated Infections EuropeFostering synergies to keep antibiotics working https://eu-jamrai.eu/

Antibióticos resistencia: factores de riesgo

Resumen: interesante y completa revisión sistemática. La exposición previa a antibióticos, las enfermedades subyacentes y el estar sometido a algún procedimiento invasivo son los principales factores de riesgo de desarrollar resistencias. Parece también que la transmisión relacionada con los alimentos y con el agua son miportantes (en la implicación de factores veterinarios y ambientales)

Conclusiones: La prescripción de antibióticos y la realización de pruebas complementarias se relacionaron significativamente con la hiperfrecuentación. También se relacionaron con la fidelización, pero de manera menos importante.

A 5-year-old girl with acute lymphoblastic leukaemia is receiving empirical intravenous antibiotic treatment for febrile neutropenia. On day 2 of her admission you are notified from the microbiology laboratory that she has a blood culture positive with a Gram-negative bacillus. You wonder if she has risk factors for antibiotic resistant Gram-negative bacteraemia and if her empirical antibiotic therapy should be adjusted.

Structured clinical question: In a child with cancer (patient) what risk factors (‘intervention’) affect probability of growth of an antibiotic resistant Gram-negative organism in blood culture (outcome) in comparison to growth of a sensitive Gram-negative organism (comparison).

Antibióticos: resistencias microbianas y uso racional (ver además apartado específico)

Antimicrobial resistance (AMR) is a priority for the Commission which adopted in 2011 an action plan against the rising threats from antimicrobial resistance. Progress towards more prudent use of antimicrobials in both humans and animals were key objectives. Guidelines on prudent use of antimicrobials in veterinary medicines were published in 20151. In 2016 Council Conclusions on the next steps under a One Health approach to combat antimicrobial resistance called on the Commission and Member States to develop European Union guidelines on prudent use of antimicrobials in human medicine to support national guidelines and recommendations2. These Guidelines on prudent use of ntimicrobials in human health are based on a technical report prepared by the European Centre for Disease Prevention and Control (ECDC) with input from EU Member States experts and stakeholders, which should be referred to for details of the methodology used in creating the guidelines as well as for additional references3

Resumen: Migrants are exposed toconditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to healthcare, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries.

  • Children with respiratory trac tinfections in Swedish primary care; prevalence of antibiotic resistance in common respiratory tract pathogens and relation to antibiotic consumptionBMC InfectiousDiseases 2017;17:603

La mayoría de los antibióticos consumidos en los países desarrollados se prescriben en atención primaria. Sin embargo, poco se sabe sobre los niveles de resistencia en estapoblación. La baja prevalencia de neumococos no sensibles a la penicilina apoya el uso de la fenoxi metilpenicilina como tratamiento empírico para las infecciones de las vías respiratorias superiores infantiles que asisten a atención primaria en nuestro entorno. Es importante que se realicen estudios sobre resistencia en poblaciones de atención primaria. El tratamiento antibiótico reciente aumenta el riesgo de resistencia bacteriana en los niños y debe priorizarse el trabajo continuo para reducir la prescripción innecesaria de antibióticos.

Este artículo presenta los datos acerca de las resistencias antimicrobianas de 7 microorganismos de gran importancia en sanidad púbilca: Escherichia coli, Klebsiella pneumoniae, Pseudomonas Aeruginosas, Acinetobacter ssp, Streptococcus pneumoniae, Staphyloccoccus Aureus y Enterococcus ssp.

Doce familias de bacterias, con nombre y apellidos, componen la lista de patógenos más peligrosos para la salud humana, por su resistencia a los antibióticos, y deben ser, según la Organizacion Mundial de la Salud (OMS), objetivo prioritario de la investigación farmacéutica. La lista de la OMS tiene tres categorías según la urgencia de nuevos antibióticos: prioridad crítica, alta o media.

Despite the many benefits of paediatric  Outpatient Parenteral Antimicrobial  Therapy (OPAT) programmes, there are risks associated with delivering inpatient-level care outside of hospital. There is a paucity of evidence defining how best to mitigate these risks. We examined the impact of introducing a dedicated medical team to OPAT, to define the role of increased medical oversight in improving patient outcomes in this cohort. A prospective 24-month pre-post observational cohort study. The Hospital in the Home (HiTH) programme at Princess Margaret Hospital (PMH) for Children, Western Australia. All OPAT admissions to HiTH, excluding haematology/oncology patients. INTERVENTIONS: PMH introduced a dedicated OPAT medical support team in July 2015 to improve adherence to best-practice guidelines for patient monitoring and review. MAIN OUTCOME MEASURES: Duration of OPAT, adherence to monitoring guidelines, drug-related and line-related adverse events and readmission to hospital. RESULTS:There were a total of 502 OPAT episodes over 24 months, with 407 episodes included in analyses. Following the introduction of the OPAT medical team, adherence to monitoring guidelines improved (OR 4.90, 95% CI 2.48 to 9.66); significantly fewer patients required readmission to hospital (OR 0.45, 95% CI 0.24 to 0.86) and there was a significant reduction in the proportion of patients receiving prolonged (≥7 days) OPAT (OR 0.67, 95% CI 0.45 to 0.99). CONCLUSION: The introduction of a formal medical team to HiTH demonstrated a positive clinical impact on OPAT patients' outcomes. These findings support the ongoing utility of me

Los Estados Miembros solicitaron a la Organización Mundial de la Salud que elaborara una lista mundial de patógenos prioritarios (PPL mundial), bacterias resistentes a los antibióticos, para ayudar a priorizar la investigación y el desarrollo (I+D) de nuevos y eficaces tratamientos antibióticos. Entre las recomendaciones realizadas por el panel de expertos destaco la que expresa la importancia de nuevos antibióticos para la población pediátrica y formulaciones orales para las enfermedades comunitarias con una alta morbilidad como Neisseriagonorrhoeae, Salmonella typhi, y Enterobacteriaceae productoras de ESBL

The handshake stewardship approach is an effective strategy for an antimicrobial stewardship program, as demonstrated by the widespread and significant decrease in antimicrobial use after implementation.

Antibiotic resistance is increasing worldwide and has become a very important threat to public health. The overconsumption of antibiotics is the most important cause of this problem. We created a World Alliance Against Antibiotic Resistance (WAAAR), which now includes 720 people from 55 different countries and is supported by 145 medical societies or various groups. In June 2014, WAAAR launched a declaration against antibiotic resistance. This article describes the process and the content of this declaration.

Los métodos más frecuentemente utilizados en Microbiología Clínica para la determinación de la sensibilidad de las bacterias a los antibióticos se basan en un estudio fenotípico, observando el crecimiento bacteriano de una cepa incubada en presencia del antibiótico a estudiar. Estos métodos requieren normalmente un tiempo de unas 24 h para la obtención de resultados. En esta revisión se exponen el fundamento y los resultados de las principales técnicas instrumentales que proporcionan un antibiograma rápido. De manera pormenorizada se exponen datos relativos a técnicas moleculares, microarrays, métodos comerciales utilizados en el trabajo de rutina, técnicas inmunocromatográficas, métodos colorimétricos, métodos de imagen, nefelometría, espectrometría de masas MALDI-TOF, citometría de flujo, quimioluminiscencia y bioluminiscencia, microfluidos y métodos de lisis bacteriana.

Age-stratified presentation of resistance percentage estimates by surveillance programs will allow identification of important variations in resistance patterns between different patient groups for targeted intervention.

RESUMEN: Comparan las estrategias más comunes para seleccionar las dosis de antibióticos para los niños y discuten la mejor manera para equilibrar la facilidad de aplicación con la precisión en la dosificación. A nivel internacional se encuentran diferencias importantes; En EE.UU. y gran parte de la Europa continental la dosificación se basa en el peso exacto, en el Reino Unido se dosifica según rango de edad y la OMS recomienda la dosificación según rango de peso. El artículo analiza los tres sistemas y concluye que la dosificación según el peso exacto es la forma más eficaz. Según rangos de peso,es relativamente fiable para niños y no está influenciada por los patrones de peso según edad. Aunque los enfoques según rango de edad son atractivos por su sencillez, es el menos seguro, están influenciados por los patrones regionales de peso según edad y una proporción importante de los niños reciben así dosis diarias totales muy bajas o altas.

Antibióticos (uso no humano)

Pronunciamiento del consejo de Salud Ambiental del comité de enfermedades infecciosas de la Academia American de Pediatría. Recomienda prudencia en la utilización de antibióticos en veterinaria para motivos diferentes que el tratamiento de sus infecciones.

Cuando se liberan aguas residuales no tratadas o tratadas inadecuadamente que contienen antibióticos y contaminan el agua, los antibióticos y sus metabolitos pueden entrar en la cadena alimentaria. La persistencia, la bioacumulación y la toxicidad pueden variar entre los diferentes antibióticos, pero todos contribuyen a la resistencia y tienen efectos adversos sobre los organismos vivos (plantas, animales, humanos). India y Bangladesh son los principales contribuyentes a la producción farmacéutica mundial. Los residuos de estas fábricas, junto con los producidos por el consumo humano y animal contribuyen a una importante contaminación del medio ambiente en esta región. En este documento, se identifican vías que contribuyen al manejo de los residuos de antibióticos en el medio ambiente y se proponen acciones prioritarias para los países del sudeste asiático para controlar y limitar esto.

Our findings suggest that antibiotic use within the first 2 years of life was a risk factor for current asthma, current atopic dermatitis, and current allergic rhinitis in 5-year-old children.

Apendicitis

While appendicectomy has been considered the mainstay of treatment for children with acute appendicitis for many decades, there has been a great deal of recent interest in non-operative treatment (NOT) with antibiotics alone. Initial results suggest that many children with appendicitis can indeed be safely treated with NOT and can be spared the surgeon’s knife. Many as yet unanswered questions remain, however, before NOT can be considered a realistic and reliable alternative to surgery. This review summaries current knowledge and understanding of the role of NOT in children with appendicitis and outlines and discusses the outstanding knowledge gaps.

In this study, we develop and validate a new score that can be used to accurately quantify risk for appendicitis.

A significant increase in NOM of nonperforated appendicitis was observed over 6 years. Patients with NOM had more subsequent ED visits and hospitalizations compared with those managed operatively at the index visit. A substantial proportion of patients initially managed nonoperatively eventually had an appendectomy.

In this timely study, Bachur et al1 reviewed data from the Pediatric Health Information System database over nearly 7 years, identifying 4190 children who met the following criteria for NOM: an emergency department (ED) visit with the diagnostic code for uncomplicated acute appendicitis, treatment with antibiotics, no procedure codes for appendectomy during the index visit, and no history of a previous appendectomy or appendicitis in the past year. The comparison group of 61 522 children had a diagnostic code for uncomplicated acute appendicitis …

Resumen: este metanálisis analiza 10 estudios que comparan niños no tratados quirúrgicamente de apendicitis aguda con niños tratados quirúrgicamente. Los resultados sugieren que el tratamiento no quirúrgico es tan efectivo y seguro como el quirúrgico en el episodio agudo, aunque hay un 14% de recurrencias.

Arañazo de gato

We identified 13 patients with cat scratch (Bartonella henselae) bone infection among those admitted to a large tertiary care children's hospital over a 12-year period. The median age was 7 years and the median time from onset of illness to diagnosis was 10 days. Multifocal osteomyelitis involving spine and pelvis was common; no patient had a lytic bone lesion. Median treatment duration was 28 days (IQR, 24.5 days). Despite significant variations in treatment duration and antimicrobial therapy choices, all patients showed improvement.

We present the case of a 13-year-old immunosuppressed patient with unrelenting cat scratch disease despite 9 months of antibiotic therapy. The patient was being treated with mycophenolate and prednisone for membranoproliferative glomerulonephritis (type 1) diagnosed 13 months before the onset of cat scratch disease. Cat scratch disease was suspected due to epitrochlear lymphadenitis and an inoculation papule on the ipsilateral thumb, and the diagnosis was confirmed by the use of acute and convalescent titers positive for Bartonella henselae. The patient experienced prolonged lymphadenitis despite azithromycin and rifampin therapy, and she developed a draining sinus tract ∼4 months after initial inoculation while receiving antibiotics. Acute exacerbation of the primary supratrochlear node prompted incision and drainage of the area, with no improvement in the disease course. Ultimately, excision of all affected nodes and the sinus tract 9 months after the initial diagnosis was required to achieve resolution. Bartonella was detected at a high level according to a polymerase chain reaction assay in the excised nodes. Persistent treatment with oral antibiotics may have prevented disseminated infection in this immunosuppressed patient. Surgical excision of affected nodes should be considered in patients with cat scratch disease that persists beyond 16 weeks.

Artritis (Ver Temas A-Z)

La artritis neumocócica es una entidad que debe ser tenida en cuenta ya que la mayoría de los cuadros de artritis en población pediátrica aparecen como complicación de una bacteriemia posterior a un cuadro catarral o una otitis. El mayor riesgo de secuelas se asocia a retrasos en el diagnóstico, por ello es imprescindible un diagnóstico precoz clínico y microbiológico.

There were no sufficiently reliable predictors for differentiating between SA and JIA at onset. The outcomes were different; JIA should be considered in cases of poor disease evolution after antibiotic treatment and joint aspiration.

Evidence for corticosteroids as adjunctive therapy in children with a diagnosis of septic arthritis is of low quality and is derived from the findings of two trials (N = 149). Corticosteroids may increase the proportion of patients without pain and the proportion of patients with normal function of the affected joint at 12 months, and may also reduce the number of days of antibiotic treatment. However, we cannot draw strong conclusions based upon these trial results. Additional randomised clinical trials in children with relevant outcomes are needed.

Presentación de un caso de un lactante de 9 meses con fiebre recurrente. Diagnóstico: artritis séptica aguda de cadera izquierda. A propósito de este caso se realiza un diagnóstico diferencial de las fiebre recurrente y la fiebre de origen desconocido

Asma

Resumen: se ha demostrado el potencial de patógenos respiratorios como desencadenantes de exacerbaciones asmáticas, pero no tanto su impacto en la gravedad y en la respuesta al tratamiento. Este estudio de cohortes, prospectivo, con 958 niños y adolescentes de 1 a 17 años, muestra que aunque no se asocien con mayor gravedad en el debut, sí que se relacionan con mayor fracaso terapéutico. Y particularmente más en casos de virus sincitial respiratorio, influenza y parainfluenza.

We found limited evidence that antibiotics given at the time of an asthma exacerbation may improve symptoms and PEFR at follow-up compared with standard care or placebo. However, findings were inconsistent across the six heterogeneous studies included, two of the studies were conducted over 30 years ago and most of the participants included in this review were recruited from emergency departments, limiting the applicability of findings to this population. Therefore we have limited confidence in the results. We found insufficient evidence about several patient-important outcomes (e.g. hospital admission) to form conclusions. We were unable to rule out a difference between groups in terms of all adverse events, but serious adverse events were rare.

Azitromicina

Conclusiones de los autores del estudio: la azitromicina disminuye la concentración de los niveles nasofaríngeos de interleucina 8 (IL-8) durante la duración del estudio y produce un retraso en la aparición de un tercer episodio de sibilancias recurrentes durante el periodo de seguimiento.

Comentario de los revisores: los resultados de este ensayo no bastan para recomendar un uso indiscriminado de la azitromicina para el tratamiento de la bronquiolitis aguda durante su ingreso hospitalario y tampoco para prevenir los posibles episodios de sibilancias recurrentes posteriores. Si realmente la azitromicina posee algún tipo de efecto clínicamente importante sobre la bronquiolitis aguda y sus recurrencias, ello tendrá que ponerse de manifiesto en un ensayo clínico específicamente diseñado para tal fin, ya que los resultados de un ensayo piloto no pueden tomarse como base para establecer cambios en la práctica clínica cotidiana.

Question Among children in sub-Saharan Africa, what is the therapeutic efficacy of azithromycin, compared with placebo, in reducing overall mortality?

Design Cluster randomized controlled trial.

Setting Malawi, Niger, Tanzania.

Participants 190,238 children, 1-59 months of age.

Intervention 4 twice-yearly doses of azithromycin or placebo.

Outcomes Mortality.

Main Results Overall mortality was reduced by 13.5% (95% CI, 6.7 to 19.8). In sub-group analysis, only Niger demonstrated a statistically significant effect among the 3 countries.

Conclusions Mass azithromycin distribution reduced overall mortality, with the largest and statistically-significant effect in Niger.

Resumen: estudio de cohortes retrospectivas sobre 1.074.236 niños menores de 90 día de vida pertenecientes a un seguro médico militr en USA. La ingesta de Azitromicina en los primeros 14 días de vida determinó un riesgo significativamente mayor de estenosis hipertrófica de píloro  (adjusted odds ratio [aOR], 8.26; 95% confidence interval [CI], 2.62–26.0); la ingesta entre los días 15 y 42 también determinó un riesgo significativamente mayor (aOR 2.98; 95% CI, 1.24–7.20). También la exposición a eritormicina en los primeros 14 días de vida y entre 15 y 42 días determinó un riesgo mayor: aOR 13.3 (95% CI, 6.80–25.9), y  aOR 4.10 (95% CI, 1.69–9.91), respectivamente. La ingesta de macrólidos por encima de los 42 días de vida no supuso mayor riesgo de la enfermedad.

In contrast to recent adult studies, among children hospitalized for community-acquired pneumonia, azithromycin use was not associated with a greater prevalence of cardiac arrest compared with penicillin or cephalosporin use.

Babesiosis

La babesiosis, una enfermedad zoonótica transmitida por garrapatas causada por protozoos intraeritrocitarios del género babesia, se caracteriza por anemia hemolítica no inmune que se resuelve con el tratamiento antimicrobiano y la eliminación de la parasitemia. El desarrollo de la anemia hemolítica autoinmune de anticuerpos calientes  (también conocida como anemia hemolítica autoinmune cálida [WAHA]) en pacientes con babesiosis no ha sido previamente bien descrito.

Bacteriemia (ver también fiebre sin foco)

In the United States, routine immunizations have made bacteremia in the previously healthy toddler a rare event. As the incidence of pneumococcal bacteremia has decreased, E coliSalmonella spp, and S aureus have increased in relative importance. New guidelines are needed to approach the previously healthy febrile toddler in the outpatient setting.

Balanitis

A. schaalii debe ser considerado como un uropatógeno emergente a tener en cuenta en pediatría, especialmente e niños menores de 4 años con enfermedad nefrourinaria, que usen pañal, tengan enuresis u otras condiciones que provoquen humedad en zona genital, y concretamente ante sospecha de infección de orina y negatividad de cultivos habituale. Esta bacteria es habitualmente resistente a fluoroquinolonas y cotrimoxazol, . Se recomienda para el tratamiento de las infecciones producidas por A. schaalii, o su sospecha, amoxicilina o cefalosporinas6. Con respecto a las infecciones balanoprepuciales, podría ser suficiente el tratamiento tópico con mupirocina.

Biofilms (Ver Temas A-Z)

Blastocystis

Blastocystis hominis es el parásito que con mayor frecuencia se encuentra en las heces de las personas, tanto sintomáticas como asintomáticas. y presenta controversias en cuanto a su patogenicidad. aunque cada vez más estudios apoyan su participación en patología clínica. Estudio retrospectivo de parásitos en heces de 786 pacientes sintomáticos de entre 1 y 15 años. De las muestras positivas para enteroparásitos, el Blastocystis hominis fue el que se aisló con más frecuencia, seguido del Cryptosporidium y en tercer lugar la Giardia lamblia. Los síntomas que presentaron por orden decreciente fueron: dolor abdominal, flatulencia/distensión abdominal, pérdida de apetito y diarrea. En base a las dudas sobre su patogenicidad, se adoptó una actitud expectante, 9 se negativizaron espontáneamente  y en los restantes 11 casos al persistir la clínica a los 2-4 meses se trató con metronidazol 10 días. El resultado fue mejoría clínica en la mayoría, negativizándose los parásitos en el 100%

Boca-mano-pie Síndrome

The ability of our models to capture the observed epidemic cycles suggests that herd immunity is driving the epidemic dynamicscaused by the multiple serotypes of enterovirus. Our results predict that the EV-A71 and CV-A16 serotypes provide a temporary immunizing effect against each other. Achieving high coverage rates of EV-A71 vaccination would be necessary to eliminate the ongoing transmission of EV-A71, but serotype replacement by CV-A16 following EV-A71 vaccination is likely to be transient and minor compared to the corresponding reduction in the burden of EV-A71-associated HFMD. Therefore, a mass EV-A71 vaccination program of infants and young children should provide significant benefits in terms of a reduction in overall HFMD burden.

A 36-year-old man presented to the dermatology clinic with a 5-day history of blisters on his palms (Panel A) and soles (Panel B) and ulcerations on his tongue (Panel C). He also reported fevers, malaise, and a sore throat. One week before his illness began, his 2- and 4-year-old children had had similar symptoms, and they received a diagnosis of hand, foot, and mouth disease

Resumen: La enfermedad de mano-pie-boca (EMPB) es una de las enfermedades exantemáticas más frecuentes en niños menores de cinco años, generalmente producida por los virusCoxsackie A16 y enterovirus 71. En los últimos años se están observando manifestaciones dérmicas diferentes a la habitual causadas por serotipos menos frecuentes como el Coxsackievirus A. Estos pacientes presentan fiebre y síntomas sistémicos como la EMPB típica, pero tienen una manifestación cutánea más grave, pudiendo simular un cuadro Gianotti Crosti-like, o, incluso, un eccema herpeticum. En estos casos, recomendamos analizar el serotipo de enterovirus (PCR de las lesiones cutáneas) para prevenir pruebas diagnósticas innecesarias o tratamientos antivirales inapropiados. Presentamos dos casos en niños menores de cinco años, de presentación atípica de EMPB, atendidos en nuestro Servicio de Urgencias. Ambos referían como antecedente padecer dermatitis atópica.

To assess whether breastfeeding duration can affect risk of severe hand, foot and mouth disease (HFMD) later in childhood, we retrospectively analyzed demographic, environmental and breastfeeding data on 603 children with severe HFMD and 1036 children with mild HFMD. Multivariate analysis showed that breastfeeding for 6–12 months significantly reduced the risk of severe HFMD, as did breastfeeding for >12 months.

CONCLUSIONS: Knowledge on HFMD remains insufficient to guide interventions such as the incorporation of an EV-A71 vaccine in pediatric vaccination schedules. Research is urgently needed to fill these gaps.

Hand, foot and mouth disease/herpangina virus outbreak enables triggering a K. kingae infections outbreak. Our findings offer support for new guidelines of K. kingae infections outbreaks management and emphasize the need for further research

Conclusions: We recommend that glucocorticoids should not be used for mild hand, foot, and mouth disease and andrographolides should undergo clinical trials for treatment of enterovirus 71 infections.

Multiple EV genotypes contributed to HFMD in Nanjing in 2013, and CVA6 was the dominant genotype. The clinical presentation of CVA6 infection differs from that of EV71 infection in HFMD.

Botulismo

The use of BIG-IV since its licensure in 2003 treated approximately 93% of US patients with laboratory-confirmed infantbotulism, and prevented >65 years in hospital stay and >$85 million in hospital charges from occurring. The greatest LOS reduction was achieved when BIG-IV was administered soon after hospital admission. Effective and appropriate use of BIG-IV in the US has continued in the postlicensure period.

From 2005 to 2015, 76 clinical mimic illnesses were identified. These illnesses were distributed into the 5 categories previously reported of (1) probable infant botulism lacking confirmatory testing (26.3%); (2) spinal muscular atrophy (19.7%); (3) miscellaneous (15.8%); (4) metabolic disorders (11.8%); and (5) other infectious diseases (10.6%). Of the 76 clinical mimic illnesses, 15.8% had no alternate diagnosis established and were therefore categorized as undetermined.

Over the 23 years 1992-2015, patients presenting with illnesses so clinically similar to infant botulism that they were treated with BIG-IV had actual diagnoses that were distributed into 5 main categories. These categories and their individual components constitute a working bedside differential diagnosis of infant botulism.

Botulism is a severe, potentially fatal neuroparalytic illness.* A single case is a public health emergency, because it can signal an outbreak

En el periodo 1997-2013 se produjeron 151 casos de botulismo en España, 6 de ellos en la Comunidad Valenciana1. El botulismo alimentario se adquiere por la ingestión de un alimento contaminado con neurotoxinas (BoNT) que producen Clostridium botulinum, C. baratii y C. butyricum.

Bronquiectasias (ver también Temas A-Z)

  • Amoxicillin-clavulanate versus azithromycin for respiratory exacerbations in children with bronchiectasis (BEST-2): a multicentre, double-blind, non-inferiority, randomised controlled trial. Lancet.  2018;392(10154):1197-1206.

Resumen: ensayo clínico de no inferioridad comparando el tratamiento de las exacerbaciones del niño con bronquiectasias, con azitromicina frente a amoxicilina/ácido clavulánico. Tras 21 días de tratamiento no hay diferencias en la tasa de resolución de exacerbaciones no graves de bronquiectasias, entre los dos antibióticos.

Further investigations including a MDCT scan should be considered in a child with a chronic wet cough that persists following 4 weeks of oral antibiotics. However, while reducing the likelihood of underlying bronchiectasis, responding well to a single prolonged course of antibiotics does not exclude this diagnosis completely.

Se revisan 18 estudios que incluyen 1157 pacientes (la mayoría adultos) con bronquiectasias no debidas a FQ. 12 estudios analizan tratamiento con antibióticos orales (azitromicina, eritromicina, roxitomicina, amoxicilina, claritromicina, penicilina, oxitetraciclina, ciprofloxacino); 6 estudios usan antibióticos inhalados. Se administran entre 4 y 83 semanas.

El uso prolongado de antibióticos en bronquiectasias disminuye el riesgo de exacerbaciones y hospitalizaciones, siendo en general bien tolerados. Sin embargo es importante el alto riesgo de desarrollar resistencias, en especial en pacientes con alergias, que pueden limitar sus tratamiento futuros.

Bronquiolitis (ver también Temas A-Z)

Introducción: La presencia de apneas en la bronquiolitis aguda (BA) varía según las series entre el 1,2 y el 28,8%. uestro objetivo es conocer la incidencia de apneas en pacientes ingresados con diagnóstico de BA y definir sus factores de riesgo asociados para construir un modelo de predicción. método: Estudio observacional retrospectivo 5 años de pacientes ingresados en un hospital terciario con diagnóstico de BA según los criterios clásicos. Se recogieron la frecuencia de apneas y las variables clínicas relacionadas, para encontrar factores de riesgo en un modelo de regresión logística binaria para la predicción de apneas. Para evaluar el modelo se elaboró una curva ROC. Resultados: De 1.197 casos, se registró apnea durante el ingreso en 53 (4,4%). Los factores de riesgo incluidos en la ecuación fueron: sexo femenino, cesárea), edad posmenstrual ≤ 43 semanas , fiebre , bajo peso al ingreso, apneas antes del ingreso observada por los cuidadores y sobreinfección bacteriana . La sensibilidad y la especificidad óptima del modelo en la curva ROC fueron de 0,842 y 0,846, respectivamente (p<0,001). Conclusiones: La incidencia de apneas durante el ingreso fue de 4,4 por cada 100 ingresos de BA y año. La ecuación del modelo de predicción estimado puede ser de ayuda al clínico para clasificar a los pacientes con mayor riesgo de apnea durante el ingreso en la BA.

Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and previously updated in 2010 and 2013.

We included a total of 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline.

Nebulised hypertonic saline may reduce hospital stay by 10 hours in comparison to normal saline for infants admitted with acute bronchiolitis. We found that 'clinical severity scores', which are used by doctors to assess patient health, for children treated as outpatients or in hospital improved when administered nebulised hypertonic saline compared to normal saline. Nebulised hypertonic saline may also reduce the risk of hospitalisation by 14% among children treated as outpatients or in the emergency department. We found only minor and spontaneously resolved adverse effects from the use of nebulised hypertonic saline when given with treatment to relax airways (bronchodilators).

Reductions in hospital stay were smaller than previously thought. However, an average reduction of 10 hours in the length of hospital stay for infants is significant because bronchiolitis usually has a short duration. Nebulised hypertonic saline appears to be safe and widely available at low cost. However, we assessed the quality of the evidence as low to moderate.

In a prospective cohort of children hospitalized for bronchiolitis, we examined the rate of and characteristics associated with bronchiolitis relapse. Bronchiolitis relapse was documented in 22 (6%) of 391 children, and median time to relapse was 2 (interquartile range, 1–7) days. Relapse occurred more often in males. Prenatal smoking and smoke exposure in the home were also associated with relapse.

Resumen: variaciones en el manejo hospitalario de la Bonquiolitis en diferentes Hospitales de 8países desarrollados. No parecen muy justificadas. La utilización de farmacoterapia (no indicada) osciló entre un 2 y un 79%. Comparado con Australia y Nueva Zelanda la ORajustada de uso de fármacos fue 22,7 en España y Portugal(IC 95%: 4,5 a 111); 11,5 en Canadá; 6,8 en USA y 1,4 em Reino Unido. Comparado con Reino Unido la OR para la realización de radiografía fue 4,9 en USA; 4,9 en Candá; 2,4 en España y Portugal (IC 95%: 0,6 a 9,8) y 1,8 en Australia y Nueva Zelanda.

Most (87%) bronchiolitis cases are managed in primary care offices. Approximately 2 out of every 10 children <2 are diagnosed of bronchiolitis, 3 out of every 100 are hospitalized and 1.6 out of every 100 are hospitalized with RSV bronchiolitis in our cohort. Infants between 2 and 10 weeks constitute a risk group for severe bronchiolitis.

Resumen: El virus respiratorio sincitial (VRS) es una causa importante de infecciones del tracto respiratorio inferior en lactantes. No queda claro por qué un pequeño porcentaje de los niños infectados por el VRS desarrollan una infección grave. En este estudio, se investiga si los portadores nasofaríngeos de neumococos se correlacionan con la inflamación de la mucosa y la gravedad de la enfermedad por VRS. Los resultados muestran correlaciones entre la densidad de S. pneumoniae y la carga viral, la inflamación y la gravedad de la enfermedad, lo que sugiere que la densidad de neumococo puede ser un indicador para la gravedad de la enfermedad por el VRS.

Se revisan 5 ECCR; 2 analizan la disminución de la estancia hospitalarias y la severidad clínica y 3 tratan de evaluar recurrencias. Existe baja calidad de evidencia en estos estudios, por lo que no nos aportan datos relevantes.

Most children's hospitals have an institutional bronchiolitis CPG in place. The content of these CPGs is largely uniform in practice recommendations against tests and treatments. The presence of institutional CPGs did not significantly reduce the ordering of tests and treatments. Online accessibility of a written CPG and prolonged duration of implementation reduce tests and treatments.

In this prospective, multicenter, multiyear study of children hospitalized with bronchiolitis, we found that RSV/RV coinfection was independently associated with a higher likelihood of bronchiolitis relapse. Present data support the concept that the infectious etiology of severe bronchiolitis affects short-term outcomes.

Resumen: variaciones en el manejo hospitalario de la Bonquiolitis en diferentes Hospitales de 8países desarrollados. No parecen muy justificadas. La utilización de farmacoterapia (no indicada) osciló entre un 2 y un 79%. Comparado con Australia y Nueva Zelanda la ORajustada de uso de fármacos fue 22,7 en España y Portugal(IC 95%: 4,5 a 111); 11,5 en Canadá; 6,8 en USA y 1,4 em Reino Unido. Comparado con Reino Unido la OR para la realización de radiografía fue 4,9 en USA; 4,9 en Candá; 2,4 en España y Portugal (IC 95%: 0,6 a 9,8) y 1,8 en Australia y Nueva Zelanda.

Revisión sistemática sobre 24 ensayos clínicos y 3209 pacientes. Parecen obtenerse discretos beneficios con el suero salino hipertónico nebulizado frente al isotónico. No obstante la consistencia de la evidencia es moderada, por la disparidad de resultados entre estudios y los sesgos detectados en ellos.

Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and previously updated in 2010 and 2013.

We included a total of 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline.

Nebulised hypertonic saline may reduce hospital stay by 10 hours in comparison to normal saline for infants admitted with acute bronchiolitis. We found that 'clinical severity scores', which are used by doctors to assess patient health, for children treated as outpatients or in hospital improved when administered nebulised hypertonic saline compared to normal saline. Nebulised hypertonic saline may also reduce the risk of hospitalisation by 14% among children treated as outpatients or in the emergency department. We found only minor and spontaneously resolved adverse effects from the use of nebulised hypertonic saline when given with treatment to relax airways (bronchodilators).

Reductions in hospital stay were smaller than previously thought. However, an average reduction of 10 hours in the length of hospital stay for infants is significant because bronchiolitis usually has a short duration. Nebulised hypertonic saline appears to be safe and widely available at low cost. However, we assessed the quality of the evidence as low to moderate.

Acute bronchiolitis is the most common cause for hospitalisation in infancy with 2–3% of all UK infants admitted in their first winter.1 ,2 It has a substantial health economic burden with annual costs in the USA of over $0.5 billion for hospital care alone.3 In addition to short-term morbidity, there are also associated long-term consequences with 40–50% of those admitted subsequently enduring recurrent wheeze.4 ,5 The significant impact of bronchiolitis has led to an extensive search for effective therapies over the last half century since Reynolds’ oft-quoted aphorism that “oxygen is vitally important in bronchiolitis and there is little convincing evidence that any other therapy is consistently, or even occasionally, useful

Un nuevo ensayo clínico sobre la terapia en bronquiolitis con nebulización de suero hipertónico frente a normotónico. En este caso en niños hospitalizados no hay diferencias ni en los días de estancia hospitalarios ni en las complicaciones.

When older infants present with symptoms of respiratory distress including wheeze, diagnosing bronchiolitis can be challenging. This is because other causes of wheeze, such as asthma and viral wheeze (VW) also feature in this age group. In my own practice, I consistently come across wide practice variations, which may indicate confusion on the subject. This study aimed to survey the diagnostic parameters employed by paediatric medical staff for bronchiolitis and the management of wheeze for children up to 2 years. One hundred and eighty-five emails were sent to the clinical directors of all UK acute paediatric units with questions related to the diagnosis of bronchiolitis and management of wheeze …

Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.

Se revisan 3 ensayos clínicos controlados, reclutando un total de 79 pacientes menores de 2,5 años, con bronquiolitis grave que precisan ventilación mecánica. 2 de ellos no comparan con placebo y dos de ellos no nos da información sobre la mortalidad. Se comprueba, con un nivel moderado de evidencia, que el uso de surfactante reduce la duración de la VM, el tiempo de estancia en UVI y mejora los parámetros gasométricos. Sin embargo el “n” muestral es pequeño, por los que son necesarios más estudios.

The most common causes of bronchiolitis obliterans organizing pneumonia (BOOP) are connective tissue diseases, organ transplantation, drug reaction, and infections. Although rare, BOOP due to gastroesophageal reflux (GER) has been reported in adults but not to date in pediatric patients. This study describes 2 pediatric patients who developed GER and BOOP. One patient had superior mesenteric artery syndrome and Helicobacter pylori infection, and the other had a gastroduodenal ulcer with reflux esophagitis. Respiratory symptoms occurred concurrently or after gastrointestinal symptoms. Monitoring of esophageal pH for 24 hours revealed pathologic acid reflux. Lung biopsy findings confirmed BOOP. No other causes of BOOP were observed in these 2 patients. Both patients were cured with antireflux therapy and corticosteroids. To our knowledge, this is the first case report to implicate GER as a reversible cause of BOOP in children.

Bronquitis

  • Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews 2017, Issue 6. Art. No.: CD000245. DOI: 10.1002/14651858.CD000245.pub4. NOTA: no especifica si los ensayos incluyen niños

We did not identify any new trials for inclusion in this 2017 update. We included 17 trials with 5099 participants in the primary analysis. The quality of trials was generally good. At follow-up there was no difference in participants described as being clinically improved between the antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15). Participants given antibiotics were less likely to have a cough (4 studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 6) and a night cough (4 studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7). Participants given antibiotics had a shorter mean cough duration (7 studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance. There is limited evidence of clinical benefit to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self limiting condition, increased resistance to respiratory pathogens, and cost of antibiotic treatment.

Bronquitis bacteriana prolongada (Ver Temas A-Z)

Protracted bacterial bronchitis (PBB) is caused by a bacterial infection of the conducting airways in children who are otherwise healthy. It is the leading cause of chronic wet cough in young children and the most common reason for referrals to the Paediatric Respiratory Clinics in the UK.1 The cough has a negative effect on the quality of life of the affected child and their family.2 If PBB is left untreated, it has been postulated that ongoing endobronchial infection may be a risk factor in the development of bronchiectasis.3 The diagnosis is based on the presence of an isolated wet cough for >4 weeks, the…

This is the first long-term review of treatment outcomes in children with PBB confirmed by FB-BAL.

Brucella

Overall, 511 brucellosis episodes were identified; 42% (N = 214) with ≥1 cytopenia, including 13% (N = 68) anemia, 28% (N = 144) leukopenia, 14% (N = 74) thrombocytopenia and 2% (N = 9) pancytopenia. Overall, 99.8% of episodes were in Bedouin children and 70% in males. In 79% of episodes, blood culture was positive for Brucella melitensis. Acute infections comprised 84% of all episodes. In univariate analysis, older age (10.49 ± 4.81 vs. 9.25 ± 4.89 years), fever (92% vs. 78%), positive blood culture (84% vs. 75%) and IgM ≥1:640 levels (50% vs. 39%) were associated with cytopenia. In contrast, arthralgia was associated with noncytopenic episodes. In multivariate analyses, older age (odds ratio = 1.063) and fever (odds ratio = 3.127) were associated with cytopenia.

Brucellosis is commonly presented with cytopenia, especially in bacteremic episodes with fever. However, pancytopenia is uncommon and its finding should alert the physician to look for other possible etiologies.

Campylobacter

El género Campylobacter está compuesto por 25 especies bacterianas. C. jejuni y C. lari son las especies que mayor cantidad de casos generan en el mundo, causando una enterocolitis de transmisión alimentaria. Alimentos como carne de pollo y leche no pasteurizada se relacionan con casos ETAs por Campylobacter spp. Campylobacter spp. es considerado como el primer agente etiológico de diarrea en países desarrollados, y el segundo o tercero en países en vías de desarrollo. En Chile, su notificación hacia los laboratorios de referencias es baja, y no está incluida en el RSA chileno. Debido al abuso de antibióticos en salud animal y humana, Campylobacter spp. ha desarrollado resistencia hacia antibióticos de primera elección en el tratamiento de la campilobacteriosis

Interventions that focus on proper handling of chicken and chicken products, hand washing and encouraging consumption of fruits and vegetables could help in controlling Campylobacter infections.

Candida

The newly recognised and emerging fungal species, Candida auris, has caused worldwide invasive infections and has been implicated in difficult to control hospital outbreaks. Challenges are encountered in the correct identification of this fungus as commonly used phenotypic and biochemical methods fail to differentiate C. auris from other Candida species. Its resistance profile, over 90% of isolates are fluconazole resistant and 35% are resistant to amphotericin, confronts clinicians with the restricted arsenal of antifungals and concerns about optimal treatment. The very first C. auris isolate was recovered from a paediatric patient in retrospect. Although infections with the more antifungal-resistant Candida species are less frequently observed in paediatric patients, this seems to be different for C. auris infections.

Carbapenemasas (ver también Temas A-Z)

Las infecciones causadas por Enterobacterias Resistentes a Carbapenems (ERC) están aumentando a nivel global pero no han sido bien descritas en población pediátrica. Este estudio explora las características clínicas, fenotípicas y genotípicas de las infecciones por ERC en una población de pacientes vulnerables, como es la población pediátrica, en un centro de referencia pediátrico de un gran área metropolitana de los EEUU. Es esencial conocer con detalle la distribución y extensión de las ERC para lograr una detección precoz y un control adecuado de estos peligrosos patógenos. 

In 2012, the European Centre for Disease Prevention and Control (ECDC) launched the ‘European survey of carbapenemase-producing Enterobacteriaceae (EuSCAPE)’ project to gain insights into the occurrence and epidemiology of carbapenemase-producing Enterobacteriaceae (CPE), to increase the awareness of the spread of CPE, and to build and enhance the laboratory capacity for diagnosis and surveillance of CPE in Europe.

Catarro  (ver también Temas A-Z)

Los antihistamínicos tienen une efecto beneficioso a corto plazo (días 1 y 2 de tto) pero no a medio/largo plazo. No hay diferencias significativas en cuanto a la obstrucción nasal/rinorrea. Aunque hay más efectos secundarios con los antihistamínicos sedantes la diferencia no es estadísticamente significativa. No hay evidencia sobre su efectividad en niños.

Current evidence does not support the use of intranasal corticosteroids for symptomatic relief from the common cold. However, there were only three trials, one of which was very poor quality, and there was limited statistical power overall. Further large, randomised, double-blind, placebo-controlled trials in adults and children are required to answer this question.

Catéter

Although the data from one small trial (n 98) indicates that antimicrobial-impregnated central venous catheters might prevent catheter-related bloodstream infection in newborn infants, the available evidence is insufficient to guide clinical practice. A large, simple and pragmatic randomised controlled trial is needed to resolve on-going uncertainty. NOTA: se analiza un único ensayo que incluye a 98 RNPT, en los que se ha canalizado la vena umbilical utilizando un catéter con una solución antimicrobiana (plata).

Ceftarolina

Celulitis

Caso clínico con características y diagnóstico “atípicos”.

A healthy 8-year-old girl presented with painful eyelid swelling and erythema predominantly affecting the left eye (Figure 1). There was no history of trauma. Visual acuity was 6/6. Pupils and eye movements were normal, and no proptosis was noted. The findings of an ocular examination were unremarkable. She was admitted and treated for preseptal cellulitis. She went to the hospital every 2-4 weeks with this clinical presentation and treated with oral or intravenous antibiotics on each occasion.

Chagas enfermedad de (ver también Temas A-Z)

Introducción: La enfermedad de Chagas, causada por Trypanosoma cruzi, es endémica en Latinoamérica y emergente en España, ligada a inmigración. La transmisión vertical se estima de alrededor del 5%. Se recomienda cribado selectivo en el embarazo para identificar al recién nacido infectado, permitiendo tratamiento precoz y curación de la enfermedad. Objetivo:estimar la prevalencia de serología positiva para T. cruzi en una cohorte de gestantes latinoamericanas y la tasa de transmisión vertical de la misma. Métodos: estudio observacional prospectivo de gestantes con serología positiva para T. cruzi en hospital terciario, desde enero del 2013 hasta abril del 2015. El seguimiento de recién nacidos se realizó con PCR al nacimiento, repetida al mes, y serología a los 9-12 meses. Se consideró infectado al niño con PCR positiva y no infectado al niño con PCR negativa y/o negativización de anticuerpos. Resultados:Se realizó cribado en 1.244 gestantes latinoamericanas, siendo positivas 40, 85% procedentes de Bolivia. Solo un niño resultó infectado con PCR positiva al nacimiento. La detección de la embarazada permitió estudiar a los hermanos, detectándose caso asintomático en paciente de 8 años. Ambos tratados con benznidazol con buena tolerancia, evolución favorable y negativización de PCR y anticuerpos. Conclusión: El cribado de embarazadas latinoamericanas ha permitido la detección de gestantes con enfermedad de Chagas y la detección y el tratamiento de casos familiares no identificados previamente.La transmisión vertical fue del 2,3%, coincidente con la literatura.

INTRODUCTION: very little data is available on the extensive, familiar, serological screening of Trypanosoma cruzi from infected-index cases. it is a parasite with possibility of mother-to-child fetal transmission.
METHODS: An observational study using a capture-recapture method that evaluates the offspring serological status of women diagnosed with T. cruzi infection (positive serology) in the northern metropolitan area of Barcelona during 2005-2016.
RESULTS: A total of 238 women with positive serology for T. cruzi were identified. Of these, 117 could be localized. Their offspring summarized 300 individuals, of which 192 had serology records, with 23 positive for T. cruzi (11.98%; CI95%: 8.1-17.3). Among the 53 children born within the study area, 5 (9.8%, CI95%: 4.2-20.9) cases of vertical transmission were recorded. All children born as of 2010 (the starting year of mother screening) had serological outputs.
CONCLUSIONS: Offspring of T. cruzi-seropositive women showed a high rate of seropositivity. The prevalence of vertical transmission is also remarkably high but comparable to that obtained in other European studies. It is reasonable to formaly include extensive, familiar, serological assessment in Chagas screening guidelines. In order to avoid losses, any eventual screening should be implemented at the time of the maternal diagnosis.

Chikungunya (ver también Temas A-Z)

Debemos sospechar la fiebre de chikungunya ante todo paciente con antecedentes epidemiológicos que presenta fiebre, poliartralgias/poliartriatis y lesiones cutáneas. En los próximos años podrían aumentar los casos importados y aparecer brotes de transmisión autóctona en España.

Chlamydia

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.

La infección por Chlamydia trachomatis es la principal causa bacteriana de infecciones de transmisión sexual. La infección puede transmitirse a través del canal del parto, pudiendo ocasionar nasofaringitis y/o conjuntivitis neonatal (habitualmente 5-12 días tras el parto), así como neumonía en los 3 primeros meses de vida.
El objetivo del presente trabajo fue investigar la tasa de transmisión perinatal de la infección por C. trachomatis. Entre octubre/2010 y septiembre/2015 se estudió prospectivamente, mediante una técnica de amplificación de ácidos nucleicos (TAAN) en tiempo real, la presencia de C. trachomatis en 103 hijos de madres infectadas, detectadas en un cribado puerperal realizado en el Hospital Universitario Donostia  .
La transmisión vertical en el neonato se evaluó 7-10 días tras el parto mediante una exploración física y la obtención de exudado faríngeo, suplementado con exudado conjuntival en el último año del estudio y en los casos con sospecha de conjuntivitis. Los neonatos infectados fueron tratados por vía oral con eritromicina 14 días mientras estuvo la formulación disponible en el hospital o con posterioridad azitromicina 3 días. Se realizó seguimiento clínico durante 3 meses .
Se constató transmisión vertical en 11 (10,7%) niños, distribuidos uniformemente en el período de estudio. El porcentaje ascendió al 15,5% (11/71) excluyendo los nacidos por cesárea y/o de madres que recibieron tratamiento antibiótico en las 48 h preparto. C. trachomatis se detectó en el 8,7% de las muestras faríngeas (9/103) y el 17,6% (6/34) de las conjuntivales (p = 0,15). Siete ninos ˜ infectados estaban asintomáticos y 4 (3,9% del total de vigilados) presentaban conjuntivitis, en un caso asociada a cuadro catarral. Todos los casos recibieron tratamiento antibiótico (7 eritromicina, 4 azitromicina), resolviéndose la infección tempranamente en 7/8 que acudieron al control microbiológico a los 15 días; en otro caso, la detección de C. trachomatis y la sintomatología (conjuntivitis) persistió durante 2 meses, por inadecuada dispensación del tratamiento por los padres.
En España asumiendo una prevalencia de infección por C. trachomatis en puérperas del 1%y con una tasa de transmisión vertical del 10,7%, estimamos 446 casos/ano˜ de neonatos infectados (área naso-faringo-conjuntival) en función de los nacidos en 2015 , cifra que ascendería a ≈ 750 si se hubiera realizado a los neonatos sistemáticamente frotis faríngeo y conjuntival.
 Por todo esto, algunos países recomiendan realizar un cribado de la infección en gestantes  y tratar a las infectadas, siendo controvertida la profilaxis neonatal.
En conclusión, en función de los datos de este trabajo estimamos que en España un mínimo de 1/1.000 neonatos es infectado por C. trachomatis en el parto, a pesar del empleo sistemático de la profilaxis ocular neonatal.

We would like to highlight the importance of screening for chlamydia (CT) and gonorrhea (GC) with a urine nucleic acid ampli-fication testing (NAAT) in all symptomatic and asymptomatic children alleging child sexual abuse (CSA)

Chlorhexidina

La administración de clorhexidina en los cuidados del cordón del recién nacido en la comunidad disminuye de forma significativa el riesgo de onfalitis (en un 50%)

Citomegalovirus (ver también Temas A-Z)

La infección por citomegalovirus (CMV) es la causa más común de infección viral congénita en los países. La infección primaria y la reinfección de adultos se producen en tasas más altas entre las personas en contacto con niños pequeños en el hogar, guarderías y escuelas. Los niños parecen ser una fuente importante de infección por CMV en todos estos entornoss desarrollados Para las mujeres en edad reproductiva, el contacto con niños pequeños representa el mayor riesgo de transmisión].

La fuente principal de CMV en las superficies de los hogares era la de los niños pequeños que vivían en el hogar. Las superficies asociadas con la saliva tenían mayores cargas virales de CMV y un virus más viable que las superficies asociadas con la orina, por lo que la saliva es probablemente el vehículo más importante para la transmisión que la orina. Una mejor comprensión de las rutas específicas de transmisión puede llevar a mensajes de prevención más efectivos y basados ​​en la evidencia.

 

Cytomegalovirus (CMV) is the most common congenital infection.1 Congenital CMV (cCMV) is diagnosed if the virus is isolated in the first 3 weeks of life. It is challenging to differentiate between congenital and postnatal infection (pCMV) if the virus is detected after this time point. Retrospective diagnosis of cCMV requires the identification of the virus on the dried blood spot, a method which has been shown to be insensitive.2 Additionally, there are no internationally accepted definitions for symptomatic pCMV…

Citomegalovirus congénito (ver también Temas A-Z)

Currently, the diagnosis of congenital cytomegalovirus (cCMV) infection in most highly resourced countries is based on clinical suspicion alone. This means only a small proportion of cCMV infections are diagnosed. Identification, through either universal or targeted screening of asymptomatic newborns with cCMV, who would previously have gone undiagnosed, would allow for potential early treatment with antiviral therapy, ongoing audiological surveillance and early intervention if sensorineural hearing loss (SNHL) is identified. This paper systematically reviews published papers examining the potential benefits of targeted and universal screening for newborn infants with cCMV. We found that the treatment of these infants with antiviral therapy remains controversial, and clinical trials are currently underway to provide further answers. The potential benefit of earlier identification and intervention (eg, amplification and speech therapy) of children at risk of later-onset SNHL identified through universal screening is, however, clearer.

In this volume of The Journal, 2 studies address the diagnosis and management of infants with congenital cytomegalovirus (cCMV) infection. Lu et al report on a prospective study evaluating the feasibility of incorporating cytomegalovirus (CMV) and genetic screening for common hearing loss mutations into current newborn hearing screening (NBHS) programs in Taiwan.1 Pasternak et al retrospectively describe their experience with antiviral therapy in a small uncontrolled cohort of infants with cCMV infection who have isolated sensorineural hearing loss (SNHL) but otherwise are asymptomatic.2

cCMV is the most common congenital infection and a leading cause of SNHL. The natural history of CMV-related hearing loss is variable, and the outcome differs in infants with symptomatic infection and asymptomatic infection. Only 10% of infants with cCMV have symptomatic infection at birth, and 40%-50% of these children will have hearing loss.3, 4 The vast majority of infants with cCMV infection are asymptomatic at birth; however, 10% of these children will have hearing loss. SNHL due to cCMV is variable, and in infants with asymptomatic infection, hearing loss will have a delayed-onset or progressive course in 40%-50% of those affected. Importantly, the median age of onset of delayed-onset hearing loss in children with asymptomatic cCMV infection is 44 months, with only 25% of children with asymptomatic cCMV infection, and 45% of affected children with symptomatic cCMV infection, having hearing loss within the first month of life. In addition, one unique feature of CMV-associated SNHL is that hearing can fluctuate, with hearing thresholds sometimes improving after documented loss.3, 5, 6 These factors have major implications when interpreting data assessing the effect antiviral treatment of cCMV on hearing outcome; if all infected infants in a cohort are treated and hearing improves, what portion is attributable to drug effect vs the natural history of the disease?

To assess risk factors, geographic distribution, length of stay, and total charges per case of symptomatic congenital cytomegalovirus infection (cCMV).

We performed retrospective analyses of serial cross-sectional data using the Kids' Inpatient Database, a nationally representative sample of US pediatric hospital discharges, from 2000, 2003, 2006, 2009, and 2012. Symptomatic cCMV was identified via use of the International Classification of Diseases, Ninth Revision, Clinical Modification code 771.1 among records with in-hospital birth that were accompanied by 1 or more characteristic symptoms. Demographic characteristics were compared with multivariable logistic regression. Temporal trend was assessed using linear regression. Charges were adjusted for inflation to 2012 US dollars.

We identified 1349 cases of symptomatic cCMV (SE 56). Symptomatic cCMV was associated with non-Hispanic black race (OR 1.70; 95% CI 1.37-2.10), government-sponsored insurance (OR 1.95; 95% CI 1.34-2.83), and birth in the American South and West (OR 1.68, 95% CI 1.35-2.09 and OR 1.61, 95% CI 1.23-2.09, respectively). In-hospital mortality and preterm birth rate ranged from 3.2%-6.8% and 50.4%-59.2%, respectively, without temporal changes. The geometric mean of total charges per case doubled from $45 771 (SE $8509) in 2000 to $89 846 (SE $10 358) in 2006 (P = .002) but did not change from 2006 to 2012. Length of stay in days was 15 (IQR 8-22) in 2000, 27 (IQR, 9-51) in 2009, and 18 (IQR, 8-47) in 2012.

Symptomatic cCMV was associated with non-Hispanic black race, low socioeconomic status, and birth in the American South and West and resulted in substantial healthcare burden.

The accurate stratification of infants with congenital cytomegalovirus (CMV) infection at risk for more severe outcome may help in the management of patients. Aim of this study was to investigate the ability of a comprehensive neuroimaging investigation in predicting the long-term neurodevelopmental outcome in patients with congenital CMV. We analyzed the prognostic accuracy of a traditional score and a recently proposed scale applied to head ultrasound (HUS), computed tomography (CT) and magnetic resonance imaging (MRI).

Methods: All consecutive neonates born from 2002 to 2015 with congenital CMV infection were considered eligible for the study. Neuroimaging findings were scored according to both scores.

Results: One hundred seventy infants were included (112 symptomatic patients). One-hundred eighteen infants received both HUS, CT and MRI. CT and MRI were normal in all 56 asymptomatic patients, while 32% of them presented an abnormal HUS. The prevalence of abnormal findings differed according to the neuroimaging study. The sensitivity of the new neuroimaging score in detecting patients at risk for poor neurologic outcome was higher than the traditional one for all neuroimaging examinations. CT and MRI showed higher positive predictive value compared with HUS. No neuroimaging examination showed a negative predictive value equal to 100%.

Conclusions: Although HUS is the safest neuroimaging technique, it performs less well in detecting some brain abnormalities that can be associated with a poor neurodevelopmental outcome. A comprehensive neuroimaging evaluation is mandatory in infants with congenital CMV infection to decide for treatment and make a prognostic evaluation.

Congenital cytomegalovirus (CMV) infection (cCMV) is an important cause of hearing loss and cognitive impairment. Prior studies suggest that HIV-exposed children are at higher risk of acquiring cCMV. We assessed the presence, magnitude and risk factors associated with cCMV among infants born to HIV-infected women, who were not receiving antiretrovirals during pregnancy.

Methods: cCMV and urinary CMV load were determined in a cohort of infants born to HIV-infected women not receiving antiretrovirals during pregnancy. Neonatal urines obtained at birth were tested for CMV DNA by qualitative and reflex quantitative real-time polymerase chain reaction.

Results: Urine specimens were available for 992 (58.9%) of 1684 infants; 64 (6.5%) were CMV-positive. Mean CMV load (VL) was 470,276 copies/ml (range: < 200–2,000,000 copies/ml). Among 89 HIV-infected infants, 16 (18%) had cCMV versus 42 (4.9%) of 858 HIV-exposed, uninfected infants (P < 0.0001). cCMV was present in 23.2% of infants with in utero and 9.1% infants with intrapartum HIV infection (P < 0.0001). Rates of cCMV among HIV-infected infants were 4-fold greater (adjusted OR, 4.4; 95% CI: 2.3–8.2) and 6-fold greater among HIV in utero–infected infants (adjusted OR, 6; 95% CI: 3–12.1) compared with HIV-exposed, uninfected infants. cCMV was not associated with mode of delivery, gestational age, Apgar scores, 6-month infant mortality, maternal age, race/ethnicity, HIV viral load or CD4 count. Primary cCMV risk factors included infant HIV-infection, particularly in utero infection.

Conclusion: High rates of cCMV with high urinary CMV VL were observed in HIV-exposed infants. In utero HIV infection appears to be a major risk factor for cCMV in infants whose mothers have not received combination antiretroviral therapy in pregnancy.

Children with cCMV, especially those with long-term impairment and those symptomatic at birth, accrue higher healthcare costs than cCMV-negative children in the first 6 years of life, although this is not statistically significant. This economic impact is of importance in the evaluation of preventive measures against cCMV

The objective of this study was to determine newborn clinical findings predictive of adverse clinical outcomes in infants with symptomatic congenital cytomegalovirus infection. Of 160 infants, significantly more children with central nervous system involvement had sensorineural hearing loss (P = 0.0007) and an IQ ≤70 (P < 0.0001) compared with infants with transient findings or only a petechial rash.

Resumen: en este estudio prospectivo de seguimiento de pacientes con diagnostico de infección congénita por citomegalovirus, se comprueba que cuando no hay infección sintomática (incluida la hipoacusia) no hay diferencias en cociente intelectual, vocabulario, o notas académicas durante la infeancia y la adolescencia al compararlos con niños no infectados.

To evaluate the feasibility and potential benefits of incorporating genetic and cytomegalovirus (CMV) screenings into the current newborn hearing screening (NHS) programs.

Newborns were recruited prospectively from a tertiary hospital and a maternity clinic between May 2016 and December 2016 and were subjected to hearing screening, CMV screening, and genetic screening for 4 common mutations in deafness genes (p.V37I and c.235delC of GJB2 gene, c.919-2A>G of SLC26A4 gene, and the mitochondrial m.1555A>G). Infants with homozygous nuclear mutations or homoplasmic/heteroplasmic mitochondrial mutation (referred to as “conclusively positive genotypes”) and those who tested positive for CMV received diagnostic audiologic evaluations.

Of the total 1716 newborns enrolled, we identified 20 (1.2%) newborns with conclusively positive genotypes on genetic screening, comprising 15 newborns (0.9%) with GJB2 p.V37I/p.V37I and 5 newborns (0.3%) with m.1555A>G. Three (0.2%) newborns tested positive on CMV screening. Twelve of the 20 newborns (60%) with conclusively positive genotypes and all 3 newborns who tested positive for CMV (100%) passed NHS at birth. Diagnostic audiologic evaluations conducted at 3 months confirmed hearing impairment in 6 of the 20 infants (30%) with conclusively positive genotypes.

This study confirms the feasibility of performing hearing, genetic, and CMV screenings concurrently in newborns and provides evidence that the incorporation of these screening tests could potentially identify an additional subgroup of infants with impaired hearing that might not be detected by the NHS programs.

ObjectiveTo evaluate the efficacy of antiviral treatment for infants with congenital cytomegalovirus (cCMV) with isolated sensorineural hearing loss (SNHL).

Study design Data were reviewed retrospectively for infants with isolated SNHL who received prolonged antiviral treatment between 2005 and 2017. Hearing status was evaluated for infants who had been followed for >1 year.

Among 329 infants treated for cCMV, 59 (18%) were born with isolated SNHL. Hearing impairment was unilateral in 38 (64.4%) infants and bilateral in 21 (35.6%). Of the 80 affected ears at baseline, 55 (68.8%) improved, and only 2 (2.5%) deteriorated. Most of the improved ears (53/55 = 96.3%) returned to normal hearing with no deterioration observed in the ears that were unaffected at baseline. On best ear evaluation, of 21 infants who had bilateral hearing loss, 16 (76.1%) improved (93.7% regaining normal functional hearing); none deteriorated.

ConclusionInfants born with isolated SNHL due to cCMV were found to benefit from prolonged antiviral treatment. These children (and ears) showed significant improvement in hearing status and no deterioration of unaffected ears at baseline. Our data serve as observational evidence of the benefits of antiviral treatment in these children. Avoiding treatment of these children due to the lack of prospective data is debatable.

Symptomatic and asymptomatic cCMV infections are a major cause of hearing loss in childhood. Reliable estimates of the long-term outcome of cCMV infection are mandatory to increase vigilance, especially among pregnant women and to draw attention to preventive measures, vaccine development, and prenatal and postnatal therapy. Universal screening of newborns for cCMV infection should be initiated and combined with longitudinal audiometric follow-up.

We found that infants born with cCMV and hearing impairment, receiving 12 months of antiviral treatment, showed significant improvement in hearing status. The probability of hearing improvement seems inversely related to the severity of the impairment at birth.

Resumen: La verdadera incidencia y el impacto de la infección por CMV materna recurrente sigue siendo difícil de conocer. Se observa una mayor incidencia de CMV congénito por infecciones maternas no primarias en embarazos complicados por la morbilidad materna (HTA, diabetes mellitus gestacional o madres sometidas a tratamiento médico). Destacan la poca eficacia de la serologíaen infecciones no primarias para detectar enfermedad fetal/neonatal, subrayando, en esos casos, la importancia del seguimiento ecográfico, la amniocentesis, la RM y la evaluación de rutina del recién nacido para un diagnóstico rápido del CMV congénito.

A pesar del pequeño tamaño muestral, nuestros datos ponen en evidencia la presencia de un número importante de falsos negativos en la detección de CMV por rt-PCR en este tipo de muestras en el diagnóstico de CMVc, especialmente en pacientes con cargas virales bajas al nacimiento.

Congenital CMV infection is traditionally diagnosed byvirus detection in saliva or urine. Virus culture was positive in significantly fewer urine samples collected using cotton balls in diapers (54.2%) than with samples collected by bags (95.7%) from newborns screened positive for CMV in saliva. However, PCR was positive in 95% of urine samples regardless of the collection method.

Clostridium difficile

A total of 39% of the patients were attended at Haematology-oncology Unit and >50% of them had previously received cephalosporins. Fever associated with diarrhea was more frequent in the group of toxin detection, whereas not receiving specific antibiotic treatment was more frequent in the group of positive PCR, without statistically significant differences.

We highlight the presence of C. difficile infection in children under 2years old. A diagnostic testing in selected paediatric patients would be advisable when there is clinical suspicion of infection

Clostridium difficile es la causa más frecuente de diarrea relacionada con los cuidados sanitarios1. Diversos estudios inciden además en la importancia de la infección por Clostridium difficile (ICD) de adquisición comunitaria2,3. Sin embargo, la ICD continúa siendo infradiagnosticada, bien por la ausencia de sospecha clínica, bien por una metodología microbiológica inadecuada. En un reciente documento sobre la ICD en España, con participación de la Sociedad Española de Quimioterapia6, se concluye entre otras recomendaciones que todas las heces diarreicas, en >2 años, recibidas deberían procesarse para diagnóstico de ICD, aun cuando no se hubiera solicitado. El objetivo es conocer la repercusión de dicha recomendación en Hospital Infantil Universitario Niño Jesús de Madrid. Entre 2014 y 2016, se procesaron para Clostridium difficile toxigénico (CDT), en ausencia de sospecha clínica, las heces diarreicas con petición de coprocultivo de pacientes de >2 años con diagnóstico clínico de gastroenteritis aguda (GEA), estuvieran o no hospitalizados.

El diagnóstico de ICD consiste en la detección simultánea de GDH y toxinas A/B como cribado y posteriormente la detección de toxina B (tcdB) en aquellas muestras positivas para GDH y negativas para toxinas A/B mediante PCR como confirmación. Se procesaron 1.162 heces para coprocultivo y determinación de CDT, fuera esta solicitada por el facultativo o ampliada por el laboratorio. En 34% no hubo sospecha clínica de ICD y 52% correspondieron a episodios de GEA en pacientes no ingresados. La detección de CDT fue positiva en 15 muestras. Dos casos correspondieron a pacientes no ingresados en los que se aisló, además, Campylobacter spp. y Salmonella spp., respectivamente, como posibles agentes implicados en el episodio diarreico. Sin embargo, en el episodio de GEA con Salmonella spp. y CDT, se detectó además rotavirus, por tanto se debe considerar también una etiología vírica. En los 13 casos restantes con CDT, no hubo coinfección ni bacteriana ni parasitaria o vírica, cuando estos estudios fueron solicitados.

El presente estudio pone de manifiesto no solo la importancia de una adecuada metodología de diagnóstico microbiológico, sino también la de un papel activo en la cobertura etiológica del proceso clínico. Los episodios de ICD en pacientes no ingresados son poco significativos numéricamente y dudosos como episodios reales, dadas las coinfecciones detectadas.

Our study reinforces the nonsignificance of CD in neonates and infants younger than 2 years old. Informing clinicians of CD isolates in this population promotes the use of antibiotics against CD, without evidence of a different outcome than those not receiving treatment.

CA-CDI is associated with medications regularly prescribed in pediatric practice, along with exposure to outpatient healthcare clinics and family members with CDI. Our findings provide additional support for the judicious use of these medications and for efforts to limit spread of CDI in ambulatory healthcare settings and households.

Conclusions CA-CDI is associated with medications commonly used in pediatric practice, as well as with outpatient healthcare setting exposure.

El trasplante de microbiota fecal (TMF) ha demostrado ser una terapia exitosa para la erradicación de Clostridium difficile en adultos, sin embargo existe poca información disponible en niños. Se exponen 6 casos de pacientes pediátricos con infección refractaria por C. difficile curados con TMF sin recurrencias hasta la fecha. Estos resultados demuestran que el TMF puede ser un tratamiento efectivo en la infección refractaria por C. difficile en pediatría. Se necesitan más estudios que evalúen su seguridad y eficacia a largo plazo. 

Conclusions Malignancy and tracheostomy tube dependence were identified as RCDI risk factors. Although RCDI was associated with positivity at a lower tcdB PCR cycle threshold, the clinical utility of cycle threshold as a tool to predict recurrence was limited. Better methods to predict RCDI are needed to prioritize pediatric populations to target for RCDI prevention efforts.)

Recent use of cephalosporins and the presence of gastrointestinal feeding devices are important risk factors for community- associated CDAD in children. Reduction in the use of outpatient antibiotics may decrease the burden of CA-CDAD in children.

Coccidium

Several studies have reported prevalence of pediatric coccidian parasitic diarrhea, but there is little information about their clinicalprofile, management and outcome. This study reviews the clinical profile and treatment outcome of coccidian parasitic diarrhea in immunocompetentchildren. Coccidian parasitic diarrhea affects immunocompetent children of all age groups. Unnecessary administration of antimicrobial agents to these children can be avoided by routinely screening pediatric diarrheal fecal specimens for coccidian parasites by a cost-effective method such as modified Ziehl-Neelsen staining.

Contagio (ver higiene y prevención en Temas A-Z)

Resumen: Analizan y diseñan diferentes estrategias para disminuir la expansión de determinadas infecciones entre escolares, como pueden ser el cierre de colegios o de clases. Aplicando nuevas técnicas de modelos de redes se puede analizar el comportamiento de la expansión de las epidemias permitiendo diseñar intervenciones dirigidas a la suspensión o modificación de actividades específicas en la escuela que implican el uso compartido de espacios (por ejemplo, actividades deportivas, en el patio de recreo, almuerzo en la cafetería, etc.).

En un brote en Noruega ocasionado por E coli productora de tóxina Shiga (STEC) en una guardería, se realiza un análisis epidemiológico y un seguimiento de los casos sintomáticos, asintomáticos y de contactos. Los resultados del examen indican que las infecciones de E. coli pueden propagarse en guarderías, demuestran la importancia de tener buenas rutinas en el cuidado de todos los niños, no solo aquellos con signos evidentes de enfermedad y que las consecuencias del cribado deben ser considerados cuidadosamente, ya que puede producir resultados imprevistos y tener consecuencias socioeconómicas significativas.

CONCLUSIONS: Parental risk and impact of AGE and ARI acquisition from their children are substantial. ARI occur more frequently overall among children, but parental work loss appears greater with AGE transmission. Our findings suggest that preventive practices to reduce the risk of secondary ARI and AGE transmission to parents warrants greater emphasis, evaluation and education.

Coronavirus

Although much recent focus has been on the recognition of Ebola virus disease among travelers from West Africa, cases of Middle East respiratory syndrome coronavirus (MERS-CoV), including travel-associated cases, continue to be reported. US clinicians need to be familiar with recommendations regarding when to suspect MERS-CoV, how to make a diagnosis, and what infection control measures need to be instituted when a case is suspected. Infection control is especially critical, given that most cases have been healthcare-associated. Two cases of MERS-CoV were identified in the United States in May 2014; because these cases were detected promptly and appropriate control measures were put in place quickly, no secondary cases occurred. This paper summarizes information that US clinicians need to know to prevent secondary cases of MERS-CoV from occurring in the United States.

Cryptosporidium

´CVA (ver catarro y Temas A-Z)

Dengue (ver también Temas A-Z)

In early October, nine cases of autochthonous dengue were confirmed in the EU, three in Spain and six in France, in three separate outbreaks. These are the first autochthonous dengue cases in continental EU/EEA Member States that were reported this year. Prior to these cases, no autochthonous dengue cases had been reported in continental EU/EEA Member States since 2017. Epidemiological investigations are ongoing.

Es la enfermedad arboviral más importante que afecta a los humanos en todo el mundo y su prevalencia mundial ha crecido de forma espectacular en las últimas décadas. Alrededor de 100 millones de personas están infectadas y 500,000 personas desarrollan dengue severo, lo que provoca alrededor de 70,000 muertes anuales. Presenta una importante carga de salud pública y económica en regiones endémicas tropicales y subtropicales

Aunque la mayoría de las infecciones son asintomáticas, pueden ocasionar un amplio espectro de signos y síntomas clínicos, que van desde una enfermedad febril aguda e indiferenciada hasta resultados graves y fatales. Pueden aparecer casos mortales en más del 10% de los casos y el 90% de las muertes se producen en niños menores de 15 años.

El dengue es una enfermedad infecciosa trasmitida por el mosquito Aedes aegypti, y representa un problema de salud pública en México; la trasmisión vertical es poco común y puede presentarse en cualquier etapa de la gestación, por lo que el diagnóstico debe considerarse en hijos de madres con cuadro sugestivo de dengue. Se describe el caso de un recién nacido que presenta hallazgos clínicos compatibles con dengue neonatal, confirmando la trasmisión vertical con la detección del antígeno NS1. Así mismo, se realiza una breve revisión basada en los casos reportados en la bibliografía científica.

Resumen: la infección durante la gestación por el virus del Dengue aumenta la mortalidad fetal.

El dengue es causado por uno de 4 serotipos del virus dengue. En España, solo se han comunicado casos importados. Las manifestaciones clínicas más frecuentes son fiebre y exantema, aunque puede haber formas graves, especialmente en infecciones secundarias. Es importante considerar este diagnóstico en todo viajero internacional que presenta fiebre dentro de los 14 días tras volver de un área endémica, para un diagnóstico precoz, un adecuado tratamiento y un buen pronóstico.

Desde la identificación de los primeros casos de dengue autóctono esporádico en áreas no endémicas (Croacia, Italia, Francia y Portugal), existe un riesgo real de que aparezca el primer caso autóctono en España, donde uno de los vectores responsables…

A raíz de un caso de dengue importado diagnosticado en nuestro hospital, y en relación con la reciente publicación titulada «Dengue importado: arbovirosis emergente en España»1 nos gustaría realizar algunas reflexiones y aportar algunos comentarios, dada la importancia y trascendencia del tema que trata desde el punto de vista epidemiológico.

Derivación ventrículo peritoneal

Children with shunts commonly present with fever, and often the focus of infection will be unrelated to their shunt. However, as shunt infections may present with few or even no specific symptoms, evaluation of a child with a shunt presenting with fever should be careful and comprehensive to ensure shunt infections are not missed. Treatment of an infected shunt involves removal of the shunt followed by a long course of antibiotics; missing or partially treating shunt infections can result in significant morbidity mortality. Our experience of managing children with shunts presenting with fever is that many non-specialist clinicians have little experience in this area so initial management may not always be appropriate. Those children who are most at risk of shunt infection are those who within the preceding 8 weeks have had insertion, revision or access of their shunt or chemotherapy device, or have had abdominal surgery in the presence of a ventriculoperitoneal shunt. We have chosen 8 weeks as a pragmatic time point, as in our experience the vast majority of children who have had shunt infections have presented within this period. The caveat is that this should not be used as an absolute cut-off where there is strong suspicion of shunt infection or no clear focus at a later time pointand potentially even.

Dermatitis perianal estreptocócica (ver Infecciones cutáneas en Temas A-Z)

Resumen: From 2009 to 2014, we prospectively enrolled 132 children with perianal infections. The presentation of painful defecation, anal fissures, and macroscopic blood in stools was highly suggestive of group A streptococcal perianal infection (probability 83.3%). We found a high sensitivity of a group A streptococcal rapid diagnostic testing (98%) but relatively low specificity (72.8%).

Following treatment with amoxicillin, we found a low recurrence rate of 12.4%. Amoxicillin can be expected to be reliable first-line therapy  for perineal streptococcal infection

Diarrea (ver Temas A-Z)

We identified high antimicrobial usage and high antimicrobial resistance in children hospitalized with bloody and/or mucoid bacteria-associated diarrhea. There was no clinical benefit of antimicrobial therapy in children with diarrhea; adequately powered randomized controlled trials are required.

Difteria (Ver Temas A-Z)

Niña de 5 años bien vacunada, consulta en servicio de urgencias por una lesión muy pruriginosa en ambas piernas. Había venido recientemente de un viaje a Sierra Leona. La lesión había aparecido tres semanas antes durante su estancia en ese país, había aumentado de tamaño y se había ulcerado.

Drepanocitosis

Resumen: revisión del cumplimiento de la profilaxis antbiótica en niños de Norteamérica con anemia de células falciformes. A pesar de las recomendaciones establecidas y de los comprobados beneficios en la calidad de vida de estos niños, las tasas de profilaxis antibióticas son bajas.

We conclude that penicillin given preventatively reduces the rate of pneumococcal infections in children with SCD under five years of age. The risk of infection in older children is lower, and the follow-on trial did not show a significant increase in riskwhen regular penicillin was halted at five years old. Further research is needed to look at how commonly bacteria develop that are resistant to treatment and how clinically important this is.

Penicilina es un tto antibiótico eficaz y sin efectos secundarios en la anemia drepanocítica.

Ébola (ver también Temas A-Z)

En una conferencia de prensa en Ginebra se anunció que tres de los ensayos sobre tratamientos frente al virus del Ebola serán probados en tres lugares diferentes, que comenzarán en diciembre y que se aplicarán a 100-200 pacientes. Estos tratamientos son Favipiravir ( equipo del Instituto Nacional de Salud e Investgación Médica en Gueckedou), Brincidofovir (consorcio liderado por la Universidad de Oxford) y el tratamiento con sangre y plasma de convalecientes (grupo liderado por el Instituto de Medicina Tropical de Amberes en ConaKry)

Resumen: Desde el 23 de enero ya se encuentran en Liberia los primeros viales de una vacuna contra el Ébola de la compañía GlaxoSmithKline. Se trata de una vacuna de adenovirus de chimpancé tipo 3 que se administrará a un grupo de 10.000 voluntarios (frente a 10.000 que recibirán placebo y otros 10.000 una vacuna experimental)

We describe the inquiries regarding Ebola virus disease (EVD) received by the Department of Public Health Alerts of the Community of Madrid between April and December 2014

Ebola virus disease (EVD) is a viral haemorrhagic fever, with a case fatality rate of 50% (25–90%). The current outbreak in West Africa (Guinea, Sierra Leone and Liberia) is the largest and most complex since the Ebola virus was discovered. Ebola spreads via direct contact with bodily fluids of infected people, and materials contaminated with these fluids. Healthcare workers have frequently been infected while treating patients with EVD. This has occurred through close contact with patients when infection control precautions were not strictly practised.

Empiema

Pleural empyema following varicella or presenting with rash, signs of circulatory failure and leucopenia may be due to GAS. These features should prompt the addition to treatment of an antitoxin drug, such as clindamycin.

To investigate the risk factors of empyema after acute viral infection and to clarify the hypothesized association(s) between empyema and some viruses and/or the use of nonsteroidal anti-inflammatory drugs (NSAIDs).

Investigators from 15 medical centers in France performed a case-control study to evaluate a hypothesized association between use of nonsteroidal anti-inflammatory drugs (NSAIDs) during viral illness and occurrence of pneumonia with empyema. Cases were consecutive children 3 months through 15 years of age hospitalized at participating centers with thoracentesis-proven bacterial pneumonia. Cases also had to have a physician-diagnosed acute viral illness during the 15 days prior to hospitalization.

 Encefalitis

Lactante de cinco meses traído al Servicio de Urgencias por fiebre e impotencia funcional del miembro superior izquierdo. Tras las pruebas complementarias correspondientes, es diagnosticado de encefalitis herpética. El texto repasa las novedades en cuanto al tratamiento, la necesidad de profilaxis y la inmunodeficiencia específica.

Enterobacterias multirresistentes

International travel is considered to be an important risk factor for acquisition of multidrug-resistant Enterobacteriaceae (MRE). The aim of this systematic review was to determine the effect of international travel on the risk of post-travel faecal carriage of MRE. Secondary outcomes were risk factors for acquisition of MRE.

Endocarditis (ver también Temas A-Z)

Enfermedad granulomatosa crónica

We present a large, single-center US experience with CGD. Twenty-three of 27 patients are alive after 3276 patient-months of follow-up (1 has been lost to follow-up), and our serious infection rate was 0.62 per patient-year.

Enterovirus (ver Temas A-Z)

Resumen: comparan la validez de la determinación de una técnica de PCR frente a enterovirus para la detección de su infección a partir de muestras séricas (en lugar de LCR) en niños con sospecha de infección grave o meningitis. En neonatos y en lactantes menores de 2 años, se detectaron más casos por esta técnica en muestra sanguínea que por PCR en LCR (99 frente a 87% con una u otra técnica en neonatos, y 92 frente a 75% en niños de 1 a 24 meses). Como conclusión proponen los autores que la detección en sangre mediante ténicas de PCR de enterovirus pase a formar parte de la baterí del estudio del niño pequeño con síndrome febril sin foco (ahorraría tiempo de estancia hospitalaria y exposición a antbióticos)

El enterovirus D68 (EV-D68) es un virus que pertenece a la especie D del género Enterovirus dentro de la familia Picornaviridae. Fue descrito por primera vez en 1962 en California como rinovirus 87, causante de infecciones respiratorias pediátricas1. En 2014 se comunicó en EE.UU. una importante epidemia de infecciones respiratorias causadas por el EV-D68, afectando a más de 1.100 pacientes2. A raíz de esta situación diferentes países iniciaron la búsqueda de este virus en las infecciones respiratorias

La descripción de casos de enterovirus D68 (ED68) en EE. UU. asociados a síndromes graves con complicaciones neumológicas y neurológicas2-6 originó un interés nuevo sobre un virus escasamente descrito en la enfermedad respiratoria…

We report 59 cases of severe paediatric conditions linked with enterovirus (EV)-A71 and EV-D68 in France between May and October 2016. Fifty-two children had severe neurological symptoms. EV sequence-based typing for 42 cases revealed EV-A71 in 21 (18 subgenotype C1, detected for the first time in France) and EV-D68 in eight. Clinicians should be encouraged to obtain stool and respiratory specimens from patients presenting with severe neurological disorders for EV detection and characterisation.

We report a cluster of atypical Guillain–Barré syndrome in 10 adults temporally related to a cluster of four children with acute flaccid paralysis, over a 3-month period in South Wales, United Kingdom. All adult cases were male, aged between 24 and 77 years. Seven had prominent facial diplegia at onset. Available electrophysiological studies showed axonal involvement in five adults. Seven reported various forms of respiratory disease before onset of neurological symptoms. The ages of children ranged from one to 13 years, three of the four were two years old or younger. Enterovirus testing is available for three children; two had evidence of enterovirus D68 infection in stool or respiratory samples. We describe the clinical features, epidemiology and state of current investigations for these unusual clusters of illness.

Most children infected with EV71 have a good prognosis if they are diagnosed early and receive proper supportive treatment.

Se comenta el hallazgo de un nuevo subgenotype EV71 C4a, detectado en Dinamarca por primera vez en la primavera de 2012. A partir de diciembre 2013 se han detectado, otros casos C4 33 EV71 la mayoría de los bebés con síntomas de moderados a graves.

If you haven't heard of enterovirus D68 yet, the chances are you will soon. In 2014, an outbreak of acute flaccid myelitis (AFM) leading to lower limb paralysis affecting about 50 children in the US and Canada caused great concern; the typical prodrome of a febrile respiratory illness led to suspicions of a viral cause, and an enterovirus seemed a liked candidate because of its known predilection for attacking neural tissue. …

Eosinofilia (ver Temas A-Z)

La asistencia a niños inmigrantes que llegan por primera vez a España continúa siendo una práctica diaria en Pediatría. En la práctica totalidad de centros de salud existen protocolos que contemplan la atención inicial de estos pacientes a su llegada. En la atención inicial a estos niños es básica la anamnesis, una exploración completa y la solicitud de pruebas complementarias específicas. Pese a que la mayoría de estos niños están asintomáticos, la aplicación de estos protocolos puede poner de manifiesto enfermedades como la malnutrición, parasitosis o anemias de diversas etiologías, que de otra forma podrían pasar desapercibidas. Se presenta un caso de un niño de diez años asintomático, procedente de Guinea Ecuatorial, que consulta por primera vez en el centro de salud tras su llegada a España.

Eritema migrans (ver Temas A-Z)

El eritema migratorio crónico es la lesión característica del estadio precoz de la enfermedad de Lyme. Aparece a los 3-32 días de la transmisión de la Borrelia burgdorferi, que se produce a las 48-72h del anclaje de la garrapata, por lo que conviene una extracción temprana de la misma. Inicialmente puede aparecer una mácula o pápula que crece centrífugamente aclarándose en el centro. Si no es reconocida y tratada en esta fase inicial, se disemina avanzando la enfermedad, por lo que es importante su sospecha ante un exantema compatible, teniendo en cuenta que una serología positiva no indica necesariamente enfermedad.

Comparison of azithromycin and amoxicillin for the treatment of children with solitary EM revealed comparable efficacy and adverse effects of treatment.

Escarlatina (Ver Temas A-Z)

Estafilococos (ver también en Temas A-Z infecciones cutáneas)

Asymptomatic carriage of Staphylococcus aureus is a source of transmission between healthy individuals. Seventy children at a primaryschool were swabbed 7 times to identify patterns of S. aureus carriage. S. aureus carriage prevalence was 53%-65% at each round and 45% carried at every round. High carriage prevalence may indicate that school-aged children are important contributors to S. aureus transmission.

Introducción: La bacteriemia por Staphylococcus aureus (SA) adquirida en la comunidad representa una causa frecuente de ingreso en niños. La aparición de focos secundarios (FS) condiciona una mayor morbimortalidad.

Objetivos: Identificar factores de riesgo de aparición de FS de infección en niños con bacteriemia por SA de la comunidad.

Material y métodos: Cohorte prospectiva: enero 2010 -diciembre 2016 se incluyeron todos los niños (de 30 días a 16 años), hospitalizados por infecciones adquiridas en la comunidad, con aislamiento de SA en hemocultivos. Se compararon características microbiológicas, demográficas y clínicas según presentaran o no FS de infección tras 72h de hospitalización.

Resultados: Se incluyeron 283 niños, el 65% varones, con una mediana de edad de 60 meses . El 17% tenían alguna enfermedad de base y el 97% un foco clínico de infección, siendo los más frecuentes: osteoarticular el 55% y abscesos de partes blandas el 27% . El 65% eran SA resistentes a meticilina. Presentaron FS el 16% de los pacientes: neumonía el 73%, osteoarticular el 11%, partes blandas el 11% y sistema nervioso central el 5% .En el análisis multivariado fueron predictores de FS la persistencia de hemocultivos positivos tras el quinto día (p<0,001) y la sepsis ( p<0,001). No hubo asociación con la sensibilidad a la meticilina.

Conclusiones: En esta cohorte predominaron las infecciones por SA resistente a la meticilina. La aparición de FS se asoció con la persistencia de la bacteriemia después del quinto día y la sepsis al ingreso.

Objectives: To assess the association between comorbidities and Staphylococcus aureus bacteremia in children aged 5-18 years, thus, in children with a matured immune system. Further, we aimed to identify presumably healthy children acquiring bacteremia.

Study design: By cross-linking nationwide registries, we consecutively included all children born from 1995 onward at their 5-year birthday or date of immigration during 2000-2015. We examined incidence rate ratios (IRR) between preselected exposures and microbiologically verified S aureus bacteremia (reference = children without exposure) using Poisson regression models.

Results: We followed 1 109 169 children in 2000-2015 during which 307 children (incidence rate: 3.7 per 100 000 person-years) acquired S aureus bacteremia (methicillin-resistant S aureus = 8; 2.6%). Children without known comorbidities or recent contact with the healthcare system comprised 37.1% of infected children. The highest IRRs were observed in children undergoing dialysis or plasmapheresis (IRR = 367.2 [95% CI) = 188.5-715.3]), children with organ transplantation (IRR = 149.5 [95% CI = 73.9-302.2]), and children with cancer (IRR = 102.9 [95% CI = 74.4-142.2]). Positive associations also were observed in children with chromosomal anomalies (IRR = 7.16 [95% CI = 2.96-17.34]), atopic dermatitis (IRR = 4.89 [95% CI = 3.11-7.69]), congenital heart disease (IRR = 3.14 [95% CI = 1.92-5.11]), and in children undergoing surgery (IRR = 3.34 [95% CI = 2.59-4.28]). Neither premature birth nor parental socioeconomic status was associated with increased disease rates.

Conclusions: S aureus bacteremia is uncommon in children between 5 and 18 years of age. Risk factors known from the adult population, such as dialysis, plasmapheresis, organ transplantation, and cancer, were associated with the highest relative rates. However, prematurity and parental socioeconomic status were not associated with increased rates. Approximately one-third of infected children were presumably healthy

La bacteriemia por Staphylococcus aureus (SAB) causa una considerable morbilidad y mortalidad en los niños. A pesar de esto, su epidemiología y factores de riesgo son poco conocidos, con un mínimo de datos de ensayos clínicos pediátricos disponibles para guiar a los clínicos en el manejo. Realizamos un estudio piloto para caracterizar SAB y validar una clasificación de gravedad para su uso en ensayos clínicos futuros.

Este es el primer intento de categorizar el SAB pediátrico como simple versus complejo, para guiar a los clínicos en la toma de de decisiones. Conclusiones: Existe un amplio espectro de gravedad en la SAB pediátric, con PCR máxima, duración de la estancia y duración de la terapia mayor en aquellos con enfermedad compleja. Se han descrito grupos diferentes con cursos simples y complejos que pueden ser un objetivo para futuros ensayos clínicos.Periorbital infections and conjunctivitis due to Panton-Valentine Leukocidin (PVL) positive Staphylococcus aureus in children. BMC Infectious Diseases201818:371

Objetivo: Estudiar la frecuencia y recurrencia de infecciones periorbitarias u orbitales como síntomas adicionales de la colonización de Staphylococcus aureus productor de la leucocidina de Panton-Valentine (SA-LPV) en niños. Los hallazgos sugieren una participación frecuente de la piel periorbital en niños con infecciones por SA-LPV. Por lo tanto los pacientes pediátrios con infecciones recurrentes podrían beneficiarse de los procedimientos de detección de SA-LPV y de descolonización estafilocócia.

Resumen: evolución de las resistencias a S.aureus en los últimos años a partir de 41.745 muestras pediátricas en USA. Disminución de cepas meticilín-resistentes, pero aumenta la resistencia a clindamicina

Resumen: El transporte de S. aureus meticilin sensible en orofaringe es frecuente en niños por lo demás sanos, incluyendo una proporción relativamente alta de los que no tienen colonización nasal. Estos resultados destacan la importancia de añadir el exudado faríngeo al nasal cuando queremos monitorizar la circulación del S. aureus en la comunidad.

Se estudian los factores virulentos de los Staphylococcus areus adquiridos en la comunidad y su capacidad de producir infecciones invasivas o infecciones localizadas musculoesqueléticas en niños pequeños. Y si hay diferencias entre los MSSA y los MRSA.

Estafilococo MR

To assess the psychosocial effects of a methicillin-resistant Staphylococcus aureus (MRSA) diagnosis on the households of children with MRSA skin and soft tissue infection (SSTI).

We constructed and administered an interview to the primary caregiver within the home of a child with a history of MRSA SSTI.

Seventy-six households were enrolled. Survey responses were analyzed and grouped into 4 themes: health behavior changes, disclosure, social interactions, and knowledge/awareness. The most common theme was disclosure; 91% of participants reported sharing their child's MRSA diagnosis with someone outside of the household. Forty-two percent of respondents reported a change in the manner in which household contacts interacted as a result of the index patient's MRSA diagnosis, including isolating the index patient from other children in the household. Many households reported adopting enhanced personal hygiene behaviors and environmental cleaning routines. Thirty-eight percent of participating households reported altering how they interact with people outside of their home, largely to avoid spreading MRSA to vulnerable individuals. In addition, many participants perceived that others regarded them with caution, especially at daycare, whereas other affected households were excluded from family gatherings.

Conclusion

Primary caregivers of children with MRSA SSTI reported changing their health behaviors, altering their interactions with people outside of their home, and feeling isolated by others in response to their child's MRSA diagnosis. The findings of our study highlight a need for community interventions and education to prevent the negative psychosocial repercussions associated with MRSA

Hospitalized children with MRSA bacteremia frequently suffered treatment failure and complications, but mortality was low. The odds of bacteremia-related complications increased with each additional day of bacteremia, emphasizing the importance of achieving rapid sterilization

Estreptococo (Ver Temas A-Z)

Group A streptococcus (GAS) is responsible for 15%–30% of cases of acute pharyngitis in children. Macrolides such as azithromycin have become popular for treating GAS pharyngitis. We report macrolide resistance rates in a primary care setting in our geographic area over the past 5 years and discuss the implications of resistance in making treatment decisions. Throat swabs were collected from children with pharyngitis from May 2011 to May 2015 in a primary care setting in Madison, Wisconsin. Susceptibility testing was performed for erythromycin and clindamycin using the Kirby–Bauer disk diffusion method. GAS was identified on 143 throat cultures. Overall, 15% of GAS isolates demonstrated nonsusceptibility for both clindamycin and erythromycin. Inducible resistance (positive D-test) was detected in 17 isolates (12%). The rate of detection of nonsusceptibility in each year of the study did not change over time. Azithromycin should only be used for patients with pharyngitis and substantial manifestations of penicillin hypersensitivity and when used, susceptibility testing should always be performed.

  • A case report of hemolyticstreptococcal gangrene in thedangertriangle of thefacewiththrombocytopenia and hepatitisBMC Pediatrics201818:198

La gangrena por estreptococo hemolítico es una infección bacteriana invasiva causada principalmente por SGA. Los humanos son los huéspedes naturales y únicos reservorios de SGA. Las infecciones necrotizantes de los tejidos blandos (INTB) se encuentran entre las graves consecuencias causadas por la infección por SGA. Los INTB causados por SGA se caracterizan por el desarrollo frecuente de shock y alta mortalidad. Se ha informado que la incidencia de la infección por SGA ha aumentado durante los últimos 10-20 años debido a la creciente colonización del SAG en la población general. El diagnóstico precoz, el tratamiento oportuno y agresivo y la pronta iniciación de la atención de apoyo son cruciales para un buen pronóstico

Estreptococo agalactiae

Nueva guía británica basada en una revisión de todos los artículos publicados sobre el estreptococo del grupo B y el embarazo desde 2011. Se encontró que el riesgo de las mujeres de transmitir la enfermedad por Streptococcus del grupo B (SGB) fue mayor en aquellas con parto prematuro. El comité de la guía encontró que el riesgo de enfermedad por SGB de inicio temprano era cuatro veces más alto en recién nacidos (RN) prematuros, en comparación con RN a término. La tasa de mortalidad fue alrededor de 10 veces mayor en los RN antes de 37 semanas, en comparación con los RN a término. Sobre la base de esta evidencia, recomiendan antibióticos intravenosos a todas las mujeres que entran en trabajo de parto prematuro, para prevenir la transmisión del SGB. También recomiendan profilaxis antibiótica intraparto a todas las mujeres que tienen un bebé anterior con enfermedad de SBG de inicio temprano o tardío.

Introducción: S. agalactiae (SGB) es el principal agente etiológico de la sepsis neonatal temprana en los países desarrollados. Este microorganismo pertenece a la microbiota del tracto gastrointestinal desde donde puede colonizar la vagina. El objetivo de este estudio fue caracterizar y comparar serotipos, factores de virulencia y la resistencia a los antimicrobianos de aislamientos de SGB embarazadas y neonatos de varios hospitales de Cataluña.

Métodos: Se analizaron 242 cepas de SGB incluyendo 95 colonizadoras y 68 cepas patógenas aisladas embarazadas y 79 cepas aisladas de neonatos con sepsis para determinar serotipo, virulencia y resistencia antimicrobiana.

ResultadosLa distribución de los serotipos fue diferente entre los 3 grupos, siendo los serotipos Ia y II significativamente más frecuentes entre las cepas colonizadoras (p=0,001 y 0,012, respectivamente). Los factores de virulencia bca y scpB fueron significativamente más frecuentes entre las cepas neonatales que entre las patógenas o colonizadoras (p=0,0001 y 0,002, respectivamente). Las cepas patógenas fueron significativamente más resistentes a eritromicina, clindamicina y azitromicina que las no patógenas.

There is no consensus regarding approaches to infantile group B streptococcal (GBS) head and neck cellulitis and necrotizing fasciitis. We present a case of GBS necrotizing cellulitis and summarize the literature regarding the presentation and management of infantile head and neck GBS cellulitis and necrotizing fasciitis.

The literature was searched using PubMed, Web of Science, EMBASE and Medline (inception to April 2017) by 2 independent review authors. Inclusion criteria encompassed case reports or case series of infants less than 12 months of age with GBS cellulitis of the head and neck or with GBS necrotizing fasciitis without restriction to the head and neck. Data were extracted using tables developed a priori by 2 independent review authors, and discrepancies were resolved by consensus.

An infant presenting at 33 days of age with GBS facial necrotizing fasciitis was successfully treated conservatively with antibiotics. Our literature search identified 40 infants with GBS head and neck cellulitis. Late-onset (98%), male gender (65%) and prematurity (58%) predominated. Penicillin is the main therapy used (97%). The 12 identified cases of necrotizing fasciitis were associated with polymicrobial etiology (36%) and broad-spectrum antibiotic use. Seventy-five percent required debridement, including 4 of 5 (80%) cases involving the head and neck.

Conclusions:

Skin and soft tissue involvement is an uncommon manifestation of late-onset GBS infection which requires antibiotic therapy and possibly surgical debridement cases with necrotizing fascitis.

Streptococcus agalactiae (Streptococcus del grupo B) se reconoce como el agente etiológico de la meningitis del recién nacido y del lactante, con una edad de hasta 90 días, a partir de la colonización del tracto genital o gastrointestinal de la madre, pero rara vez es responsable de meningitis en lactantes mayores. Presentación del caso: lactante de 9 meses diagnosticado de meningoencefalitis por S. agalactiae asociada a la enfermedad por reflujo gastroesofágico crónico tratada con un inhibidor de la bomba de protones (IBP).

Conclusión: el uso de un PPI es un factor de riesgo para la aparición tardía de la meningitis por Streptococcus del grupo B. El uso de IBP en lactantes debe controlarse estrechamente a la luz de los cambios en la microbiota intestinal, en la orofaringe y en la colonización potencial del tracto respiratorio, con flora patógena. El uso de esta clase de medicamentos durante más de un mes requerirá un control estricto de los recuentos de glóbulos blancos, exámenes bacteriológicos (hisopado faríngeo, hisopado nasal, etc.) para detectar un cambio en el espectro bacteriano con predominio de uno especie con factores de virulencia reconocidos. Es más importante reconocer que los medicamentos supresores de ácido causan una disfunción inmune que persiste después de la interrupción del medicamento, por lo tanto, los médicos deben ser prudentes al recetar estos medicamentos.

No se han producido cambios significativos en la incidencia de SNP por Streptococcus agalactiae en los 7 años del estudio. El aumento de la sensibilidad de los métodos de cribado, las técnicas moleculares intraparto, la realización del antibiograma de las cepas de gestantes y la mayor comunicación entre los centros sanitarios pueden contribuir a una mejor aplicación del protocolo y a una reducción de la incidencia de SNP.

The administration of intrapartum antibiotic prophylaxis to negatively GBS screened women in presence of risk factors was a deviation from the recommendations issued by the Centers for Disease Control and Prevention, and it should deserve further consideration. Routine surveillance and molecular typing of circulating clones are essential for the effective management of the neonatal GBS disease.

GBS LOD and VLOD are encountered in similar at-risk populations, with LOD associated with higher morbidity. Infants presenting with meningitis are at significantly higher risk of sequelae compared with bloodstream infection.

Exantema (ver Temas A-Z)

A 7-month-old boy was admitted with generalised blisters to the paediatric emergency room. The lesions had first developed on the head and neck, then rapidly spread to the trunk and extremities (figure 1). The patient was ill but not toxic or febrile. Initially bullous impetigo was suspected.

A 23-month-old girl presented with fever, vomiting and diarrhoea for 3 days. Her palms were warm, pruritic and erythematous with papules and patches (figure 1). The dorsal surfaces of the hands (figure 2) and soles were largely spared.

A 6-year-old boy presented to our department with a 1-week history of generalized pustules with a high fever.

A 2½-year-old previously well Afro-Caribbean girl presented with a 1-week history of fever and a generalised non-healing, painful and itchy ulceration on the body 3 weeks after acute varicella infection. On examination, she had multiple punched-out ulcers on her torso measuring 0.5–2 cm in diameter associated with central necrosis (figure 1). She had a normal white cell count and inflammatory markers. Her varicella …

El síndrome de la escaldadura estafilocócica está causado por Staphylococcus aureus productor de toxinas exfoliativas y su incidencia en nuestro medio es baja. El diagnóstico es clínico, pudiendo confirmarse posteriormente con los cultivos de mucosas (faríngeo, nasal y conjuntival) y con la biopsia de piel. El tratamiento precoz es prioritario para evitar complicaciones. Sin embargo, en fases iniciales, el diagnóstico puede no resultar tan evidente y confundirse con otras entidades dermatológicas más frecuentes en Pediatría. Presentamos el caso clínico de una niña de dos años y diez meses que, tras tres visitas a Urgencias con diferentes diagnósticos, finalmente fue diagnosticada de síndrome de escaldadura estafilocócica.

El eccema herpético es una dermatosis aguda causada por el virus herpes simple tipo I en pacientes con dermatitis atópica y es considerada una urgencia dermatológica. Ocurre en menos del 3% de los pacientes atópicos. Se presenta el caso de un niño con antecedente de dermatitis atópica que consulta en el servicio de urgencias por lesiones cutáneas compatibles con erupción variceliforme de Kaposi. Fue tratado con aciclovir intravenoso y antibiótico oral, con resultado satisfactorio.

A 5-year-old girl presented with high grade fever, cough, headache, and abdominal pain for 1 week. Physical examination revealed mild periorbital edema and hepatosplenomegaly. She had a skin lesion on her left shoulder, which had developed a week before she became ill. It measured 10 mm × 10 mm and had a black, necrotic center surrounded by a scaly, erythematous margin (Figures 1 and 2; Figure 1 available atwww.jpeds.com). Left axillary lymph nodes were palpable. The lesion strongly resembled an eschar, which is classically described as the “skin burn of a cigarette.” Eschars are seen in rickettsial infections (Mediterranean spotted fever, scrub typhus, African tick bite fever, and rickettsialpox, where they represent the site of tick or chigger bite) tularemia, anthrax, bacterial ecthyma, brown recluse spider bite, and rat-bite fever.

A previously healthy 3-month-old male presented to the hospital with an acute onset of vesicles coalescing into tense bullae on the hands and feet. On admission, vesicles, erosions and tense bullae were noted on the palms and soles (figure 1). Complete blood count showed mildly elevated white blood cells with peripheral eosinophilia. A punch biopsy revealed a subepidermal …

A 3-year-old boy presented with a 4-day history of fever and diffuse itchy eruption, spreading from the face. His medical history was unremarkable, except for a recent diagnosis of adenoidal hypertrophy treated with oral betamethasone sodium phosphate for 10 days followed by budesonide nebuliser.

Physical examination showed erythematous patches with mild scaling of the face and, on the forearms, hands and legs, fixed hive-like target lesions (figure 1), with 

A 14-month-old Caucasian girl presented with a rash affecting the left side of her body of 7 days' duration. The rash began abruptly in the left axilla and then coalesced and spread along the lateral thoracic wall to the left side of the abdomen. Physical examination showed numerous erythematous macules and papules on her left axilla, left lateral chest, and left side of the abdomen, coalescent at places around the left axilla (Figure). A supraumbilical hernia was noted incidentally.

A 7-year-old boy presented with a pruritic skin eruption, which had been present for 8 weeks. His mother reported the onset of the rash in the axillary region shortly after scarlet fever and streptococcal angina, which subsequently was treated with amoxicillin/clavulanic acid. Findings of the dermatologic examination revealed disseminated erythematous papules and small plaques of 2-8 mm in size, predominantly on the trunk and thighs. Some of the lesions were hemorrhagic, and others were crusted and necrotic.

A female infant was born premature at 27 weeks by emergency cesarean delivery because of an abnormal fetal heart rate at 5 days after premature rupture of the membranes. Chorioamnionitis was suspected because of discolored amniotic fluid and a vaginal swab positive for Escherichia coli, but was finally excluded by histopathological examination of the placenta. She had erosions larger than 1-2 cm distributed across the limbs, trunk, and scalp, sparing the extremities, as well as vesicles and bullae on the limbs (Figure 1; available at www.jpeds.com ).

Faringoamigdalitis (ver también Temas A-Z)

El objeto de este estudio fue evaluar y comparar de manera retrospectiva la evolución de pacientes con faringitis por estreptococo grupo A (EGA) tratados con pautas de amoxicilina de 7 y 10 días de duración.

Análisis retrospectivo de todos los casos de faringitis por EGA atendidos S.Urgencias en 2014. Se analizaron variables demográficas, uso y resultados de pruebas de detección rápida de antígeno (PDRA), tratamiento, complicaciones y reingreso en un plazo de 30 días. Se definieron 2 grupos : tratamiento con amoxicilina: a) pauta corta (hasta 7 días), y b) pauta larga (10 días).

Resultados La amoxicilina fue el antibiótico más prescrito (94,9%), con una duración media de 7 días. Se prescribieron pautas de 10 días al 31,9% de los pacientes. No se encontraron diferencias entre los grupos con pautas cortas y largas en cuanto a la edad , el género o las complicaciones . Concluimos que en lo referente a la variable de resultado «regreso al servicio de urgencias», la pauta de 7 días no es inferior a la de 10 días.

Oral antimicrobial treatment of acute streptococcal pharyngitis commonly is given for 10 days. An investigation was conducted of journal publications and textbooks from the dawn of the antimicrobial era to the present in order to discover the basis for this settled practice. Current treatment duration for acute streptococcal pharyngitis was established half a century ago under conditions significantly different from those currently encountered by the average clinician. The 10-day treatment standard evolved without scientific justification. There have been no therapeutic trials that have validated the necessity for 10 days of oral antimicrobial treatment. Yet, despite the lack of a scientific foundation, the rarity of acute rheumatic fever in developed countries, the high failure rate for streptococcal eradication and evidence that short-course therapy with a nonpenicillin antimicrobial yields equivalent eradication rates, the 10-day rule persists because of long clinical usage and the inherent power of the number 10. Efforts to change this clinical benchmark will likely meet with resistance from practicing physicians.

Resumen: la mayoría de los test de detección de antígeno estreptocócico en la práctica y antes de la intervención, estaban fuera de indicación según la guía de práctica cínica de la IDSA. Tras la aplicación de un proyecto de mejora de la calidad se racionalizó la implantación del test (de un uso innecesario del 64% se bajó al 40,5%).

Analizan 82.176 procesos en 65.052 pacientes menores de 14 años. Al menos un 10% de estos procesos no deberían ser tratados con antibiótico. Tto antibiótico adecuado en 67% de faringoamigdalitis. Prescripción de macrólidos 17,5%, prescripción de amoxicilina_clavulánico 12%, prescripción de cefalosporinas de tercera generación 2%.

Se estima que al menos el 80% de las prescripciones de macrólidos no se justifica por alergia a betalactámicos. Puede estar sobre-utilizándose porque presentan posologías más cómodas y más cortas, de hecho la azitromicina es el segundo principio activo más prescrito (el 17% del total de antibióticos).

Amoxicilina-clavulánico no es tratamiento de primera elección para la FAA estreptocócica, pues el EBHGA no es productor de betalactamasas y se trata de un antibiótico de amplio espectro que podría derivar en selección de cepas resistentes de otras bacterias de la flora nasofaríngea.

Existen importantes diferencias entre pediatras y médicos "No pediatras". Las actividades de formación no deben olvidarse de estos últimos.

Existe un 25% de cupos de pediatría cuyos indicadores de selección de antibióticos en el tratamiento de la faringoamigdalitis se aleja de los estándares de uso adecuado.

La utilización de las Técnicas de Diagnóstico Rápido para la faringoamigdalitis aguda estreptocócica, reduciría el uso inadecuado de antibióticos.

Because many asymptomatic children are carriers of GAS, judicious use of laboratory testing for GAS pharyngitis remains an important target for antimicrobial stewardship.

The new 4-variable CDR for GAS pharyngitis (ie, tonsillar swelling and one of tonsillar exudate, no rhinorrhea, no cough) outperformed existing rules for GAS pharyngitis diagnosis in children with symptomatic sore throat in Cape Town.

Introducción: la faringoamigdalitis aguda (FAA) es una de las enfermedades más comunes en la infancia. El manejo diagnóstico y terapéutico es sencillo y, desde 2011, está consensuado. El objetivo principal es analizar la adecuación al consenso en un hospital de media complejidad, donde trabaja uno de los autores de dicho documento de consenso.

Pacientes y métodos: estudio descriptivo, transversal, unicéntrico y de ámbito local. Se realiza un análisis retrospectivo de los informes de alta y pruebas complementarias en todos los niños ≤ 14 años diagnosticados de FAA en Urgencias Pediátricas. Periodo: del 1 de enero al 31 de diciembre de 2015.

Resultados: se analizan 176 FAA (el 52,3%, niñas). La valoración clínica se realiza siempre mediante la escala de McIsaac. El 46,5% recibieron antibióticos antes de la realización de una técnica de detección rápida de antígeno estreptocócico o cultivo, en todos ellos. El 100% de los antibióticos y dosis prescritas se ajustaron al consenso. Los intervalos de dosis y la duración del tratamiento fueron adecuados en > 85% de los casos. Las prescripciones inadecuadas fueron pautadas por solo dos de los 17 pediatras del hospital.

Conclusiones: la adecuación es superior a lo descrito en otras series. El uso apropiado de antibióticos puede mejorar mediante la formación continuada y regular por parte de pediatras especializados en enfermedades infecciosas. Además, se sugiere que los tratamientos inadecuados se analicen según prescriptor, para seleccionar qué facultativos deben recibir una formación específica. Es prioritario adecuar la prescripción de antimicrobianos en la FAA a la evidencia científica en nuestro país.

The incidence of acute pharyngitis associated with accurately identified SDSE was 2/15 of that with SP. Epidemiologic and clinical features of acute pharyngitis associated with SDSE are indistinguishable from those with SP, with the exception of age and seasonal variation.

  • Different antibiotic treatments for group A streptococcal pharyngitis. Cochrane Database of Systematic Reviews 2016, Issue 9. Art. No.: CD004406. We included 19 trials (18 publications) that involved 5835 people. Trials studied different antibiotics for people with sore throat who tested positive for GABHS, and were aged from one month to 80 years. Nine trials included only children; and nine included people aged 12 years or older. Most studies were published over 15 years ago; all but one reported on clinical outcomes.

There were no clinically relevant differences in symptom resolution when comparing cephalosporins and macrolides with penicillin in the treatment of GABHS tonsillopharyngitis. Limited evidence in adults suggests cephalosporins are more effective than penicillin for relapse, but the NNTB (Lumber needed to treat to benefit) is high. Limited evidence in children suggests carbacephem is more effective than penicillin for symptom resolution. Data on complications are too scarce to draw conclusions. Based on these results and considering the low cost and absence of resistance, penicillin can still be regarded as a first choice treatment for both adults and children. All studies were in high-income countries with low risk of streptococcal complications, so there is need for trials in low-income countries and Aboriginal communities where risk of complications remains high.

Even in the late afternoon, a full dose of amoxicillin (50 mg/Kg) administered after notification of positive RADT results for group A streptococcus, resulted in non-detection of GAS in 91% of children the next morning. All children treated with amoxicillin for "strep throat" by 5 PM of day 1 may, if afebrile and improved, attend school on day 2.

Children are exposed to GAS and other BHS at a young age, which is important for determining the target age for vaccination in order to protect before the period of risk.

Two promising strategies could reduce rheumatic heart disease in low-resource settings. Administering antibiotics to children with sore throat and tender cervical adenopathy could treat most GAS-positive children while reducing use of unnecessary antibiotics for uninfected children. Broad coverage against M types associated with pharyngitis in Bamako schoolchildren might be achieved with the 30-valent GAS vaccine under development.

La bacteria Fusobacterium necrophorum es una causa conocida de la enfermedad de Lemierre y existen evidencias sobre su papel patogénico en el absceso periamigdalino, mientras que en la amigdalitis recurrente y crónica es incierto. En este estudio se evalua la prevalencia de la colonización orofaríngea con F. necrophorum y Streptococcuss beta hemolítico en una cohorte de pacientes programados o la amigdalectomía, y además la dinámica de la colonización con muestreo repetido durante una tiempo de seguimiento de 6 a 8 meses

Fibrosis quísica (ver también Temas A-Z)

Our retrospective analysis revealed an increase of important CF-related pathogens, the emergence of new pathogens and a substantial increase of multidrug-resistant CF-specific isolates. Our findings are of importance to clinicians for the alertness of local epidemiology, which may be useful for prevention and treatment strategies.

Fiebre (ver también Temas A-Z)

  • Knowledge, attitudes and misconceptions of Italian health care professionals regarding fever management in childrenBMC Pediatrics201818:194

La fiebre fobia sigue siendo un problema importante en pediatría. Se presenta en el trabajo una muestra de pediatras italianos realizada seis años después del lanzamiento de las directrices italianas para el tratamiento de la fiebre en niños. Se observaron mejoras en los conceptos erróneos de algunos pediatras a lo largo del tiempo. Sin embargo, algunos hábitos incorrectos persisten. Se necesitan más estudios para comprender mejor los "puntos débiles" de la comunicación entre las sociedades científicas y los pediatras con el fin de impactar en la práctica clínica cotidiana.

Introducción: la fiebre es un síntoma muy común en la infancia, que provoca estrés y ansiedad en los cuidadores por sus creencias en las consecuencias fatales de la misma. Fiebrefobia es un término que expresa el temor de los padres y profesionales de la salud ante la presencia de fiebre en el niño.

Objetivo: determinar los conocimientos, actitudes y prácticas de los cuidadores de niños que acuden al Servicio de Urgencias.

Pacientes y métodos: estudio observacional, descriptivo y transversal, en el que se han obtenido datos mediante muestreo consecutivo de los padres o cuidadores de niños que acudieron al Servicio de Urgencias del Hospital Universitario Río Hortega de Valladolid (España) por el motivo “fiebre”, mediante la cumplimentación de una encuesta autoadministrada.

Resultados: se han evaluado 124 encuestas, de las cuales el 60,5% fueron cumplimentadas por madres. El 42,7% tenían estudios universitarios y el 74% tenían trabajo. La medición de la fiebre fue realizada mayoritariamente mediante termómetro digital (82,3%). La zona corporal preferentemente utilizada para medir la temperatura fue la axila (76%). Las medidas utilizadas para bajar la fiebre fueron en su mayoría físicas (25,8%) y fármacos antitérmicos (24,2%). Se observó una relación estadísticamente significativa (p < 0,05) entre el nivel académico y la utilización de medidas para bajar la fiebre (p = 0,028); así como en el nivel académico y las creencias con respecto a la peligrosidad de la fiebre (p = 0,016).

Fiebre después de viaje internacional 

A chatty, 4 year-old girl is brought to the emergency department (ED) by her mother with a 3-day history of fever and loose stool. They returned from Nigeria 7 days earlier, having visited friends and relatives for the school holidays. Clinical examination is unremarkable, she is currently afebrile, and there are no signs of serious bacterial infection. A malaria blood film and histidine rich protein-2 (HRP-2) based rapid diagnostic test (RDT) are both negative. RDTs are for malaria antigens such as HRP-2 and lactate dehydrogenase (LDH).

The paediatric registrar discharges the patient but expresses concern regarding the ability of a single RDT and blood film to rule out malaria, following current guidelines, and insists she returns in 24 and 48 hours to repeat the tests. You wonder if this is really necessary.

Fiebre origen desconocido

Our expert panel examines her case, offers a definition of fever of unknown origin, and makes diagnostic considerations.

Fiebre Q

Notified Q fever was less frequent in children/adolescents than adults. While underrecognition contributed to this phenomenon, lower infectivity in children following community exposure played an unexpected major role. On-source (presumed high-dose) exposure, by contrast, was associated with high serologic and clinical attack rates not only in adults, but also in children/adolescents. Our findings allow for improved age-specific clinical and public health risk assessment in Q-fever outbreaks.

Fiebre recurrente

Presentación de un caso de un lactante de 9 meses con fiebre recurrente. Diagnóstico: artritis séptica aguda de cadera izquierda. A propósito de este caso se realiza un diagnóstico diferencial de las fiebre recurrente y la fiebre de origen desconocido

Fiebre reumática

In June 1944, the Journal of the America Medical Association (JAMA) published “The Diagnosis of Rheumatic Fever” by T. Duckett Jones.1 Eventually known as the “Jones criteria,” these benchmarks became the fundamental cornerstones for the clinical diagnosis of acute rheumatic fever (ARF). Since then, every medical student and most other primary health care professionals have memorized the 5 cardinal manifestations of ARF outlined by Jones even as the disease itself came under the control of modern medical care in most developed countries worldwide.2 Eventually, ARF became relatively rare, but was not completely eliminated in those countries. Nevertheless, in large parts of the world, ARF remains endemic and among the medical problems causing high rates of hospitalization, lifelong morbidity, need for high-cost therapies such as open heart surgery, and unduly high mortality.

To estimate the incidence of acute rheumatic fever (ARF) in a metropolitan area of Northern Italy and study how the introduction of the 2015 revised Jones criteria affects the epidemiology in a region with moderate to high incidence of ARF.

The incidence of ARF in children 5-14 years old living in the Province of Turin was estimated using low-risk criteria in a 10-year period (group A patients). The proportion of patients fulfilling only high-risk (HR) criteria (group B patients) was also calculated both prospectively (from July 2015 through December 2016) and retrospectively (from January 2007 through June 2015).

One hundred thirty-five group A patients were identified for an annual incidence of 3.2-9.6 out of 100 000 children. The use of HR criteria identified an additional 28 patients (group B), resulting in a 20.7% increase in the incidence of ARF. Age, sex annual incidence, and seasonal distribution pattern were comparable between group A and group B patients.

HR criteria should be used for the diagnosis ARF in our region. The application of these criteria led to a 20% increase in patients with the diagnosis of ARF. The characteristics of patients fulfilling only HR criteria are similar to the remaining patients, suggesting that these criteria are sensitive and specific.

In this volume of The Journal, Licciardi et al from Turin, Italy, report their experience using the newest version of the Jones Criteria for the diagnosis of acute rheumatic fever (ARF) and appear to validate the rationale for the revision.1

In 2015, the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the American Heart Association (AHA) published a revised Jones Criteria for the diagnosis of ARF.2 The major impetus for revising the Jones Criteria, which were first proposed in 1944 by T. Duckett Jones3 and modified several times between 1955 and 1992 to aid clinicians in the diagnosis of ARF, was to incorporate newer data derived from experience with echocardiography. In addition, different criteria for low-risk and moderate-to-high risk ARF regions are now included in the Jones Criteria.

En esta sección (Endgames) se revisa un caso clínico de interés: En este caso se trata de un niño de 8 años que acude al servicio de urgencias con una historia de 7 días de fiebre moderada, cefalea, odinofagia, artralgia de muñecas y dolor en la planta de los pies.

Sydenham's chorea (SC) is characterised by chorea, emotional lability and hypotonia. In this study, we investigated the incidence and clinical presentation of childhood SC in Ireland (years 2006-2014). Nineteen cases were diagnosed. Five patients had rheumatic fever. An increasing trend with an incidence of 0.23/100 000 is reported. As most referral diagnoses included psychogenic illness, head injury and stroke, modern physicians may not be aware of this age old illness. A review of the manifestations and diagnosis of SC is presented.

Fiebre sin foco (ver Temas A-Z)

The identification of serious bacterial infection (SBI) in children with fever without source remains a challenge. A risk score called Lab-score, based on C-reactive protein, procalcitonin and urinary dipstick results was derived to predict SBI. However, all biomarkers were initially dichotomized, leading to weak statistical reliability and lack of transportability across diverse settings. We aimed to refine and validate this risk-score algorithm.

The Lab-score was refined using a secondary analysis of a multicenter cohort study of children with fever without source via multilevel regression modeling. The external validation was conducted on data from a Canadian cohort study.

Eight hundred seventy-seven children (24% SBI) were included for the derivation study, and 347 (16% SBI) for validation. Only C-reactive protein, procalcitonin, age and urinary dipstick remained independently associated with SBI. The model achieved an area under the receiver operating characteristic (ROC) curve of 0.94 (95% confidence interval [CI]: 0.93–0.96), which was significantly higher than any other isolated biomarker ( P < 0.0001), and the original Lab-score ( P < 0.0001). According to a decision curve analysis, the model yielded a better strategy than those based on independently considered biomarkers, or on the original Lab-score. The threshold analysis led to a cutoff that yielded 96% (95% CI: 92–98) sensitivity and 73% (95% CI: 70–77) specificity. The external validation found similar predictive abilities: 0.96 area under the ROC curve (95% CI: 0.93–0.99), 95% sensitivity (95% CI: 85–99) and 87% specificity (95% CI: 83–91).

The refined Lab-score demonstrated higher prediction ability for SBI than the original Lab-score, with promising wider applicability across settings. These results require validation in additional populations.

  • Clinical prediction models for young febrile infants at the emergency department: an international validation studyArch Dis Child. 2018 Nov;103(11):1033-1041

We identified four CPMs, including clinical signs and symptoms, urine dipstick analysis and laboratory markers, which can aid clinicians in identifying serious bacterial infections. We suggest clinicians should use CPMs as an adjunctive clinical tool when assessing the risk of serious bacterial infections in febrile young infants.

En los últimos años, están cambiando tanto la etiología de las infecciones graves, como las herramientas con las que contamos y vamos a contar para acercarnos al diagnóstico etiológico.

Respecto a la etiología bacteriana de las infecciones en lactantes pequeños, 2 hechos han modificado la situación

In this large prospective cohort of febrile infants ≤60 days of age, neither the YOS score nor unstructured clinician suspicion reliably identified those with invasive bacterial infections. More accurate clinical and laboratory predictors are needed to risk stratify febrile infants.

In this multicenter study, we evaluate the performance characteristics of the Rochester and modified Philadelphia criteria for risk stratification of febrile infants with bacteremia and/or bacterial meningitis.

CONCLUSIONS: The modified Philadelphia criteria had high sensitivity for IBI without routine CSF testing, and all infants >28 days old with bacterial meningitis were classified as high risk. Because some infants with bacteremia were classified as low risk, infants discharged from the emergency department without CSF testing require close follow-up.

Objective: To determine the risk of serious bacterial infections (SBIs) in young febrile infants with and without viral infections.

Study design: Planned secondary analyses of a prospective observational study of febrile infants 60 days of age or younger evaluated at 1 of 26 emergency departments who did not have clinical sepsis or an identifiable site of bacterial infection. We compared patient demographics, clinical, and laboratory findings, and prevalence of SBIs between virus-positive and virus-negative infants.

Of the 4778 enrolled infants, 2945 (61.6%) had viral testing performed, of whom 1200 (48.1%) were virus positive; 44 of the 1200 had SBIs (3.7%; 95% CI, 2.7%-4.9%). Of the 1745 virus-negative infants, 222 had SBIs (12.7%; 95% CI, 11.2%-14.4%). Rates of specific SBIs in the virus-positive group vs the virus-negative group were: UTIs (33 of 1200 [2.8%; 95% CI, 1.9%-3.8%] vs 186 of 1745 [10.7%; 95% CI, 9.2%-12.2%]) and bacteremia (9 of 1199 [0.8%; 95% CI, 0.3%-1.4%] vs 50 of 1743 [2.9%; 95% CI, 2.1%-3.8%]). The rate of bacterial meningitis tended to be lower in the virus-positive group (0.4%) than in the viral-negative group (0.8%); the difference was not statistically significant. Negative viral status (aOR, 3.2; 95% CI, 2.3-4.6), was significantly associated with SBI in multivariable analysis.

Conclusions: Febrile infants ≤60 days of age with viral infections are at significantly lower, but non-negligible risk for SBIs, including bacteremia and bacterial meningitis.

Objective To analyse the outpatient management of selected febrile infants younger than 90 days without systematic lumbar puncture and antibiotics.

Methods A prospective registry-based cohort study including all the infants ≤90 days with fever without a source (FWS) who were evaluated in a paediatric emergency department (ED) over a 7-year period (September 2007–August 2014). We analysed the outcome of those infants with low-risk criteria for serious bacterial infection (SBI) managed as outpatients without antibiotics and without undergoing a lumbar puncture. Low-risk criteria: Well appearing, older than 21 days of age, no leucocyturia, absolute neutrophil count ≤10 000, serum C reactive protein ≤20 mg/L, procalcitonin <0.5 ng/mL and no clinical deterioration during the stay in the ED (always <24 hours).

Results 1472 infants with FWS attended the ED. Of these, 676 were classified to be at low risk for SBI without performing a lumbar puncture. After staying <24 hours in the short-stay unit of the ED, 586 (86.6%) were managed as outpatients without antibiotics. Two patients were diagnosed with SBI: one occult bacteraemia and one bacterial gastroenteritis. Both were afebrile when evaluated again and did well. No patient returned to the ED due to clinical deterioration. Fifty-one infants (8.7%) returned to the ED mainly due to persistence of fever or irritability. None was diagnosed with definite SBI or non-bacterial meningitis.

Conclusions Outpatient management without antibiotics and systematic lumbar puncture is appropriate for selected febrile infants younger than 3 months of age with close follow-up.

Febrile infants <3 months of age, especially those <1 month, are at risk for serious bacterial infection (SBI), urinary tract infections, bacteremia, and meningitis. In this issue of Pediatrics, Nigrovic et al1 report on 5997 infants ≤60 days of age with fever ≥38.0°C enrolled in 14 pediatric emergency departments over a 4.5-year period in the Pediatric Emergency Care Applied Research Network...

The pCRT and cCRT values showed only fair agreement in a general population of febrile children at the ED, and no significant association with age or body temperature was found. Only a small part of febrile children at risk for serious infections at the ED show abnormal CRT values. Both abnormal pCRT and cCRT (defined as >2 s) performed poorly and were non-significant in this study detecting SBI in a general population of febrile children.

Aplicabilidad en la práctica clínica: este estudio ofrece datos preliminares sobre un test que utiliza un biomarcador ARN. Aunque parece diferenciar entre infecciones bacterianas y víricas, la información disponible no permite evaluar su utilidad clínica. Se precisa demostrar su utilidad en diversos escenarios, como los Servicios de Urgencias o Atención Primaria, y poder valorar su contribución en la disminución del uso de antibióticos con un diagnóstico más preciso de la infección bacteriana.

Risk factors for PAU and ward admissions are different in this setting with high reattendance rates and very low proportion of confirmed/probable serious bacterial infections. Future studies need to focus on reducing avoidable admissions and antibiotic treatment.

If asked what would be top of their wish-list, my guess is that most acute paediatricians would want a test to be used in febrile infants that could exclude serious bacterial infection reliably, quickly and simply. We know that the majority will turn out to have a viral cause but identifying the few with bacterial infections is difficult, resulting in hospital admissions and much investigation and treatment that turns out to be unnecessary. Infants under 3 months are the most difficult, as clinical signs can be non-specific and lab tests …

CRP point-of-care testing in children is feasible in primary care and is likely to be acceptable. However, it will not reduce antibiotic prescribing and hospital referrals until general practitioners accept its diagnostic value in children.

The use of clinical prediction models can improve discrimination between serious and self-limiting infections in children. The application of low-risk thresholds may help to rule out serious infections and discharge children from the ED without empirical antibiotics. A growing evidence base for prediction rules has so far failed to translate into validated rules to aid decision-making. Future work should evaluate decision rules in well designed impact studies, focusing on the need for hospital admission and antibiotic therapy.

Compared with earlier studies, UTIs now are found significantly more often than bacteremia and meningitis with 92% of occult infections associated with UTIs. These data emphasize the importance of an urinalysis in febrile infants.

Background: Classical criteria differ when performing cerebrospinal fluid (CSF) analysis in infants younger than 90 days with fever without a source (FWS). Our objectives were to analyze the prevalence and microbiology of bacterial meningitis in this group and its prevalence in relation to clinical and laboratory risk factors.

Methods: This is a substudy of a prospective registry including all infants of this age with FWS seen between September 2003 and August 2013 in a Pediatric Emergency Department of a Tertiary Teaching Hospital.

Results: Lumbar puncture was performed in 639 (27.0%) of the 2362 infants with FWS seen, the rate being higher in not well-appearing infants [60.9% vs. 25.7%; odds ratio (OR), 4.49] and in those ≤21 days old (70.1% vs. 20.4%; OR, 9.14). Eleven infants were diagnosed with bacterial meningitis: 9 were ≤21 days old (prevalence 2.8% vs. 0.1%; OR, 30.42) and 5 were not well-appearing infants (5.7% vs. 0.2%; OR, 23.06). Bacteria isolated were Streptococcus agalactiae (3), Escherichia coli (3), Listeria monocytogenes (3), Streptococcus pneumoniae(1) and Neisseria meningitidis (1). None of the 1975 well-appearing infants >21 days old were diagnosed with bacterial meningitis, regardless of whether biomarkers were altered.

Conclusions: In infants younger than 90 days with FWS, performing CSF analysis for ruling out bacterial meningitis must be strongly considered in not well-appearing infants and in those ≤21 days old. The recommendation of systematically performing CSF analysis in well-appearing infants 22–90 days of age on the basis of analytical criteria alone must be reevaluated.

The total white blood cell count and absolute neutrophil count are not sufficiently accurate triage tests for febrile children with suspected serious bacterial infection.

Fiebre tifoidea

Typhoid fever and paratyphoid fever continue to be important causes of illness and death, particularly among children and adolescents in south-central and southeast Asia. Two typhoid vaccines are widely available, Ty21a (oral) and Vi polysaccharide (parenteral). Newer typhoid conjugate vaccines are at varying stages of development and use. The World Health Organization has recently recommended a Vi tetanus toxoid (Vi-TT) conjugate vaccine, Typbar-TCV, as the preferred vaccine for all ages.

We found 18 relevant trials that evaluated four vaccines: 9 reported on vaccine effectiveness only, 4 reported on effectiveness and side effects, and 5 reported on side effects only (we could not analyse one additional trial on adverse events that met the inclusion criteria as it did not provide enough information). The two main vaccines currently licensed for use, Ty21a and Vi polysaccharide, were effective in reducing typhoid fever in adults and children over two years in endemic countries; adverse events such as nausea, vomiting, and fever were rare. Other vaccines, such as new, modified, conjugated Vi vaccines called Vi-rEPA and Vi-TT, are in development. These could be given to infants, which would be helpful as they are probably at higher risk for infection, although further evidence for these vaccines is still needed.

Authors' conclusions: The licensed Ty21a and Vi polysaccharide vaccines are efficacious in adults and children older than two years in endemic countries. The Vi-rEPA vaccine is just as efficacious, although data is only available for children. The new Vi-TT vaccine (PedaTyph) requires further evaluation to determine if it provides protection against typhoid fever. At the time of writing, there were only efficacy data from a human challenge setting in adults on the Vi-TT vaccine (Tybar), which clearly justify the ongoing field trials to evaluate vaccine efficacy

Fiebre tras vacunación

Artículo Valorado Críticamente : Effect of prophylactic or therapeutic administration of paracetamol on inmune response to DTwP-HepB-Hib combination vaccine in Indian infants. Vaccine, 2017;35:2999-3006.

Conclusiones de los autores del estudio: no se encontraron evidencias de que el paracetamol, administrado tanto de forma profiláctica como terapéutica, tenga un impacto sobre la respuesta inmunológica a la vacuna pentavalente DTPc-HepB-Hib.

Comentario de los revisores: las limitaciones metodológicas de este estudio no permiten realizar ningún cambio en la práctica clínica actual, que desaconseja la administración profiláctica del paracetamol en la vacunación infantil.

Artículo Valorado Críticamente: A randomized study of fever prophylaxis and the immunogenicity of routine pediatric vaccinations. Vaccine. 2017;35:1926-35.

Conclusiones de los autores del estudio: la administración de antitérmicos de forma profiláctica afecta a la respuesta inmune a las vacunas. Estos efectos varían según la vacuna, el antitérmico utilizado y el momento de administración. En lactantes, el paracetamol interfiere con la respuesta inmune a los antígenos neumocócicos y el ibuprofeno puede reducir la respuesta a la tosferina y al tétanos.

Comentario de los revisores: este estudio sugiere que la mejor respuesta inmune a la vacunación se alcanza sin la utilización de antitérmicos profilácticos.

  • En el Editorial de este número Evid Pediatr.2017;13 (3). “Fármacos antitérmicos y vacunas: ¿sabemos ya lo que necesitamos saber? el Dr. A.Hernández Merino hace una breve exposición de la evidencia disponible en el momento actual y concluye que sigue siendo prudente mantener la recomendación de no usar fármacos antitérmicos para prevenir la fiebre posvacunal. La pauta del uso de paracetamol, cuándo y qué dosis, parece una cuestión crítica respecto al posible efecto sobre la inmunogenicidad y parece limitarse al uso previo o simultáneo con la vacunación y no cuando se usa horas después, y también solo con la primovacunación, no con la dosis de refuerzo

Garrapatas (enfermedades trasmitidas por) (Ver Temas A-Z y entidades concretas)

La babesiosis, una enfermedad zoonótica transmitida por garrapatas causada por protozoos intraeritrocitarios del género babesia, se caracteriza por anemia hemolítica no inmune que se resuelve con el tratamiento antimicrobiano y la eliminación de la parasitemia. El desarrollo de la anemia hemolítica autoinmune de anticuerpos calientes  (también conocida como anemia hemolítica autoinmune cálida [WAHA]) en pacientes con babesiosis no ha sido previamente bien descrito.

Presentamos una serie retrospectiva de casos pediátricos diagnosticados de rickettsiosis durante los años 2013-2014. Se incluyeron un total de 8 pacientes, 2 de ellos diagnosticados de fiebre botonosa mediterránea y 6 de linfadenopatía por picadura de garrapata, identificándose en 3 de ellos Rickettsia slovaca, Rickettsia sibirica mongolitimonae y Rickettsia massiliae. Se describen la etiología, las características clínicas y el tratamiento realizado en cada uno de ellos.

Las enfermedades trasmitidas por garrapatas son poco frecuentes en nuestro medio. Presentamos un caso de linfadenopatía por picadura de garrapata (TIBOLA, por su nombre en inglés: tick-borne lymphadenopathy). Es una enfermedad emergente causada por Rickettsia slovaca. Se manifiesta como una escara necrótica en cuero cabelludo, en el lugar de la picadura, fiebre y múltiples adenopatías craneales y laterocervicales posteriores. La duración media del periodo de incubación desde la picadura es de siete días.

Ante un paciente con adenitis cervical y el antecedente de picadura de garrapata y/o escara en el cuero cabelludo el diagnóstico de TIBOLA es el más frecuente.

GEA (Ver Temas A-Z y diarrea)

Se observó un aumento real del 4,1% en el porcentaje de casos con agente etiológico identificado al implementar la técnica diagnóstica CerTest Norovirus GI+GII. El rotavirus sigue siendo la causa más frecuente de gastroenteritis aguda en nuestro medio, seguido de cerca por el norovirus.

Ensayo prospectivo, aleatorizado, doble ciego en niños de 3 meses a 4 años de edad con gastroenteritis aguda. Los participantes recibieron un tratamiento de 5 días de Lactobacillus rhamnosus GG en una dosis de 1 × 1010 unidades formadoras de colonias dos veces al día versus un placebo. Conclusiones: Los que recibieron un curso de 5 días de L. rhamnosus GG no tuvieron mejores resultados que los que recibieron placebo.

Resumen: La diarrea bacteriana es una causa común de mortalidad y morbilidad en niños de 0-59 meses en el UniversityTeaching Hospital en Lusaka, Zambia. La mayoría son tratadas empíricamente. El objetivo fue identificar las bacterias causantes y su susceptibilidad antibiótica. Los datos sugieren que la mayoría de las bacterias aisladas son multirresitentes por lo que hay que revisar el tratamiento empírico actual con ampicilina y cotrimoxazol e implementar programas de prevención de diarreas en niños

Resumen: en conjunto, las muertes por enfermedades diarreicas, han disminuido sustancialmente en los últimos 25 años, aunque la mejora ha sido muy diferente según el nivel de vida de los países. En global, todavía la diarrea continúa siendo una causa evitable de morbilidad y muerte a nivel mundial, y las medidas más efectivas siguen siendo las sanitarias (calidad y canalización de aguas) y un buen estado nutricional de los niños.

Giardia (Ver Temas A-Z)

El hallazgo de una alta prevalencia de infecciones asintomáticos entre el grupo familiar ha planteado la cuestión de salud pública de si estaría justificado tratar los contactos para prevenir la reinfecciones del caso índice o prevención de casos secundarios. Siendo particularmente pertinente en grupos familiares con niños menores de 5 años. Es un estudio de prevalencia y no pude proporcionar evidencia del impacto de tratar las infecciones asintomáticas.

Gripe (ver también Temas A-Z)

Children <2 years old had the highest influenza-associated pediatric mortality in the United States from 2010 to 2016. Half of the deaths occurred in previously healthy children.

Estudio prospectivo multinacional de niños menores de 1 año que tiene como objetivo evaluar la frecuencia de las infecciones por virus de la influenza y del virus sincitial respiratorio asociadas con hospitalizaciones, describir las características clínicas y la respuesta de anticuerpos a la infección y examinar los predictores de enfermedad muy grave que requieren cuidados intensivos.

Our model identifies scenarios in which identification of influenza in the emergency department using rapid multiplex PCR testing is a cost-effective strategy for infants and children 3 months through 18 years. Including detection of other respiratory viruses in the analysis would further improve cost-effectiveness.

Gripe vacunas (ver también Temas A-Z)

We included 41 clinical trials (> 200,000 children). Most of the studies were conducted in children over the age of two and compared live attenuated or inactivated vaccines with placebo or no vaccine. Studies were conducted over single influenza seasons in the USA, Western Europe, Russia, and Bangladesh between 1984 and 2013. Restricting analyses to studies at low risk of bias showed that influenza and otitis media were the only outcomes where the impact of bias was negligible. Variability in study design and reporting impeded meta-analysis of harms outcomes.

Compared with placebo or do nothing, live attenuated vaccines probably reduced the proportion of children who had confirmed influenza from 18% to 4% (moderate-certainty evidence), and may reduce ILI (influenza-like illness) from 17% to 12% (low-certainty evidence). Seven children would need to be vaccinated for one child to avoid influenza, and 20 children would need to prevent one child from experiencing an ILI. We found data from one study that showed similar risk of ear infection in the two groups. There was insufficient information available to assess school absence and parents needing to take time off work. We found no data on hospitalisation, and harms were not consistently reported.

Compared with placebo or no vaccination, inactivated vaccines reduce the risk of influenza from 30% to 11% (high-certainty evidence), and they probably reduce ILI from 28% to 20% (moderate-certainty evidence). Five children would need to be vaccinated for one child to avoid influenza, and 12 children would need to be vaccinated to prevent one case of ILI. The risk of otitis media is probably similar between vaccinated children and unvaccinated children (31% versus 27%, moderate-certainty evidence). There was insufficient information available to assess school absenteeism due to very low-certainty evidence from one study. We identified no data on parental working time lost, hospitalisation, fever, or nausea.

In children aged between 3 and 16 years, live influenza vaccines probably reduce influenza (moderate-certainty evidence) and may reduce ILI (low-certainty evidence) over a single influenza season. In this populationinactivated vaccines also reduce influenza (high-certainty evidence) and may reduce ILI (low-certainty evidence). For both vaccine types, the absolute reduction in influenza and ILI varied considerably across the studypopulations, making it difficult to predict how these findings translate to different settings. We found very few randomised controlled trials in children under two years of age. Adverse event data were not well described in the available studies. Standardised approaches to the definition, ascertainment, and reporting of adverse events are needed. Identification of all global cases of potential harms is beyond the scope of this review.

Resumen: se había hipotetizado sobre el aumento de casos de epilepsia infantil en poblaciones inmunizadas con la vacuna de la gripe A pandémica (H1N1). Este estudio sobre registros en Noruega, de 572.857 niños vacunados no encuentra ningñun tipo de asociacion o riesgo de epilepsia en niños que han recibido la vacuna (Hazard ratio 1,07; IC 95%: 0,94 a 1,23).

En EEUU la eficacia de la vacunación frente a los virus de la gripe de forma global es un 36% (95% IC 27-44%). 25%(13-36%) frente virus A H3N2. 67% (54-76%) frente virus A H1N1 pdm09 y 42% (25-56%) frente a virus B (EEUU vacunación con vacuna cuadrivalente).

La eficacia vacunal frente al virus A H3N2es mayor en el grupo de edad pediátrico- 6meses a 18 años.

Dada la limitada efectividad de la vacunación los autores recomiendan el tratamiento antiviral en los pacientes de riesgo con síntomas compatibles independientemente del estado vacunal e incluso del resultado de los test rápidos.

Los autores también refieren la necesidad de vacunas maseficaces que reduzcan de forma sustancial la incidencia de la enfermedad.

EFECTIVIDAD VACUNAL

  • Contra cualquier tipo de gripe: 25-52 % para todas las edades, 36-40 % para los grupos de riesgo y del 35 % frente a la hospitalización en mayores de 65 años de edad.
  • Frente a la gripe por virus A(H1N1)pdm09 y todas las edades: 55-68 % (moderada a buena).
  • Frente a la gripe por virus A(H3N2): <8 % (entre -42 y 8 %) para todas las edades (pobre).
  • Frente a la gripe por virus B: 36-54 % (moderada).

La baja EV encontrada para el virus A(H3N2) tiene importancia especial en la población de mayores de 65 años de edad y por ello, en el RU en la temporada 2018-2019, se usará una vacuna adyuvada en este rango de edad.

En cuanto al virus B, en los niños la EV encontrada fue mejor (83 %; 54-94 %) y peor en el caso de los de ≥65 años hospitalizados (34 %). La inmensa mayoría de los aislamientos correspondieron al linaje Yamagata, no incluido en la vacuna, sugiriendo, en conjunto, una importante protección cruzada entre linajes.

Los datos del RU hacen referencia a la vacuna tetravalente: la EV en niños que recibieron la vacuna atenuada (53 %) fue similar a la de los niños vacunados con la trivalente en otros lugares (59 %), pero la interpretación de este dato puede estar influido por el hecho de que en el RU la circulación del virus A(H3N2) fue mayor que en el resto de los países.

Si bien estos resultados son provisionales, los autores predicen, a modo de conclusión, que finalmente la protección de las vacunas trivalentes frente a los virus A(H1N1) y B será buena.

Question Among children, what is the therapeutic efficacy of the live attenuated influenza vaccine, compared with those not receiving any influenza vaccine, in preventing influenza disease?

Design Prospective cohort during the 2015-2016 influenza season using the test-negative design.

Setting Geographically diverse US sites.

Participants Patients 6 months of age or older, with cough for 7 or fewer days.

Intervention Live attenuated influenza vaccine or none.

Outcomes Vaccine efficacy.

Main Results The live attenuated vaccine was not effective: 5% (95% CI, −47%-39%) among those who received versus those who did not receive vaccination. The inactivated vaccine was effective: 60% (95% CI, 47%-70%).

Conclusions The live attenuated influenza vaccine was not effective.

Commentary This is one of the studies that were the reason the Advisory Committee on Immunization Practices did not recommend the live attenuated influenza vaccine for the 2016-2017 season.1 The authors analyzed the data in detail with many calculations and adjustments, all supporting the main conclusion. It is discouraging that the reason for the failure of this live attenuated vaccine during 2015-2016 is not known. Clearly, surveillance of influenza vaccine effectiveness on an annual basis needs to be continued, considering surprises and the baseline low effectiveness. The test-negative design was used in the study. If, in a group of children presenting with respiratory illness, fewer children with proven influenza have been vaccinated compared with those without influenza, it can be presumed that the vaccine prevented influenza specific illness in the proportion of the children with alternative etiologies. The quantitation of the presumed protection (effectiveness) is described and discussed in the current paper and in their reference 20.2 This is a somewhat new technique that has appeared in the pediatric literature for only a few years and readers may wish to review it to understand how it is valid yet different from more traditional methods.

The USA has a long-standing paediatric influenza vaccination programme, including use of live attenuated influenza vaccine (LAIV). Following US evidence of apparent lack of vaccine effectiveness (VE) of LAIV in 2015/2016, particularly against A(H1N1)pdm09, the USA suspended the use of LAIV in the 2016/2017 season. The UK introduced LAIV for children in 2013/2014 and Finland in 2015/2016. Both countries have since been closely monitoring programme performance. In 2015/2016, the UK and Finland, unlike the USA, found evidence of significant VE of LAIV against laboratory-confirmed influenza. Several studies, however, reported relatively lower VE of LAIV against A(H1N1)pdm09 infection compared with inactivated influenza vaccine, although not for A(H3N2) or B. The reasons for these apparent differences remain under investigation. Both the UK and Finland continue to recommend the use of LAIV in children for the 2017/2018 season and are intensifying further monitoring of their childhood programmes against a range of end-points.

This study provides interim estimates of the 2017 southern hemisphere influenza vaccine in the outpatient setting and may no tapply to in patient settingsor severe illness. Interim estimates can reliably predict final season estimates [19], particularly when made after the peak [20], as is the case here. Should the circulating A(H3) influenza viruses predominate in the 2017/18 northern hemisphere influenza season [21], our results suggest that the vaccine may confer limited protection. Health authorities should consider ther influenza prevention measures, including antivirals and health promotion messaging, in the event of a severe season and low VE against A(H3).

Influenza vaccination was associated with reduced risk of laboratory-confirmed influenza-associated pediatric death. Increasing influenza vaccination could prevent influenza-associated deaths among children and adolescents.

The inactivated influenza A(H1N1)pdm09 vaccine exhibited a favorable safety profile at both dosage levels. While a single 15 or 30 µg dose induced seroprotective antibody responses in most children 10–17 years of age, younger children required 2 doses, even when receiving dosages 4- to 6-fold higher than recommended. Well-tolerated vaccines are needed that induce immunity after a single dose for use in young children during influenza pandemics.

There is limited evidence (from one small trial at a high risk of bias) on the effectiveness on Hib during pregnancy for improving maternal, neonatal and infant health outcomes. Evidence from one large high quality trial on the effectiveness of viral influenza vaccine during pregnancy suggests reduced RT-PCR confirmed influenza among women and their babies, suggesting the potential of this strategy for scale up but further evidence from varying contexts is required. Further trials for both Hib and viral influenza vaccines with appropriate study designs and suitable comparison groups are required. There are currently two 'ongoing' studies - these will be incorporated into the review in future updates.

Guarderías

Resumen: en un estudio de cohorte realizado en Dinamarca, investigan la variabilidad y frecuencia de infección en los primeros 3 años de vida, intentando encontrar asociaciones entre infecciones y factores de riesgo. Hubo asociación significativa entre mayor nñumero de infecciones y la asistencia a guardería, y los metros cuadrados por niño en la guardería. Las infecciones respiratorias de vías altas también se asociaron con un mayor número de niños en la guardería. Las infecciones respiratorias de vías bajas se asociaron significativamente con parto instrumental, tabaquismo materno, tenencia de hermanos y la menor edad de entrada en la guardería.

First-year day care attendance is a major risk factor for AOM symptom episodes among infants in the community. This adjusted effect estimate is higher than previously reported and is age-dependent. AOM prevention strategies in day care facilities should therefore focus in particular on the youngest age groups.

Conclusiones: 1) la asistencia a guardería se asocia con mayor probabilidad de ser HF en Urgencias y en la consulta de Pediatría de Atención Primaria (AP); 2) los niños HF padecen más enfermedades respiratorias e infecciosas, que no son explicadas por su asistencia a guardería, y 3) lo anterior conlleva un mayor consumo de fármacos.

Se estudiaron 975 niños. ˜ A los 24 meses acuden a la guardería el 43,7%. Asistir a guardería incrementa el riesgo de padecer neumonía en un 131%, el de sibilancias recurrentes en un 69%, el de bronquitis un 57% y el de otitis media en un 64%. La exposición temprana a la guardería incrementa el riesgo de neumonías de 2,31 a 2,81 y la media de visitas a urgencias desde 1 a 2,3. La media de ciclos de antibióticos es de 1,7 para los que no van a la guardería, de 3,4 si la inician en los 6 primeros meses y de 2 si comienzan a partir de los 18 meses. La asistencia a guarderías es un factor de riesgo de padecer enfermedades infecciosas que aumenta si asisten desde edades tempranas.

Guillén-Barre

Gianotti-Crosti

Haemophillus (ver Temas A-Z)

Resumen: en 2016 se detectó en Holanda un discreto repunte de enfermedad invasiva por Haemophilusinfleunzae b en niños menores de 5 años, coincidiendo con la introducción en 2011 de la vacuna hexavalente con componente acelular de vacuna pertussis (BTPa-HBV, IPV/Hib). El estudio estima que la efectividad de la nueva vacuna frente a enfermedad invasiva por Hib, no ha disminuido con la introducción de dicha vacuna. La efectividad de la vacuna fue alta, aunque disminuyó con la edad. Otras razones que expliquen el incremento en la enfermedad invasiva por Hib deberían de ser investigadas

Conclusions: The high level of genetic diversity in invasive NTHi strains highlights the difficulties in developing an effective vaccine against this pathogen.

 Helicobacter (ver también Temas A-Z)

(estudios en población adulta)

We included 101 studies involving 11,003 participants, of which 5839 participants (53.1%) had H pylori infection. The prevalence of H pyloriinfection in the studies ranged from 15.2% to 94.7%, with a median prevalence of 53.7% (interquartile

range 42.0% to 66.5%). Most of the studies (57%) included participants with dyspepsia and 53 studies excluded participants who recently had proton pump inhibitors or antibiotics.There was at least an unclear risk of bias or unclear applicability concern for each study.

In people without a history of gastrectomy and those who have not recently had antibiotics or proton ,pump inhibitors, urea breath tests had high diagnostic accuracy while serology and stool antigen tests were less accurate for diagnosis of Helicobacter pylori infection.This is based on an indirect test comparison (with potential for bias due to confounding), as evidence from direct comparisons was limited or unavailable. The thresholds used for these tests were highly variable and we were unable to identify specific thresholds that might be useful in clinical practice.

We need further comparative studies of high methodological quality to obtain more reliable evidence of relative accuracy between the tests. Such studies should be conducted prospectively in a representative spectrum of participants and clearly reported to ensure low risk of bias. Most importantly, studies should prespecify and clearly report thresholds used, and should avoid inappropriate exclusions.

Hemocultivo

El hemocultivo (HC) es el método diagnóstico de elección ante la sospecha de bacteriemia, siendo una de las técnicas microbiológicas más solicitadas en pediatría. Diversos cambios han acontecido en los últimos años como la introducción de nuevas vacunas, el aumento creciente de pacientes portadores de catéteres vasculares centrales, o la irrupción de los sistemas automáticos de procesamiento de los HC. Dichos cambios han propiciado la revisión y la actualización de los distintos aspectos relacionados con esta técnica con el fin de optimizar su uso. Se presenta una guía práctica sobre recomendaciones acerca de la extracción, el procesamiento y la interpretación de los HC elaborada por la Sociedad Española de Urgencias de Pediatría y la Sociedad Española de Infectología Pediátrica. Tras revisar la información científica disponible, se presentan una serie de recomendaciones para cada uno de los siguientes apartados: indicaciones en Urgencias, técnica de extracción, transporte y procesamiento de la muestra, factores a tener en cuenta en situaciones especiales (indicaciones e interpretación de resultados en el paciente inmunodeprimido y/o portador de catéter vascular central, indicaciones de HC para anaerobios), diferenciación entre bacteriemia y contaminación ante un HC con crecimiento bacteriano y actitud a tomar ante un HC positivo en el paciente con fiebre sin foco.

Hepatitis (ver también Temas A-Z)

Hepatitis A (ver Temas A-Z)

Hepatitis A vacuna (ver Temas A-Z)

Hepatitis B (ver también Temas A-Z)

Hepatitis B virus is a bloodborne pathogen typically transmitted through sexual contact, injection drug use or perinatally. A hepatitis B vaccine (HepB) is available; the first dose is recommended at birth. We sought to identify hospital policy, maternal characteristics and birth factors associated with HepB receipt at birth in West Virginia.

We conducted a retrospective cohort study of West Virginia live births in 2015 using vital records matched to immunization registry records to determine frequency of HepB birth dose receipt (<3 days postdelivery). We surveyed all West Virginia birthing facilities in 2015 (N = 26) about perinatal hepatitis B virus prevention policies. We examined associations of hospital policy, maternal characteristics and birth factors with HepB receipt at birth by using a mixed-effects regression model to calculate adjusted prevalence ratios (aPRs) and 95% confidence intervals (CIs).

Of 17,458 births, 14,006 (80.2%) infants received a HepB birth dose. Hospital use of preprinted newborn routine admission vaccination orders was associated with HepB birth dose receipt (aPR: 10.60; 95% CI: 2.12–52.72). Not using illicit drugs during pregnancy, maternal age <35 years and weekday births were associated with HepB birth dose receipt (aPR: 1.81; 95% CI: 1.54–2.13; aPR: 1.34, 95% CI: 1.17–1.54 and aPR: 1.15; 95% CI: 1.03–1.28, respectively).

Hospitals using preprinted admission orders had higher frequencies of HepB birth dose receipt. Additional study is needed to identify HepB birth dose receipt barriers among infants with maternal illicit drug use, maternal age ≥35 years or deliveries during a weekend.

Perinatal HBV infection occurred among 1% of infants, most of whom received recommended immunoprophylaxis. Infants at greatest risk of infection were those born to women who were younger, hepatitis B e-antigen positive, or who had a high viral load or those infants who received <3 HepB vaccine doses.

Hepatitis B vacuna (ver también Temas A-Z)

Hepatitis C (ver también Temas A-Z)

The development of oral hepatitis C virus (HCV) direct-acting antivirals (DAAs) has revolutionized the therapeutic field. Nowadays, multiple safe and highly effective antiviral regimens are commercially available to treat adults with hepatitis C infection. These new regimens for the first time genuinely raise the prospects of eradicating HCV. Many challenges, however, remain from identifying infected individuals to optimizing treatment and ensuring global access to antiviral therapy to all population groups, including children. Recently, in April 2017, the association of sofosbuvir with ribavirin and the fixed-dose combination sofosbuvir/ledipasvir have been approved by the Food and Drug Administration for treatment of children with chronic HCV infection 12 years of age and older. The only drugs currently approved for children younger than 12 years are pegylated interferon and ribavirin. There are 6 registered ongoing pediatric trials assessing safety and efficacy of DAAs, but their current completion timelines are years away. Herein, we summarize the state of the art of DAAs' development for adult and children and highlight the crucial importance of overcoming barriers to treating children with HCV.

Aunque no está realizado en población pediátrica, sí es población sin fibrosis y con mínimo grado (Metavir F0, F1), que suele ser como están los niños y los tratamientos que incluyen Sofosbuvir alcanzan en la totalidad de los casos una respuesta virológica sostenida.

Children respond well to therapy for CHC. Treatment was tolerated with minimal impact on QoL and no significant effect on growth. Knowledge of viral and IL28 genotypes and early viral response is useful to plan treatment in children and provide appropriate counseling

The increases of HCV in hospitalized children are largely in teenagers, highly associated with substance abuse, and concentrated in Northeast and Southern states. These results strongly suggest that public health efforts to prevent and treat HCV will also need to include adolescents.

Hepatitis D (ver Temas A-Z)

Hepatitis E (ver Temas A-Z)

Herpes (Ver Temas A-Z)

The majority of infants with HSV (84%) presented with seizure, vesicular rash, or critical illness. A subset of patients (16%) lacked classic signs at hospitalization; most manifested signs suggestive of HSV within 24 hours. Further studies are needed to validate the risk factors identified in this study including age <14 days and cerebrospinal fluid pleocytosis at presentation. Management of Herpes Simplex Virus Keratitis in the Pediatric Population. The Pediatric Infectious Disease Journal. 37(9):949-951

Herpes simplex virus (HSV) keratitis is a highly prevalent and visually disabling disease in both the pediatric and adult population. While many studies have investigated the treatment of HSV keratitis in adult patients, few have focused on managing this condition in children. Children are at particularly high risk for visual morbidity due to unique challenges in diagnosis and treatment, and the often more aggressive disease course that results in corneal scarring, and subsequently amblyopia. This review presents the pathogenesis and most current recommendations for the medical and surgical management of HSV keratitis in the pediatric population.

A 2-week-old boy was bitten on his forehead by his 18-month-old cousin. Three days later, he was seen by his pediatrician because several fluid-filled vesicles had appeared at the site. He was afebrile, vigorous, and feeding and voiding well. Amoxicillin-clavulanate and topical mupirocin were prescribed for presumed cellulitis. However, at follow-up, the lesions had progressed to partially coalesced, purulent, fluid-filled vesicles with surrounding erythema (Figure). His mother recalled that the cousin had similar lesions around his mouth at the time of the bite.

Se identificaron 21 niños con encefalitis por virus herpes en el "California Encephalitis Project". Las características más reseñables fueron 6 (29%) pacientes con PCR de VHS en LCR inicialmente negativa y 13 (59%) pacientes con afectación extratemporal en la neuroimagen. 11 casos fueron pacientes menores de 4 años. Todos los casos fatales ocurrieron en adolescentes. 

Interpretation: Our incidence rate of 17.5 per 100 000 live births represents a significant increase and is much more in line with the higher incidence rates seen in the USA. The range of presentations shows the non-specific nature of this disease. We advocate a heightened awareness of this treatable disease in the UK, and encourage adoption of modern rapid diagnostic techniques and the wider inclusion of Aciclovir in treatment regimens for neonatal sepsis.

This retrospective study characterized the clinical course of 13 neonates who died with herpes simplex virus infection from 2001 to 2011, representing a 26% case-fatality rate. Fatal disease developed at ≤48 hours of age in one-third of infants, was mostly disseminated disease, and occurred despite early administration of high-dose acyclovir therapy.

A 15-day-old infant presented with vesicular lesions over the chest, scalp and axilla (figures 1 and 2). Clinical examination appeared normal. She was a term vaginal delivery with no septic risk factors. Maternal herpes simplex virus (HSV) IgG was negative on booking bloods. However, there was postnatal exposure to a relative with an active cold sore. Full blood count and inflammatory markers were … 

Herpes tipo 6

La investigación del VHH-6 se debería de incluir en el estudio de las infecciones virales neurológicas en niños, para conocer la etiología de estos cuadros clínicos y su evolución y, si es necesario, instaurar tratamiento antiviral con ganciclovir que, aunque se desconoce la repercusión clínica del mismo, podría favorecer una recuperación precoz o evitar secuelas

A 4-day-old neonate was transferred to a tertiary heart center for further evaluation and management of sudden-onset acute heart failure (HF). The birth history was significant for being born at 37 weeks' gestation to a 26-year-old mother with a probability 2 A0 blood type.

Herpes 7

We present a case report of a meningoradiculopathy associated with human herpesvirus 7, with long-term motor neurologic sequelae. It is important to consider human herpesvirus 7 as a potential pathogen of severe neurologic disease and sequelae in immunocompetent children, especially in older patients presenting neurologic signs.

Herpes Zoster (Ver varicela y Temas A-Z)

Herpes zoster vacuna (Ver Temas A-Z)

  • Vaccines for preventing herpes zoster in older adults. Cochrane Database of Systematic Reviews 2016, Issue 3. Art. No.: CD008858. We found 13 randomised controlled trials including 69,917 healthy older adults. Only five of the 13 trials were of high quality and had a low risk of bias. Pharmaceutical companies that produce the vaccines funded all of the included studies.

Herpes zoster vaccine is effective in preventing herpes zoster disease and this protection can last three years. In general, zoster vaccine is well tolerated; it produces few systemic adverse events and injection site adverse events of mild to moderate intensity.

There are studies of a new vaccine (with a VZV glycoproteic fraction plus adjuvant), which is currently not yet available for clinical use.

Hidatidosis

A 4.5-year-old boy was brought to the emergency room with a history of multiple generalized tonic–clonic seizures for 1 day. On examination, there was no focal neurologic deficit and no signs of increased intracranial pressure. The fundus examination was normal, as was the examination of other body systems. The patient was administered anticonvulsants and the seizures were controlled. The T1- and T2-weighted magnetic resonance imaging of his brain showed a well-circumscribed, spherical, cystic lesion in the right temporal region, with no calcification or wall enhancement, causing a mass effect, consistent with a diagnosis of a hydatid cyst (Figure, A and B). An ultrasound examination of the abdomen showed 3 thin-walled anechoic cystic lesions 21 × 18 mm, 16 × 12 mm, and 6 × 6 mm in segments III and IV of the liver, also suggestive of hydatid cysts. However, the hydatid serology was negative.

Homeopatía

Se analizan 6 estudios: 2 preventivos y 4 de tratamiento. Los 2 estudios preventivos no muestran resultados a favor del oscillococcinum. Los 4 de tratamiento parece que alivian los sintomas 48 horas, pero esto puede deberse  a factores de confusión o fallos en el diseño del estudio.

We included eight studies involving 1562 children that compared oralhomeopathic treatment to either placebo or standard treatment to prevent or treat respiratory infections in children. All studies investigated upper respiratory tract (from the nose to the windpipe (trachea)) infections, but one combined reporting of upper and lower respiratory tract (from the windpipe to the lungs and pleura (membranes covering the lungs)) infections, so the numbers of children with upper or lower infections is unknown.

Pooling of two prevention and two treatment studies did not show any benefit of homeopathic medicinal products compared to placebo on recurrence of ARTI or cure rates in children. We found no evidence to support the efficacy of homeopathic medicinal products for ARTIs in children. Adverse events were poorly reported, so conclusions about safety could not be drawn.

Infecciones

Infecciones bacterianas/virales (ver Marcadores)

To determine the prevalence of invasive bacterial infections (IBI, pathogenic bacteria in blood or cerebrospinal fluid) in infantsless than 90 days old with fever without a source related to the presence or absence of fever on arrival to the emergency department (ED).

Prospective registry-based cohort study.

Paediatric ED of a tertiary teaching hospital.

We included infants less than 90 days old with a history of fever evaluated in the ED from 2003 to 2016.

The prevalence of IBI in patients with a history of fever who were febrile and afebrile on arrival to the ED.

We included 2470 infants: 678 afebrile and 1792 febrile when evaluated in the ED. Fifty-nine (2.4%) were diagnosed with an IBI (bacteraemia 46, meningitis 7 and sepsis 6): 16 in the group of afebrile infants with a history of fever (2.4%, 95% CI 1.4 to 3.8 vs 43 in the febrile group, 2.4%, 95% CI 1.8 to 3.2). Of the 16 afebrile infants with a history of fever diagnosed with an IBI, 14 were well appearing. The rate of non-IBI (pathogenic bacteria in urine or stools) was similar in both groups (15.5% and 16.7%).

The prevalence of IBI in infants ≤90 days with a history of fever is similar regardless of the presence of fever on the arrival at the ED. The approach to infants with a history of fever who are afebrile in the ED should not differ from that recommended for infants who are febrile in the ED.

In England and Wales, replacement of childhood 7-valent pneumococcal conjugate vaccine (PCV7) with a 13-valent vaccine (PCV13) in 2010 was associated with a significant reduction in PCV13-serotype invasive pneumococcal disease (IPD), with a small increase in IPD due to non-vaccine serotypes. Here, we describe the clinical presentation, comorbidity prevalence, serotype distribution and outcomes of childhood IPD during the first 6 years after PCV13 introduction.

Public Health England conducts enhanced IPD surveillance in England and Wales, with detailed information requested from general practitioners for all cases in children <5 years of age. Invasive isolates are routinely serotyped at the Public Health England reference laboratory.

From April 2010 to March 2016, 1280 IPD episodes were confirmed in 1255 children 3–59 months of age; 84.3% (1059/1255) isolates were serotyped. Clinical presentation with meningitis was most prevalent in 3- to 11-month olds (45.8%, 209/456) and lower respiratory tract infection in 24- to 59-month olds (46.7%, 133/285). Overall, 259 (20.6%) children had 292 comorbidities, particularly immunosuppression (31.6%, 92/292). Twenty-one children (1.8%) had recurrent IPD. The case fatality rate was 5.1% (64/1255; 95% confidence interval [CI]: 3.9%–6.5%) and independently associated with meningitis (aOR 3.53; 95% CI: 1.62–7.70) and presence of comorbidity (aOR, 2.41; 95% CI: 1.25–4.64). In 2015/2016, PCV13 serotypes were responsible for 10.8% (25/232) of serotyped cases; the most prevalent non-PCV13 serotypes were 12F (18%), 10A (12%), 23B (10%), 33F (10%), 15B/C (10%) and 8 (8%).

Most childhood IPD cases are now due to non-PCV13 serotypes. A higher proportion of children with IPD have underlying comorbidity, but, reassuringly, the risk of recurrent IPD or death remains low.

Vaccines against Haemophilus influenzae type B (Hib), Neisseria meningitidis and Streptococcus pneumoniae have been serially introduced into the New Zealand national immunization schedule since the 1990s. This study aimed to describe long-term trends in the rates of these invasive bacterial infections in children from New Zealand and compare these to recent UK data.

Methods: This population-based observational study used 2 national datasets that collect data about hospital discharges (National Minimum Dataset) and notifiable diseases (Epurv). Annual age-specific and age-standardized hospital admission rates and notification rates were analyzed for all children <15 years of age.

Results: Hospital admissions for Hib reduced by 79% during the 2 years after the introduction of the Hib vaccine (5.94–1.24/100,000). Meningococcal disease notifications fell by 75% over 8 years after the introduction of MeNZB vaccine (26.15–2.48/100,000) and have continued to decline. Meningococcal disease rates were lower than in the United Kingdom despite the absence of an ongoing meningococcal vaccination program in New Zealand (8.16 compared with 10.37/100,000 for 2007–2011). There rates of notifications and hospital admissions for pneumococcal disease were discordant, but both reduced substantially after the introduction of pneumococcal conjugate vaccines. Maori children had the highest rates of disease and the greatest reduction in rates after the introduction of both meningococcal and pneumococcal vaccines.

Conclusions: Vaccines have had a substantial impact on the rates of invasive bacterial disease in children from New Zealand because of Hib, pneumococcus and meningococcus. Reductions in rates of disease have been greatest in Maori children, improving longstanding disparities in disease burden.

Of the 442 infants with invasive bacterial infection, 353 (79.9%) had bacteremia without meningitis, 64 (14.5%) had bacterial meningitis with bacteremia, and 25 (5.7%) had bacterial meningitis without bacteremia. The peak number of cases of invasive bacterial infection occurred in the second week of life; 364 (82.4%) infants were febrile. Group B streptococcus was the most common pathogen identified (36.7%), followed by Escherichia coli(30.8%), Staphylococcus aureus (9.7%), and Enterococcus spp (6.6%). Overall, 96.8% of pathogens were susceptible to ampicillin plus a third-generation cephalosporin, 96.0% to ampicillin plus gentamicin, and 89.2% to third-generation cephalosporins alone.

For most infants ≤60 days old evaluated in a pediatric emergency department for suspected invasive bacterial infection, the combination of ampicillin plus either gentamicin or a third-generation cephalosporin is an appropriate empiric antimicrobial treatment regimen. Of the pathogens isolated from infants with invasive bacterial infection, 11% were resistant to third-generation cephalosporins alone.

Woll et al present the compilation of bacteriologically confirmed bloodstream infection (BSI) and meningitis in infants <60 days of age who were evaluated in 11 children's hospital emergency departments over 5 years, 2011-2016. They also assessed infectious etiologies by weeks of age, and susceptibility of organisms to frequently used regimens for empiric therapy.

Infecciones congénitas (ver Temas A-Z y cada entidad)

This document aims to support the strengthening of antenatal screening programmes for HIV, hepatitis B, syphilis and rubella susceptibility in the general population and in groups identified as vulnerable to mother-to-child-transmission in the EU/EEA. Vulnerable groups specifically targeted by this guidance include: 1) migrant women and women from ethnic minority groups; 2) women engaging in high-risk behaviour or with a partner at high risk for HIV, HBV and syphilis infections; and 3) women belonging to minority groups refusing vaccinations.

For HIV, hepatitis B and syphilis, most studies suggest that comprehensive, population-based antenatal screening iscost effective in all assessed settings.The effectiveness of antenatal screening programmes has not been widely studied in Europe. The availableliterature mainly provides authors’ opinions regarding factors that influence effectiveness; there are no comparativestudies on effectiveness. Implementing antenatal screening programmes was found to be cost-effective in several countries.

Infección cutánea (ver también Temas A-Z)

In children with varicella (population), does the use of non-steroidal anti-inflammatory drugs (NSAID) (exposure) increase the risk of infectious complications of varicella (outcome)?

Resumen: mediante un proyecto con metodología de mejora de calidad, consiguen disminuir significativamente la duración del tratamiento antibiótico al alta hospitalaria en infecciones cutáneas y de tejidos blandos, sin que se detecten cambios significativos en la evolución (fallos en la curación o reinfecciones)

Point-of-care ultrasonography demonstrates excellent test characteristics for the identification of skin abscess and has superior test characteristics compared with physical examination alone.

Patients with MRSA skin abscesses are more likely to experience treatment failure and recurrent skin infection if given 3 rather than 10 days of trimethoprim-sulfamethoxazole after surgical drainage.

We included 445 cases: 348 (78.2%) cellulitis, 78 (17.5%) abscess and 19 (4.3%) impetigo. BCs were performed on 353 (79.3%) patients. Two (0.6%; 95% confidence interval: 0.2-2.0%) were positive and 10 (2.8%; 95% confidence interval: 1.5-5.1%) contaminated. The positive BCs grew S. aureus and Streptococcus pyogenes. Wound cultures were performed on 148 (33.3%) patients; 98 (66.2%) were positive. In 22 (22.4%) patients CA-MRSA grew, accounting for 14.9% of overall wound cultures.

BCs are not useful in the management of immunocompetent patients admitted to the hospital with uncomplicated SSTIs. The prevalence of CA-MRSA is low in our area, but continuing careful surveillance is needed.

Presentamos el caso clínico de dos hermanas que acuden a la consulta por lesiones cutáneas papulopustulosas, sin otra sintomatología, con antecedente de haber acudido días previos a balnearios y piscinas. La foliculitis por Pseudomonas es una infección cutánea de los folículos pilosos causada por P. aeruginosa, frecuente en personas que usan baños calientes, saunas, piscinas, juegos de agua y piscinas de fisioterapia. Es una infección autolimitada que se resuelve sin dejar lesiones residuales.

Infecciones respiratorias (Ver Temas A-Z)

Introducción: la leche y los derivados lácteos son alimentos importantes para el desarrollo. Sin embargo, la creencia de que se asocian con infecciones respiratorias está provocando que se limite su consumo o se sustituya por bebidas vegetales. El objetivo del estudio fue analizar si el consumo de lácteos se asocia con determinadas infecciones respiratorias en la infancia.

Material y métodos: estudio transversal con 169 voluntarios de entre 4 y 7 años. Información recogida mediante cuestionarios en papel. Información dietética recogida mediante cuestionario de frecuencia de consumo de alimentos semicualitativo de 151 ítems. Se valoró la asociación del consumo de leches, quesos y yogures con determinadas enfermedades respiratorias (otitis media aguda, sinusitis, mastoiditis, neumonía), comparando dos categorías de consumo definidas a partir de la mediana de cada alimento, mediante regresión logística multivariable.

Resultados: no se encontraron asociaciones entre el consumo de lácteos y las enfermedades respiratorias analizadas (odds ratio: 0,85; intervalo de confianza del 95%: 0,44 a 1,64]). Al analizar cada lácteo por separado, se encontró una asociación inversa entre el consumo de quesos y las enfermedades respiratorias en conjunto (odds ratio: 0,50; intervalo de confianza del 95%: 0,26 a 0,98), pero no para cada una de las infecciones por separado (otitis media aguda ni neumonía). No se encontró asociación significativa con los desenlaces para ningún otro derivado lácteo (leche o yogures).

Conclusiones: los resultados no apoyan una asociación directa entre el consumo de leche y derivados con infecciones respiratorias en la infancia. Con los datos actuales no está justificado restringir el consumo de leche o derivados en niños en edad escolar.

OBJECTIVE: To determine the early predictors of respiratory hospital admissions in young people with cerebral palsy (CP).

DESIGN: A 3-year prospective cohort study using linked data.

PATIENTS: Children and young people with CP, aged 1 to 26 years.

MAIN OUTCOME MEASURES: Self-reported and carer-reported respiratory symptoms were linked to respiratory hospital admissions (as defined by the International Statistical Classification of Diseases and Related Health Problems 10th Revision codes) during the following 3 years.

RESULTS: 482 participants (including 289 males) were recruited. They were aged 1 to 26 years (mean 10 years, 10 months; SD 5 years, 11 months) at the commencement of the study, and represented all Gross Motor Function Classification Scale (GMFCS) levels. During the 3-year period, 55 (11.4%) participants had a total of 186 respiratory hospital admissions, and spent a total of 1475 days in hospital. Statistically significant risk factors for subsequent respiratory hospital admissions over 3 years in univariate analyses were GMFCS level V, at least one respiratory hospital admission in the year preceding the survey, oropharyngeal dysphagia, seizures, frequent respiratory symptoms, gastro-oesophageal reflux disease, at least two courses of antibiotics in the year preceding the survey, mealtime respiratory symptoms and nightly snoring.

CONCLUSIONS: Most risk factors for respiratory hospital admissions are potentially modifiable. Early identification of oropharyngeal dysphagia and the management of seizures may help prevent serious respiratory illness. One respiratory hospital admission should trigger further evaluation and management to prevent subsequent respiratory illness.

OBJECTIVE: To determine the risk of death from two potentially avoidable causes with different aetiologies: respiratory tract infection (RTI) and sudden unexplained death (SUD) in children with and without chronic conditions.

DESIGN: Whole-country, birth cohort study using linked administrative health databases from Scotland.

SETTING AND PARTICIPANTS: Children aged 2 months to less than 5 years in Scotland between 2000 and 2014.

MAIN OUTCOME MEASURES: Relative risk of death (expressed as the HR) related to RTIs or SUD, in children with and without chronicconditions. We separately analysed deaths at ages 2-11 months and at 1-4 years and adjusted for birth characteristics, socioeconomic status and vaccination uptake using Cox regression.

RESULTS: The cohort comprised 761 172 children. Chronic conditions were recorded in 9.6% (n=72 901) of live births, 82.4% (n=173) of RTI-related deaths and 17.4% (n=49) of SUDs. Chronic conditions were very strongly associated with RTI mortality (2-11 months: HR 68.48, 95% CI (40.57 to 115.60), 1-4 years: HR 38.32, 95% CI (23.26 to 63.14)) and strongly associated with SUD (2-11 months: HR 2.42, 95% CI (1.67 to 3.63), 1-4 years: HR 2.53, 95% CI (1.36 to 4.71)).

CONCLUSIONS: The very strong association with chronic conditions suggests that RTI-related mortality may sometimes be a consequence of a terminal decline and not possible to defer or prevent in all cases. Recording whether death was expected on death certificates could indicate which RTI-related deaths might be avoidable through healthcare and public health measures.

Objetivo: Comparar la clínica y la gravedad entre la infección por virus único y la coinfección en niños admitidos por IVRI (Infección vías respiratorias inferiores) Métodos: Se realizó un estudio durante 3 años (2012-2015) que incluyó a niños menores de 2 años ingresados por IVRI. La identificación viral se realizó mediante la técnica de PCR para 16 virus. Los datos clínicos y el uso de los recursos hospitalarios se recogieron de forma estándar durante la estancia hospitalaria y se compararon la infección única con coinfecciones virales. Resultados: Fueron analizadas 524 muestras (451 pacientes); 448 (85,5%) tuvieron al menos un virus identificado. Coinfecciones virales se encontraron en 159 (35,5%). RSV y HRV fueron los virus más frecuentes; bronquiolitis y neumonía, los diagnósticos principales. Los pacientes con coinfecciones virales eran mayores, iban a la guardería, tenían sibilancias recurrentes con más frecuencia y eran más sintomáticos al ingreso. No fueron sometidos a más exámenes, pero les fueron prescritos medicamentos con más frecuencia. El grupo de la coinfección viral no mostró una mayor duración de la estancia hospitalaria, de la necesidad de oxígeno, de UCI o soporte ventilatorio. Discusión: proporción significativa de coinfecciones virales en los niños pequeños ingresados con IVRI y confirma dados previos que muestran que la prescripción es más frecuente en las coinfecciones virales, sin asociación con peor resultado clínico.

Multiplex polymerase chain reaction–based methods are increasingly used to detect respiratory pathogens in children. While rapid identification of viruses has been shown to reduce antibiotic use, the impact of detecting specific viruses on antibiotic utilization has not been ascertained. This study compared antibiotic utilization among hospitalized children who tested positive for different respiratory viruses at admission.

A single-center study of hospitalized children under 21 years of age who tested positive at admission for at least 1 respiratory virus by multiplex polymerase chain reaction from October 1, 2012 to October 1, 2015 was performed. Multivariable logistic regression was used to determine the association of testing positive for specific viruses with the use of antibiotics for ≥ 2 days, adjusted for demographic and clinical characteristics.

The study included 1416 patients with a median age of 2.1 years (interquartile range: 0.6–6.2 years). Patients positive for influenza (odds ratio: 2.0, 95% confidence interval: 1.1–3.4) and human metapneumovirus (odds ratio: 2.0, 95% confidence interval: 1.1–3.7) were more likely to receive ≥ 2 days of treatment compared with patients positive for respiratory syncytial virus (RSV). Other variables affecting prolonged use of antibiotics included respiratory support, primary nonrespiratory diagnosis, complex comorbid conditions and admission to the intensive care unit.

Providers are more likely to use antibiotics in non-RSV–infected patients compared with RSV. These trends likely represent concern about bacterial superinfection and may reflect lack of familiarity with these pathogens.

El número de patógenos virales identificados asociados con las infecciones agudas de las vías respiratorias (IRA) pediátricas ha aumentado desde la introducción de la reacción en cadena de la polimerasa inversa en tiempo real (RT-PCR). En una cuarta parte de estas IRA están implicados varios virus. El objetivo del presente estudio fue determinar la relevancia clínica de estos hallazgos en niños menores de 12 años con síntomas respiratorios. En un análisis multivariante, las únicas variables que se correlacionaron con una mayor estancia hospitalaria fueron el uso de oxígeno y nebulizaciones, con independencia del patógeno viral y del número de virus implicados.

Children with recurrent respiratory infections frequently use health care services and antibiotics, undergo surgical procedures and are at risk for asthma in early life. Having older siblings increases the risk of recurrent infections

Resumen: Estudio realizado en 900 niños menores de 6 años que acudieron al pediatra por una infección respiratoria.  Se obtuvieron muestras de nasofaringe con torunda para cultivo y aislamiento de Streptococcuspneumoniae.  Destacan el  impacto negativo que su presencia tiene sobre el curso de la infección de las vías respiratorias (mayor duración y pérdida de días de colegio) y frecuencias más altas de bronquitis,neumonía, otitis media aguda, sinusitis y la necesidad de tratamiento antimicrobiano. E indican, indirectamente la importancia de las vacunas antineumocócicaspara prevenir la infección  por S. pneumoniae

Bacterial interactions may result in differing pathogen prevalence in the first year of life. In addition, nasopharyngeal pneumococcal colonization may have an effect on the risk of infant wheeze. The result could help clinicians to clarify the relation between bacterial colonization and respiratory illnesses in infancy.

The variation of acute symptoms in young children may be influenced by both nasopharyngeal bacteria andrespiratory viruses. Our results showed a strong association between fever and respiratory viruses; rhinitis, nasal congestion and cough were associated with M. catarrhalis in the presence of viruses. Further studies are required to determine the possible synergistic role of M. catarrhalis in symptoms of RTI.

Viruses are associated with different nasopharyngeal bacterial colonization patterns.Observedpathogens'associations may play a role in disease, and continuous surveillance is required to follow possible effects of interventions such as vaccines.

Our results demonstrate that besides respiratory syncytial virus, other viruses mainly rhinovirus and human bocavirus are important pathogens in severe respiratory infections in preterm children. Human metapneumovirus and parainfluenza virus seem also to play a significant role in this group of children. There is increased medical resource utilization, not only among EPT but also in MPT hospitalized children with respiratoryinfections as many of them require more medical support than FT children.

Human rhinoviruses (HRV) are the most common respiratory viruses identified in humans with respiratory infections. HRV-induced wheezing during early life is strongly associated with the later development of asthma. However, detailed information is lacking on prevalence of HRV types and their association with respiratory symptoms. We therefore investigated the prevalence of HRV types in nasal swabs of 20 unselected healthy infants and its association with respiratory symptoms on a weekly basis during the first year of life. HRV was detected in 261 out of 825 of all nasal swabs (32%). HRV species A (HRV-A) and -C were equally frequent (39%), followed by HRV-B (12%). 76 different HRV types were detected with A78, A16 and B6 being the most frequent ones. HRV species A and C tended to induce more respiratory symptoms than HRV-B. The presence of different HRV species and types in the airways and the association between HRV types and respiratory symptoms during infancy is highly heterogeneous and dynamic without any immediately recognizable pattern.

As paediatricians we are sometimes guilty of underestimating the possible consequences in adult life of common childhood illnesses. Children with acute lower respiratory infections (LRIs) are usually treated and discharged, with full reassurance that their lungs will subsequently be normal. However the findings of a very long-term follow-up cohort study from Tucson, Arizona are far from reassuring (Chan JC, et al. Pediatrics 2015:135;607–616).

Estudio realizado en Addis Ababa con familias con niños de 5 o menos años en el que se muestra una fuerte asociación entre el combustible de biomasa y la prevalencia de infecciones respiratorias agudas en niños menores de cinco años. Se contemplan otras variables como el tamaño de la familia, el nivel educativo, el tipo de cocina, el hábito de fumar cigarrillos, el tipo de combustible, la ventilación, la presencia del niño mientras se cocina y la influencia que cada una de ellas puede tener en la prevalencia de IRA. Y se establecen posibles estrategias para mitigar esta relación.

Viral culture and real-time PCR assays were used together to identify causative pathogens in 83% of febrile outpatient children with RTI; specific viruses were associated with particular clinical diagnoses.

The relationship between viral infection, host immune response in infants with respiratory syncytial virus (RSV) bronchiolitisand subsequent wheezing is discussed. We measured RSV-RNA load and interferon-λ1-3 expression in the nasopharyngeal washings from 68 infants hospitalized for RSV bronchiolitis, and wheezing was assessed 36 months after the first episode ofbronchiolitis. Higher RSV-RNA load and higher interferon-λ2/3 levels were found in children with recurrent wheezing at 36-month follow-up.

Back-to-school illness consisting of URI has a distinct epidemiological pattern demonstrating a rapid rise peaking within 2 weeks of school opening and is associated predominantly with rhinovirus.

Alrededor del 35% de las infecciones por VRS se presentan como coinfecciones víricas. Es importante conocer este patrón para poder valorar la evolución y el pronóstico de estas infecciones.

Infecciones tracto urinario (ver también Temas A-Z)

  • Sensibilidad antimicrobiana de microorganismos causantes de infecciones del tracto urinario en pacientes pediátricos Enferm Infecc Microbiol Clin 2018;36:417-22
    Introducción: Los informes de sensibilidad acumulada son una herramienta valiosa para guiar el tratamiento empírico de infecciones urinarias. Objetivo: analizar la sensibilidad antimicrobiana de bacterias aisladas de urocultivos de pacientes pediátricos durante un período de 5 años.
    Métodos: Estudio retrospectivo de los urocultivos del período 2011-2015. La identificación y estudios de sensibilidad se realizaron con el sistema Vitek-2 y se interpretaron según los criterios de EUCAST. Se analizaron los datos de sensibilidad antimicrobiana según sexo y tramos de edad (neonatos, 1 mes-5 años, 5-15 años) y se compararon con los datos de mayores de 15 años.
    Resultados: se procesaron 17.164 urocultivos de 7.924 pacientes menores de 16 años. Los porcentajes de sensibilidad en estos pacientes fueron: ampicilina 36,3%; amoxicilina/clavulánico 75,3%; cefuroxima 83,2%; cotrimoxazol 68,9%; ciprofloxacino 85,3%; fosfomicina 85,5%; nitrofurantoína 84,4%, y cefalosporinas de tercera generación 89-91%. Aminoglucósidos (>92%) y carbapenemas (95%) mantienen las mayores tasas de sensibilidad. La prevalencia de aislamientos productores de BLEE fue significativamente menor en niños menores de 16 años (1,5% vs. 4,1%). En menores de 16 años, los aislamientos de Escherichia coliprocedentes de mujeres fueron significativamente (p<0,0001) más sensibles a ampicilina (41% vs. 30%) y amoxicilina-clavulánico (82% vs. 72%) que en varones.
    Conclusiones: En nuestra área, cefuroxima puede considerarse como primera opción de tratamiento empírico en pacientes pediátricos.Top story: Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiologya | Clinical Infect…
  • Patrón de aislamiento bacteriano y sensibilidad antimicrobiana en urocultivos positivos obtenidos de una población pediátrica Rev Esp Quimioter 2016; 29(3): 146-150 

E. coli fue el germen mayoritariamente aislado, con un alto porcentaje de resistencias a ampicilina, cefalosporinas orales de primera generación y cotrimoxazol. Este patrón urinario de aislamientos y sensibilidad antimicrobiana fue similar al reportado en otros estudios pediátricos y tampoco se modificó respecto a una serie comparable de la década de los noventa, por lo que puede considerarse que las recomendaciones actuales del tratamiento antibiótico empírico en las infecciones urinarias se mantienen vigentes.  

Antibiotic prophylaxis is not indicated for the prevention of renal scarring after a first or second symptomatic or febrile UTI in otherwise healthy children.

Resumen: estudio prospectivo sobre niños de menos de 60 días de vida con síndrome febril. Analizan 4147 lactantes de esas edades atendidos en servicios de emergencias. Definida la positividad del análisis de orina como la presencia de leucocituris, nitrituria o piuria, este análisisi mantiene una alta sensibilidad (0,94; IC 95%: 0,91 a 0,97) para el diagnóstico de ITU, especialmente en los niños con contaje de colonias igual o mayor de 50 000 CFUs/mL.

To assess whether antibiotic reduces voiding cystourethrogram (VCUG)-associated urinary tract infection (UTI).

DESIGN: Open-labelled randomised controlled trial.

SETTING:Tertiary paediatric nephrology centre.

PATIENTS:120 children (age 2 months-5 years) undergoing VCUG.

INTERVENTIONS: Children were randomised into group A (antibiotic, n=72) or group B (no antibiotic, n=48) in 3:2 ratio. Group A received oral antibiotic (cephalexin if <6 months or co-trimoxazole if >6 months old) a day prior to VCUG and continued for 1 day post VCUG.

MAIN OUTCOME MEASURES: The main outcome measure is incidence of VCUG-associated UTI. Urine was checked on day 3 after VCUG and UTI was defined as significant growth of a single organism in a symptomatic child.

RESULTS:The median age was 8 months (IQR 13 months) with 68% male. Indication for undertaking VCUG was history of UTI (first UTI in infancy=43, recurrent UTI=49) and congenital anomaly of kidney and urinary tract without any UTI (n=28). Post-VCUG UTI was significantly higher among group B in comparison to group A (17% (n=8) vs 1.4% (n=1); p=0.01, OR=14.2 (95% CI 1.7 to 117)). Multivariate binary logistic regression analysis found an abnormal pre-VCUG ultrasound scan to be a significant independent risk factor for post-VCUG UTI (p=0.02, OR=9.51, 95% CI 1.43 to 63.4). The number needed to treat with antibiotic to prevent one post-VCUG UTI was 6.5, which reduced to 4 if only the group with abnormal pre-VCUG ultrasound scan was included.

CONCLUSIONS: Antibiotic significantly reduces post-VCUG-acquired UTI especially in those with abnormal ultrasound scans.

Resumen: en los pacientes que reciben profilaxis, fue significativamente más probable tener infección por gérmenes multiresistentes (33% frente a 6%; p< 0,001) y recibir antibióticos de amplio espectro (68% frente a 49%, p = 0,004). La odds de desarrolar infección por germen multiresistente fue 6,4 en los que llevaban profilaxis frente a los que no (IC 95%: 2,7 a 15,6). Una infección por germen multiresistente se desarrollo por cada 21 niños con reflujo tratados con profilaxis antibiótica.

Using an employer-based insurance data set, we describe in this study the association of circumcision with UTIs within 1 year of life in infants with hydronephrosis.

Post-hoc analysis of the Randomized Intervention for Children with Vesicoureteral Reflux study suggests that, in concordance with European guidelines, using bacteriologic criterion of ≥10 000 colony forming units/mL of a single organism does not decrease diagnostic specificity of an urinary tract infection in children aged 2 months to 6 years in a properly collected urine if symptoms/fever and pyuria are present.

Delay in treatment of febrile UTIs and permanent renal scarring are associated. In febrile children, clinicians should not delay testing for UTI.

In this retrospective study 829 positive urine cultures were analyzed. Escherichia coli bacterium was the leading uropathogen (86%). Almost 60% were resistant to ampicillin and first generation cephalosporins, and about 30% of them resistant to amoxicillin-clavulanic acid and trimethoprim-sulfamethoxazole. Almost none of them were resistant to second and third generation cephalosporins, aminoglycosides, ciprofloxacin or nitrofurantoin.

El objetivo del estudio fue investigar la presencia, las características clínicas y los factores de riesgo para la adquisición de infección urinaria febril/pielonefritis (ITU/PNA) de la comunidad por microorganismos productores de betalactamasas de espectro extendido (BLEE+) en niños <2años que fueron ingresados en el hospital.

Las ITU/PNA BLEE+ se asociaron a recurrencias más frecuentes. El RVU fue el doble de frecuente en el grupo BLEE+. Piperacilina/tazobactam, meropenem y fosfomicina mostraron una excelente actividad. Los aminoglucósidos pueden ser una opción terapéutica, y en nuestra serie la gentamicina fue el antibiótico más utilizado.

Resumen: en infecciones urinarias en niños menores de tres meses, ingresados, se ha producido una disminución en la duración del tratamiento intravenoso en los últimos años (2005 a 2015), aproximándose a las recomendaciones de las guías de práctica clínica y sin detectarse ninguna repercusión sobre el número de reingresos

Resumen: con muy buena sensibilidad y especificidad (97,1% [95% CI: 83,4 a 99,9];y95,6% [95% CI: 91,7 a 97,7], respectivamente) la determinación de lipocalina asociada a gelatinasa de los neutrófilos, parece mostrarse como una buena herramienta para la detección de infección urinaria febril según este estudio sobre esta prueba diagnóstica.

The frequency of ABM in neonates with febrile UTI is low. Further prospective studies are needed to evaluate the safety of a tiered approach to evaluate for serious bacterial infection, in which lumbar puncture potentially could be avoided in well-appearing febrile neonates with suspected UTI

Among toilet-trained children, those with both BBD and VUR are at higher risk of developing recurrent UTIs than children with isolated VUR or children with isolated BBD and, accordingly, exhibit the greatest benefit from antimicrobial prophylaxis.

Parenteral antibiotic treatment duration in young infants with bacteraemic UTI was variable and only minimally explained by measurable patient factors. Relapses were rare and were not associated with treatment duration. Shorter parenteral courses may be appropriate in some infants.

To evaluate the test performance of microscopic bacteriuria by automated urinalysis for presumptive urinary tract infection (UTI) in young children.

This is a retrospective cross-sectional study of children aged <2 years evaluated for UTI in a single large emergency department with paired automated microscopic urinalysis and culture. Test characteristics were calculated for automated microscopic bacteriuria and pyuria, and a practical diagnostic threshold of bacteriuria was determined. Standard test performance measures

and receiver operator characteristic curves were generated. The diagnostic performance of bacteriuria was compared with microscopic pyuria.

Two thousand five hundred fifty-four children with a median age of 6.1 months were studied, 19% of whom had a positive urine culture. Automated microscopic bacteriuria ≥1+ resulted in a positive likelihood ratio (LR+) of 4.5 (95% CI, 3.9-5.2) and negative LR (LR-) of 0.52 (95% CI, 0.47-0.57). Pyuria alone (≥5 WBC/high-power field) had a LR+ of 4.5 (95% CI, 4.1-5.0) and a LR- of 0.14 (95% CI, 0.11-0.18), whereas the addition of automated microscopic bacteriuria ≥1+ improved the LR+ to 16.3 (95% CI, 12.6-21.1) but raised the LR- to 0.51 (95% CI, 0.47-0.56). Test performance of automated microscopic bacteriuria measured by area under the curve analysis was lower (0.73; 95% CI, 0.70-0.76) than for pyuria (0.92; 95% CI, 0.90-0.93). Isolated automated microscopic bacteriuria without pyuria occurred in only 204 patients (8.0%), among whom only 20 (9.8%) had a positive urine culture.

Microscopic bacteriuria measured by automated urinalysis augments the diagnostic value of pyuria for identifying presumptive UTI in young children aged <2 years. Bacteriuria is diagnostically inferior to microscopic pyuria, and in children with bacteriuria without pyuria, presumptive UTI is unlikely.

La bolsa adhesiva perineal no es un método suficientemente válido para cultivo de orina porque casi la mitad resultarán contaminados y de los positivos 2 de cada 3 serán falsos. Aun siendo estimaciones imprecisas, por su gran heterogeneidad, deben ser tenidas en cuenta en la elección del método de recogida de orina. Las estimaciones de sensibilidad y especificidad no son aplicables por no considerar el riesgo de contaminación.

Resumen de ambos (Revisión y editorial): El equipo de Bryce llevó a cabo una revisión sistemática diseñada para identificar la prevalencia global de la resistencia a los antibióticos en ITU por E coli adquirida en la comunidad en niños. La prevalencia de la resistencia es elevada, sobre todo en países fuera de la OCDE, en los que una posible explicación es la disponibilidad de antibióticos sin receta médica. Esto podría contribuir a que algunos antibióticos fueran ineficaces como tratamientos de primera línea para la ITU. Además el uso rutinario de antibióticos contribuye a la resistencia a los antimicrobianos en niños, que puede persistir durante 6 meses después del tratamiento. La notable variabilidad de la resistencia de E coli entre los países, sugiere que los médicos necesitan acceso a datos actualizados sobre los patrones de resistencia de sus propias áreas y fuera de ellas.

En el editorial se destaca finalmente que ninguno de los actores responsables de esta tragedia (la resistencia antimicrobiana), legislador, productor de ganado, médico acosado y paciente ansioso, sienten las consecuencias de sus decisiones directamente, sin embargo, sus acciones combinadas, reducen la disponibilidad de antibióticos eficaces para todos. El plan de acción global de la OMS pide a “toda la sociedad” adoptar enfoques para la prevención, para mejorar y difundir un mayor conocimiento sobre la resistencia a los antimicrobianos y para desarrollar argumentos económicos para inversiones en nuevos medicamentos.

Strategies for using non-invasive methods to collect urine samples from pre-continent children is a prime concern of clinicians aiming to avoid the use of invasive techniques in the diagnosis of urinary tract infection (UTI)

In infants aged 0-3 months with a first febrile UTI, the presence of E. coli and normal renal US findings allow to safely avoid VCUG. Performing VCUG only in infants with UTI secondary to non-E. coli bacteria and/or abnormal US would save many unnecessary invasive procedures, limit radiation exposure, with a very low risk (<1%) of missing a high-grade VUR.

Uncircumcised males, Hispanic children, children with bladder bowel dysfunction, and children who received 1 course of antibiotics in the past 6 months were more likely to have a urinary tract infection caused by pathogens resistant to 1 or more narrow-spectrum antimicrobials.

Febrile infants with enterococcal UTIs had a low likelihood of adverse events or severe clinical course, similar to those with Gram-negative UTIs. Infants with enterococcal UTIs frequently had underlying hydronephrosis and/or vesicoureteral reflux. The preliminary diagnosis of enterococcal UTIs may be inaccurate if based on UA.

There are similarities in clinical characteristics, antimicrobial resistance, imaging findings and clinical outcomes after a first UTI between the young infants ≤2 months and children 2–24 months of age. The same guidelines for the diagnosis and management after the first febrile UTI can be applied to children who are ≤24 months of age.

We aimed to determine which children are prone to non-Escherichia coli urinary tract infection (UTIs). We included 769 children with UTI. We found that circumcised males, Hispanic children, children without fever and children with grades 3 and 4 vesicoureteral reflux were more likely to have a UTI caused by organisms other than E. coli. This information may guide clinicians in their choice of antimicrobial therapy.

Es habitual el ingreso hospitalario de los lactantes < 3 meses con infección del tracto urinario. Estudios recientes plantean un manejo menos intensivo para los que tienen ≥ 29 días.

La frecuencia de complicaciones es baja en los < 3 meses con infección del tracto urinario, especialmente en los ≥ 29 días; detectar los pacientes con bajo riesgo de complicaciones posibilitaría un manejo menos intensivo. La sensibilidad antibiótica de Escherichia coli se mantiene estable; su monitorización es esencial para optimizar el tratamiento antibiótico empírico.

El objetivo fue determinar las tasas y los predictores del uso inapropiado de los antimicrobianos en pacientes con infecciones no complicadas del tracto urinario (ITU) en comparación con las directrices de las Guías de Práctica Clínica Internacionales de 2010 (GPCI). El 63,1% de los pacientes que fueron tratados por ITU no complicada recibieron antibióticos fuera de las indicaciones de las GPCI. La educación de los médicos sobre las directrices basadas en la evidencia en el tratamiento de la ITU no complicada disminuiría el uso de antibióticos de amplio espectro y la resistencia a los medicamentos de los uropatógenos.

In young infants with bacteremic UTI, UA sensitivity is higher than previous reports in infants with UTI in general. This finding can be explained by spectrum bias or by inclusion of faulty gold standards (contaminants or asymptomatic bacteriuria) in previous studies.

Resumen:Los gérmenes que con mayor frecuencia causan infecciones del tracto urinario (ITU) son las enterobacterias, incluyendo Escherichia coli y Klebsiella pneumoniae. Las cefalosporina de tercera generación han sido ampliamente utilizadas en estas infecciones adquiridas en la comunidad; sin embargo la tasa de ITUs causadas por E. coli y K pneumoniae productoras de Betalactamasas de espectro ampliado (BLEA), resistentes a las cefalosporinas, han ido en aumento en adultos y también en niños. En el estudio se compara la sensibilidad de ambos tipos de cepas a los diferentes antibióticos. Concluyen que en los niños, los aminoglucósidos pueden ser una alternativa a los carbapenémicos en los casos de cepas productoras de BLEEs

E. coli O25b-ST131 is a major community-acquired uropathogen in the infant population. Regardless of O25b-ST131 or non-O25b-ST131 clones, CTX-M-14 accounts for majority of the ESBL genotype. The O25b-ST131 clone is not associated with more severe clinical disease, but it may make the diagnosis and selection of antimicrobials for treatment more challenging.

This updated review increases the body of evidence that oral antibiotics alone are as effective as a short course (three to four days) of IV antibiotics followed by oral therapy for a total treatment duration of 10 to 14 days for the treatment of acute pyelonephritis in children. When IV antibiotics are given, a short course (two to four days) of IV therapy followed by oral therapy is as effective as a longer course (seven to 10 days) of IV therapy. If IV therapy with aminoglycosides is chosen, single daily dosing is safe and effective. Insufficient data are available to extrapolate these findings to children aged less than one month of age or to children with dilating vesicoureteric reflux (grades III‐V). Further studies are required to determine the optimal total duration of antibiotic therapy required for acute pyelonephritis.

Infecciones trasmisión sexual (ver Temas A-Z)

Inmigrante (Ver Temas A-Z)

Conclusión: el manejo del paciente inmigrante en urgencias no debe diferir en líneas generales del habitual; sin embargo, los procesos febriles, y especialmente si van a acompañados de sintomatología neurológica, exigen una evaluación sistemática y completa dado el amplio diagnóstico diferencial que pueden presentar estos pacientes.

Inmunodeficiencias

Our results quantify the magnitude of conditions in children with PID and demonstrate that the deleterious health effects borne by patients already are evident in childhood. These results emphasize the need to closely monitor this vulnerable population and establish multidisciplinary healthcare teams from childhood.

Inmunodeficiencia combinada severa

Severe combined immunodeficiency (SCID) is a rare but important condition. Affected infants are born with profound abnormalities of immune cell function that lead to severe and recurrent infection that are almost always fatal in the first year of life without treatment. Infants with SCID are often initially seen by general paediatricians in the hospital care setting, and the recognition of the cardinal features of the disease and alertness to specific laboratory parameters are important in making an early diagnosis. There is also increasing interest in newborn screening for SCID, which has the potential to significantly improve outcome through early diagnosis and implementation of prophylactic medications. Definitive treatments such as haematopoietic stem cell transplantation and gene therapy have also made major advances over the last decade and again promise to improve the overall outcome for SCID with reduced long-term toxicities. In this review, we highlight some of the major advances in diagnosis and management of the disease, but we also want to emphasise the important role of the general paediatrician in making an early diagnosis and in ongoing management.

A 4-month-old boy presented with fever, lethargy and irritability on a background of faltering growth. He was pale, febrile, in respiratory distress. He had red papular skin lesions on torso and a large discharging ulcer at BCG inoculation site (administered shortly after birth) (figure 1).

He was anaemic (haemoglobin 4.8 g/dL) and lymphopenic (1.16×109/L) …

Ivermectina

You are working in a remote clinic in Northern Australia and see an 18-month-old girl (weight 10 kg) who presents with a pruritic rash on her extremities. She has a history of persistent scabies despite multiple treatments with topical permethrin 5%. You diagnose her with scabies and although you are aware that oral ivermectin is used for scabies in children over 5 years and weighing more than 15 kg, you consider whether it would be safe to use ivermectin for the treatment of scabies in this child.

Kawasaki

To describe the epidemiology, response to therapy, and outcomes of Kawasaki disease in a multiethnic community with a large Hispanic and Asian population.

Study design: We analyzed prospectively collected data from 788 unselected patients with Kawasaki disease diagnosed and treated at a single medical center over a 10-year period.

Results: The average incidence of Kawasaki disease in children <5 years in San Diego County over the 10 years from 2006 to 2015 was 25 per 100 000 children, with the greatest incidence (50 per 100 000) for Asian/Pacific Islanders. Compared with other race/ethnicities, Asian/Pacific Islander patients with Kawasaki disease were younger, were diagnosed earlier in the course of their fever, had higher levels of inflammatory markers, and were more likely to develop aneurysms. There was no difference across race/ethnicity groups in response to intravenous immunoglobulin therapy. Filipino children had the highest recurrence rates (9.1%; 95% CI, 3.0%-22.6%) and 12 of 788 patients (1.5%) had a first- or second-degree relative with a history of Kawasaki disease. After correcting for age of onset, sex, and illness day at diagnosis, Asian/Pacific Islander children had an increased risk of developing aneurysms (aOR, 2.37; 95% CI, 1.37-4.11; P  = .002). Overall, 180 of 788 patients (22.8%) had a maximal Z score of 2.5-10.0 and 14 of the 788 patients (1.8%) had a maximal Z score ≥10.0 despite 84% of these patients being treated within 10 days of fever onset.

Conclusions: Our data provide new insights into the natural history of treated Kawasaki disease in a multiethnic population. Patient race/ethnicity influenced susceptibility to Kawasaki disease, timing of diagnosis, coronary artery outcome, and recurrence rates.

The diagnosis and treatment of Kawasaki disease might be delayed if intestinal symptoms appear before the characteristic clinical features of Kawasaki disease, thus, increasing the risk of cardiac complications. Furthermore, patients may undergo unnecessary invasive procedures. Pediatricians and pediatric surgeons, therefore, should consider Kawasaki disease among diagnoses in children with fever, abdominal symptoms, and radiologic findings of pseudo-obstruction.

In conjunction with intravenous immunoglobulin, low-dose ASA in acute KD is not inferior to high-dose ASA for reducing the risk of CA abnormalities.

You are looking after a previously well child recently diagnosed with Kawasaki disease (KD). You start him on intravenous immunoglobulin (IVIG) and are about to start him on aspirin. Knowing the potential adverse effects of aspirin, you wonder whether low-dose aspirin is as effective as high-dose aspirin to prevent coronary artery complications.

The use of medium- or higher-dose ASA in acute Kawasaki disease did not prevent CAA. A future randomized controlled trial is needed to determine the optimum dose of ASA.

Question Among children with Kawasaki disease (KD), what is the therapeutic efficacy of adjunctive corticosteroids plus intravenous immunoglobulin (IVIG) therapy compared with IVIG therapy alone, in reducing coronary complications?

Main Results Adjunctive corticosteroids reduced the coronary artery abnormality rate: odds ratio, 0.42 (95% CI, 0.27-0.67). Coronary abnormalities were inversely related to duration of KD prior to corticosteroids administration.

Conclusions Early adjunctive corticosteroids decrease coronary complications in patients with KD.

Seven trials consisting of 922 participants were included in this analysis. Trials ranged from 32 to 242 participants. On pooled analysis, corticosteroids reduced the subsequent occurrence of coronary artery abnormalities (odds ratio (OR) 0.29, 95% confidence interval (CI) 0.18 to 0.46; 907 participants; 7 studies; I² = 55%) without resultant serious adverse events (no events, 737 participants) and mortality (no events, 915 participants). In addition, corticosteroids reduced the duration of fever (mean difference (MD) −1.65 days, 95% CI −3.31 to 0.00; 210 participants; 2 studies; I² = 88%), time for laboratory parameters (erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP)) to normalise (MD −2.80 days, 95% CI −4.38 to −1.22; 178 participants; 1 study) and length of hospital stay (MD −1.41 days, 95% CI −2.36 to −0.46; 39 participants; 1 study). No studies detailed outcomes beyond 24 weeks. Subgroup analysis showed some potential groups that may benefit more than others; however, further randomised controlled trials are required before this can be the basis for clinical action.

Moderate-quality evidence shows that use of steroids in the acute phase of KD can be associated with improved coronary artery abnormalities, shorter duration of hospital stay and a decreased duration of clinical symptoms. High-quality evidence shows reduced inflammatory marker levels. There were insufficient data available regarding incidence of adverse effects attributable to steroids, mortality and long-term (> 1 year) coronary morbidity. Certain groups, including those based in Asia, those with higher risk scores, and those receiving longer steroid treatment may have greater benefit from steroid use, especially with decreasing rates of heart problems, but more tests are needed to answer these questions. Evidence presented in this study suggests that treatment with a long course of steroids should be considered for all children diagnosed with KD until further studies are performed.

A 7-year-old girl was admitted with Kawasaki disease (KD), and treated with aspirin and intravenous immunoglobulin (Ig) therapy. After 48 hours of treatment she is still miserable and febrile, and you wonder what would be the most effective next step in treatment to reduce the risk of her developing coronary artery aneurysms.

Incidental adenovirus detection in Kawasaki disease (KD) is important to differentiate from acute adenovirus disease. Twenty-four of 25 children withadenovirus disease and mimicking features of KD had <4 KD-like features, predominance of species B or E, and higher viral burden compared with those with KD and incidental adenovirus detection.

A 7-year-old girl was admitted with Kawasaki disease (KD), and treated with aspirin and intravenous immunoglobulin (Ig) therapy. After 48 hours of treatment she is still miserable and febrile, and you wonder what would be the most effective next step in treatment to reduce the risk of her developing coronary artery aneurysms.

Kawasaki disease (KD) is a childhood vasculitis and the most frequent cause of paediatric acquired heart disease in North America, Europe and Japan. It is increasingly recognised in rapidly industrialising countries such as China and India where it may replace rheumatic heart disease as the most common cause of acquired heart disease in children. We review the current global epidemiology of KD and discuss some public health implications.

A 7-month-old boy presented to the emergency department with fever of 7 days' duration. Physical examination revealed bilateral nonexudative conjunctivitis, anterior cervical lymphadenopathy, erythematous hands and feet, erythematous truncal rash, and erythema and eschar at the bacillus Calmette–Guérin (BCG) inoculation site (Figure 1; available at www.jpeds.com). He received the diagnosis of Kawasaki disease and was treated with intravenous immunoglobulin and aspirin. The symptoms of Kawasaki disease resolved after 2 days.

Where KD is suspected, characteristic BCG site changes should be looked for.

A 4-year-old Australian-born girl of Taiwanese background presented with 5 days of fever and rash. She had previously had Kawasaki disease at the age of 22 months from which she made a full recovery. Examination at this presentation revealed mucosal injection, strawberry tongue, widespread blanching maculopapular rash, palmar erythema and conjunctival injection. Recurrent Kawasaki disease was diagnosed. She was treated …

Kingella

J uchler et al have done a service to the pediatric community in their assiduous and aggressive approach to the bacteriologic confirmation of etiologic agents of osteoarticular infections (OAIs). Using culture and molecular techniques, their work is a weighted modern compendium of relevant pathogens. They also carefully categorized cases and causes by age and a constellation of markers of the host’s inflammatory responses, which will improve clinical decision making. Remarkably, Kingella kingae represented 88% of etiologically identified cases in the age group of 6 through 47 months, and Staphylococcus aureus 78% of cases in those 48 months and older. They also documented that a patient with Kingella OAI compared with S. aureus OAI is more likely to be afebrile or only modestly febrile, have elevated sedimentation rate and platelet count, but only a modestly elevated C-reactive protein level. The authors are cautious about generalizability of their documented Kingella prevalence to other regions and continents. They needn’t be overly cautious. As we in the US have picked up on specific molecular testing of blood and bone and joint specimens in the relevant age group, Kingella kingae is confirmed not infrequently. The finding of taphylococcus aureus as the predominant organism in school-age children seems generalizable. However, the virtual absence of methicillin-resistant S. aureus (MRSA) in the Geneva case series over 14 years is “special.” Across multiple studies in the US since the 1990s, staphylococcal infections have increased, and community-acquired MRSA is responsible for approximately one-half of staphylococcal OAIs. A final, interesting speculation of the authors is that the finding of 21% of clinical cases of OAI without proven etiology despite aggressive pursuit suggests that other fastidious microorganism(s) may yet be discovered. Borrelia burgdorferi certainly is long ago discovered and is on the list for culture-negative pyogenic arthritis in regions of endemicity. Additionally, some culture-negative cases undoubtedly occur as autoinflammatory or autoimmune conditions-

A significant temporal association was observed between HRV circulation and K kingae osteoarticular infection, strengthening the hypothesis of a role of viral infections in the pathophysiology of K kingae invasive infection.

A 14-month-old-girl was diagnosed with influenza A encephalomyelitis based on fever, prostration, hypertonia, hyperalgesia, urinary retention, positive influenza A real-time polymerase chain reaction on nasopharyngeal sample, and meningitis. Cerebral and medullary magnetic resonance imaging showed multiple white matter lesions with T2-weighted hypersignal and apparent diffusion coefficient restriction (Figure, A-C). Thus, she was treated with 5 methylprednisolone bolus. After the last bolus, a systolic cardiac murmur was heard.

Over the last few decades Kingella kingae has ascended in the family of pathogenic bacteria from a rare cause of endocarditis to a relatively common cause of osteoarticular infections in children younger than 4 years of age. Fastidious nature of growth in culture likely hampered establishing the organism's rightful place among infectious diseases in children. Molecular diagnostic techniques now available will permit a better assessment of the role(s) of K kingae in an expected wider spectrum of infections and across continents.

Clusters of invasive K kingae infections characterized by sudden onset, high attack rate, and wide dissemination of the outbreak strain can occur in daycare facilities and closed communities. Because the mild clinical presentation of invasive K kingae infections and the fastidious nature of the organism, a high index of suspicion and use of sensitive detection methods are recommended

 K. kingae outbreaks displayed severe K. kingae diseases that were poorly confirmed with culture methods. We argue for the use of genomic technologies to investigate further K. kingae outbreaks.

Lactancia materna

Conclusions: Our results support the recommendation to fully breast-feed for 4 months and to continue breast-feeding beyond 6 months, and suggest that protection against infections is limited to the first 12 months.

Breastfeeding remains a mainstay of prevention for numerous diseases, though it does not seem to play a role against pertussis. Alternative strategies to protect unvaccinated infants from pertussis should be considered.

In a cross-sectional analysis of 629 mother-infants dyads, breastfeeding (ever vs. never) was associated with a decreased relative odds of a lower versus upper respiratory tract infection (AOR: 0.64; 95% CI: 0.42, 0.99). There was not a significant association between breastfeeding and bronchiolitis severity score or length of hospital stay.

CONCLUSIONS: This prospective longitudinal study suggests that breastfeeding may protect against ear, throat, and sinus infections well beyond infancy.

Larva

Una paciente de 6 años presentó una erupción cutánea pruriginosa de un mes de evolución. El examen físico reveló incontables lesiones (fig. 1) compuestas, de hecho, de pápulas eritematosas serpiginosas lineales de distintos tamaños que habían convergido y formado costras (fig. 2), rasgo característico de larva migrans cutánea. Durante la anamnesis, la madre refirió que el domicilio estaba en obras y que en su exterior había grandes cantidades de arena para construcción donde a menudo jugaban la paciente y muchos perros callejeros.

A 9-year-old boy, a native of Haiti, was referred to our department for a skin rash that recurred since age 6 years. Each outbreak had a stereotypical presentation and lasted about 7 days but recurred every 3 months. Findings of the physical examination revealed linear papular skin lesions, slightly pruriginous, on the trunk (Figure), that migrated a few centimeters per hour. General examination was unremarkable. Biological investigations showed hypereosinophilia 1.2 × 109/L. Stool examination, performed 4 times, was negative; the fifth examination revealed Strongyloides stercoralis larvae. The child received ivermectin, 200 µg/kg, on days 1, 2, 14, and 15. The disease was in complete remission at 6 months.

An 8-year-old boy was seen with a facial skin eruption. The boy lived in an industrialised city in Romania, but spent 2 months of his summer holidays in a rural village, 150 km away, playing with cats and dogs. Initial pruritus on the left cheek was followed by progressive serpiginous erythematous papules along the left aspect of …

Legionella (Ver Temas A-Z)

A 1-month-old girl developed respiratory failure due to bilateral interstitial pneumonia after bathing in reheated and reused water. A molecular test for sputum and an environmental culture detected Legionella pneumophila serotype 1. This is the first report of infantile legionellosis contracted from a bathtub at home.

Leishmania cutánea

Este brote de leishmaniasis cutánea confirma el carácter endémico y la elevada prevalencia de la enfermedad en la cuenca mediterránea. El tratamiento más utilizado fue el antimoniato de meglumina intralesional. Para el control del brote fue necesario desarrollar un plan integral de actuación.

Leishmania visceral

Visceral leishmaniasis (VL) remains a public health issue in Greece. The aim of this study was to describe the clinical and epidemiologic characteristics of pediatric VL in our region as well as to evaluate the laboratory findings and the diagnostic techniques that are applied.

We retrospectively reviewed the medical records of all children diagnosed with VL in an 11-year period at a tertiary public hospital in the region of Athens. Demographic features, clinical information and laboratory findings were accessed.

A total of 43 cases were recorded during 2005–2015. Median age of the patients was 3.7 years. Pallor (100%), fever (98%), hepatosplenomegaly (55.8%) and appetite loss (32.6%) were the most common presentations of the disease. The predominant laboratory abnormalities were anemia (100%), thrombocytopenia (90.7%), elevated inflammatory markers (86.1%) and decreased albumin/globulin (A/G) ratio (72.1%). Four patients developed secondary hemophagocytic lymphohistiocytosis syndrome, whereas in 3 others abdominal ultrasound showed splenic nodules. Bone marrow aspiration detectedLeishmania parasites in 92.7% of cases and the rapid rK39 strip test indicated anti-Leishmania antibodies in 97.1% of children. In addition, all patients in whom indirect immunofluorescent antibody test was implemented had positive results.

VL still affects children in our area. Fever, splenomegaly, anemia and appetite loss are the typical findings in children. Noninvasive techniques (immunofluorescent antibody test, rK39) in combination with bone marrow microscopy are useful in the diagnosis of pediatric VL.

Visceral leishmaniasis affects 200–400 thousands people annually worldwide. For last few decades, there has been a steady decline in the response to pentavalent antimonial (Sb v ), the drug that has been used for treating visceral leishmaniasis for almost a century. Oral miltefosine and amphotericin B are alternative drugs being been used in the treatment of leishmaniasis in children. Liposomal amphotericin B has the advantage over conventional amphotericin B is that higher doses can be given with fewer adverse effects. Liposomal amphotericin B in combination with other drugs is the preferred treatment option globally especially in Indian subcontinent. Combination therapy with multiple drugs should undergo larger clinical trials in children as these will shorten the duration of therapy, improve compliance and decrease both toxicity and drug resistance.

Visceral leishmaniasis (VL or kala-azar) is most endemic in Asia and Africa and commonly affects young children. It is usually caused by Leishmania donovani or Leishmania infantumthat are transmitted by Phlebotomine sand flies. Transmission may be anthroponotic or zoonotic or both, depending on the endemic area. Clinical features include fever, hepatosplenomegaly, weight loss and pancytopenia. Younger age, malnutrition and immunosuppression (HIV infection, use of immunosuppressive drugs) are risk factors. Many infections remain asymptomatic. Diagnosis is made by demonstration of the Leishmaniaparasite in aspirates of lymph node, bone marrow or spleen. Serological tests such as rK39 strip test are widely used but the sensitivity varies. qPCR is useful to detect low numbers of parasites and to monitor treatment. Treatment is with AmBisome monotherapy in most areas but with drug combinations elsewhere. HIV co-infected patients are most difficult to treat and often relapse. Control efforts focus on case finding, availability of diagnostic tools, reservoir control and protection from sand flies (insecticides, bed nets). There is no human vaccine.

We included 157 cases of cutaneous (CL) and 90 cases of visceral (VL) leishmaniasis diagnosed at Fuenlabrada University Hospital between July 2009 and April 2013

Acquired hemophagocytic lymphohistiocitosis (HLH) syndrome can be a complication of visceral leishmaniasis (VL). A multicenter prospective study was conducted to determine the frequency of HLH syndrome in children with VL. Twenty-four children with VL were identified, and 10 (41%) developed HLH syndrome. VL should be ruled out in all children with HLH criteria living in or coming from endemic areas.

HLH was not a rare complication of VL. Main symptoms were compatible with both VL and HLH. Main laboratory findings reflected HLH pathophysiology. Mild forms of AKI were a common complication of HLH. Despite the disease severity and complications, mortality was low.

Sobre resultados de S y E de 5 test de diagnóstico rápido para leishmania.

Dos niñas gemelas de 18 meses que viven en la frontera entre Alemania y Suiza, que desarrollan leishmaniasis visceral 7 y 15 meses después de viajar a Toscana. Se presentaron con fiebre de origen desconocido y pancitopenia. Ambas tenían esplenomegalia y, en el primer caso, se incluyó inicialmente en el diagnóstico diferencial la linfohistiocitosis hemofagocítica o leucemia. La madre y dos hermanos mayores no se infectaron, mientras que al padre se le diagnosticó como portador asintomático.

La leishmaniasis visceral es un diagnóstico diferencial importante para la fiebre de origen desconocido y la pancitopenia en niños pequeños que viven en países con enfermedades endémicas y destaca la importancia de obtener un historial detallado de viajes. Se puede justificar la detección de los hermanos de las personas afectadas.

Listeria

Listeria monocytogenes es un patógeno de origen alimentario que suele producir gastroenteritis, procesos febriles, sepsis y meningitis. Afecta característicamente a neonatos, embarazadas, ancianos e inmunocomprometidos, con una epidemiología controvertida y poco conocida. Se presenta un niño de 4 años inmunocompetente con meningitis y síndrome de secreción inadecuada de hormona antidiurética secundario.

Listeria monocytogenes is a Gram-positive bacterium which can cause invasive infection in the immunocompromised, pregnant women and young infants. Listeria are not susceptible to the third generation cephalosporins (such as cefotaxime or ceftriaxone) usually given as empirical antibiotic treatment to unwell children. Amoxicillin or ampicillin is thus added for infants less than 3 months of age with suspected serious bacterial infection. However empirical antibiotic cover for L. monocytogenes infection beyond the neonatal period may not be needed.

Loiasis

An 8-year-old girl, a native of Equatorial Guinea, grew up close to a river. She was evaluated in our center for ocular pruritus, swollen eyelid, and observation of “a worm” beneath the conjunctiva (Figure).

Lyme enfermedad de (ver también Temas A-Z)

  • Occurrence of erythema migrans in children with Lyme neuroborreliosis and the association with clinical characteristics and outcome – a prospectivecohortstudyBMC Pediatrics 2018;18:189

Erythemamigrans (EM) es la manifestación más común de la borreliosis de Lyme (BL), causada por la espiroqueta Borreliaburgdorferi sensu lato

La neuroborreliosis de Lyme (NBL) es la segunda manifestación de BL más frecuente en los niños. El objetivo del estudio era describir la aparición de EM entre los niños con NBL y su asociación con las características clínicas y evaluar las posibles diferencias entre los pacientes con NBL con y sin EM. El EM ocurrió en el 36% de los niños con NBL y las áreas más frecuentes de localización en los niños con parálisis del nervio facial eran la cabeza y el cuello. Destacan en el estudio que la aparición de EM en niños con NBL no es útil como factor pronóstico para el resultado.

Malaria (ver también Temas A-Z)

A chatty, 4 year-old girl is brought to the emergency department (ED) by her mother with a 3-day history of fever and loose stool. They returned from Nigeria 7 days earlier, having visited friends and relatives for the school holidays. Clinical examination is unremarkable, she is currently afebrile, and there are no signs of serious bacterial infection. A malaria blood film and histidine rich protein-2 (HRP-2) based rapid diagnostic test (RDT) are both negative. RDTs are for malaria antigens such as HRP-2 and lactate dehydrogenase (LDH).

The paediatric registrar discharges the patient but expresses concern regarding the ability of a single RDT and blood film to rule out malaria, following current guidelines, and insists she returns in 24 and 48 hours to repeat the tests. You wonder if this is really necessary.

Se revisan 4 ensayos en los que valoran la eficacia de tto de la combinación de artemisina-naftoquina en la infección por plasmodium falciparum no complicada vs otras combinaciones con artemisina. Los resultados son prometedores, aunque son necesarios más estudios para poder establecer conclusiones.

En zonas endémicas de paludismo, esta enfermedad es la principal causa de anemia en niños. Se incluyen 6 estudios: 3 realizados en zonas de baja endemia y 3 en zonas de alta endemia. El tratamiento antipalúdico preventivo intermitente, parece aumentar los niveles de Hb, pero esto no se traduce en una disminución de la mortalidad ni de los ingresos hospitalarios.

Se recopilan 47 estudios en donde se compara la precisión en el diagnóstico de Plasmodium no falciparum de los test de diagnóstico rápidos vs técnicas clásicas (microscopio, PCR). A destacar la alta S y E de los nuevos test rápidos específicos frente P. Vivax.

Malaria vacuna

GlaxoSmithKline ha desarrollado una vacuna contra la malaria, Mosquirix, que por primera vez, ha sido aprobado por la Agencia Europea del Medicamento. Aunque con efectos modestos, vale la pena en los niños de entre 6 semanas y 17 meses. Ensayos de GSK mostraron que, en los 12 meses después de la vacunación, previene la malaria en el 56% de los niños de edades comprendidas entre 5 meses y 17 meses y en el 31% de los bebés de entre 6 semanas y 12 semanas.

Marcadores inf viral/bacteriana

Fever is a very common reason for consultation among children attending the emergency department. Most of these children have a self-limiting viral infection. Nevertheless, despite advances in vaccinations and antibiotics, serious infections remain significant causes of death of children. Early identification of children with serious bacterial infections is essential to initiate immediate antibiotic therapy. But, identification of these patients may be difficult, mainly in an overcrowded emergency department, in which most of the incoming patients appear well. In fact, a large number of children with an invasive bacterial infection are not identified at first contact.1

Different efforts have been made in order to identify children at low risk and high risk for serious bacterial infection. In this way, the appearance of the child, the vital signs and certain laboratory data are useful to identify these children.

In selected populations, complementary tests are helpful to identify children at high risk or low risk of serious bacterial infection. Classically, leucocyte count has been used to identify children with serious bacterial infection. During the last decades, new blood tests such as C reactive protein (CRP) and, mainly, procalcitonin (PCT) have shown a better performance. Thus, leucocyte indicators are less valuable than inflammatory markers for …

Results An algorithm was developed consisting of clinical features and CRP. This achieved 97.1% (95% CI 94.3% to 98.7%) sensitivity and 99.6% (95% CI 99.2% to 99.8%) negative predictive value, excluding serious infections in 36.4% of children. It stratifies patients into three groups based on CRP level: high-risk group with CRP >75 mg/L (26.8% risk of infection), intermediate-risk group with CRP 20–75 mg/L and at least one of seven clinical features (8.1%), and lower risk group with CRP <20 mg/L with at least one of the 11 features (3.8%). Children in intermediate-risk or low-risk groups with normal clinical assessment have 0.6% and 0.4% risk of serious infections, respectively.

Conclusions Conducting a CRP test may first enable children to be stratified into three risk groups, guiding assessment of clinical features that could be performed by junior doctors or nurses. In one-third of acutely ill children, the algorithm could exclude serious infection. Prospective validation of the algorithm is needed.

Resumen: un nuevo kit diagnóstico que integra la determinación de TNF relacionado con el ligando del inductor de la apoptosis, interferón-gamma inductor de proteína-10 y proteína C reactiva fue probado. El procedimiento investigado logró distinguir entre pacientes con infección bacteriana y viral con un 93,8% de sensibilidad (IC 95%: 87,8 a 99,8%) y un 89,8% de especificidad (IC 95%: 85,6 a 94,0%). 11,7% de casos fueron resultados erróneos. Fue significativamente más preciso que PCR, procalcitonina y parámetros rutinarios de laboratorio

Aplicabilidad en la práctica clínica: este estudio ofrece datos preliminares sobre un test que utiliza un biomarcador ARN. Aunque parece diferenciar entre infecciones bacterianas y víricas, la información disponible no permite evaluar su utilidad clínica. Se precisa demostrar su utilidad en diversos escenarios, como los Servicios de Urgencias o Atención Primaria, y poder valorar su contribución en la disminución del uso de antibióticos con un diagnóstico más preciso de la infección bacteriana.

Question Among children, what is the diagnostic accuracy of a host RNA signature, compared with bacterial culture and viral identification testing, in detecting bacterial vs viral infection?

Main Results All 23 patients with microbiologically-confirmed bacterial infection were classified as bacterial, sensitivity, 100% (95% CI, 100%-100%) and 27 of 28 patients with definite viral infection were classified as viral, specificity, 96.4% (95% CI, 89.3%-100%).

Conclusions The RNA signature test for infection identification appears accurate

La intención de esta revisión es poner de manifiesto las evidencias científicas publicadas recientemente, aclarar las controversias existentes y comparar la capacidad y el valor diagnóstico para predecir bacteriemia de los principales BMRII en los pacientes con infección atendidos en los SUH. Y así, a partir de ella, generar distintas recomendaciones que ayuden a definir el papel que pueden tener éstos en la mejora de la indicación de obtención de los HC, así como en la toma inmediata de otras decisiones diagnóstico-terapéuticas (administración precoz y adecuada del tratamiento antibiótico, pruebas complementarias y otras muestras microbiológicas, intensidad del soporte hemodinámico, necesidad de ingreso, etc.).

Clinicians should apply different CRP cut-off values depending on whether they are trying to rule in or rule out bacterial infection, but also depending on fever duration at the time of CRP testing.

Procalcitonin-guided decision making was superior to standard care in reducing antibiotic therapy in neonates with suspected early-onset sepsis. Non-inferiority for re-infection or death could not be shown due to the low occurrence of re-infections and absence of study-related death.

Resumen: se trata de una proteína cuya determinación sérica podría ayudar a distinguir entre infección viral y bacteriana. Al menos se han demostrado cifras significativamente más elevadas en infeciones por VRS y rotavirus.

Mastitis (ver Temas A-Z)

investigadores españoles cultivan muestras de leche de 529 mujeres que amamantaban a sus bebés, entre las que había 393 diagnosticadas de candidiasis mamaria. Además, se buscó la presencia de Candida spp., Streptococcus spp. y Staphylococcus spp. mediante reacción en cadena de la polimerasa (PCR).Candidaspp.  solo apareció en el 2% de los cultivos y en bajas concentraciones. No fue detectada ninguna levadura de Candida spp. ni por microscopía óptica, ni por PCR. En todos los medios de estudio se detectaron, en las muestras de mujeres con dolor, altas concentraciones de bacterias de los géneros Staphylococcus  (S. epidermidis  y S. aureus, principalmente), Streptococcus, Rothia  y  Corynebacteria. Estos resultados muestran que no puede establecerse ninguna asociación entre el tipo de dolor conocido como burning nipple pain (candidiasis mamaria) y la presencia de Candida spp.

Mastoiditis

Delayed antibiotic treatment for antecedent AOM is not associated with an increase in severity parameters in subsequent acute mastoiditis admission.

After the introduction of PCV7, a significant increase of serotype 19A and replacement of PCVs serotypes was identified. After PCV13, the overall proportion of pneumococcal mastoiditis and the incidence of serotype 19A were not significantly declined. A significant proportion of resistant isolates to penicillin and erythromycin is attributed to serotype 19A.

Meningitis

Resumen: E.Coli y Estreptococo beta hemolítico del grupo B, siguen siendo los principales responsables de las meningitis en los primeros 90 días de vida. Para un tratamiento empírico se debería de considerar la utilización de una cefalosporina de tercera generación (con ampicilina si el niño es menor de 30 días), u opcionalmente carbapenem en lugar de cefalosporina si hay evidencia de meningitis por Gram negativo.

Classical criteria differ when performing cerebrospinal fluid (CSF) analysis in infants younger than 90 days with fever without a source (FWS). Our objectives were to analyze the prevalence and microbiology of bacterial meningitis in this group and its prevalence in relation to clinical and laboratory risk factors.

In infants younger than 90 days with FWS, performing CSF analysis for ruling out bacterial meningitis must be strongly considered in not well-appearing infants and in those ≤21 days old. The recommendation of systematically performing CSF analysis in well-appearing infants 22-90 days of age on the basis of analytical criteria alone must be reevaluated.

Presentación inusual de una meningitis B como parálisis bilateral del VI par craneal.

Meningitis W

The annual incidence rate of serogroup W invasive meningococcal disease in the Netherlands increased from < 0.05/100,000 (n < 10) before 2015 to 0.5/100,000 (n = 80) in 2017. Most isolates (94%) belong to clonal complex 11. The incidence rate is highest among  < 5 year-olds and 15-24 year-olds. The case fatality rate was 12% (17/138) in 2015-2017. From May 2018, MenACWY vaccination replaces MenC vaccination at age 14 months and from October 2018, 13-14 year-olds are offered MenACWY vaccination.

Meningococo (ver también Temas A-Z)

In Italy, the incidence of invasive meningococcal disease (IMD) has remained stable since 2007 (around 0.3 cases/100,000 inhabitants). However, as reported for other European countries, an increase of serogroup Y Neisseria meningitidis has been observed. In this study we report IMD cases from 2007 to 2013 in Italy and investigate the clinical and epidemiological features of cases affected by serogroup Y.

Chronic meningococcemia is a rare diagnosis seen in patients with recurrent fever and rash. We describe a case of chronic meningococcemia in ateenage girl who presented with a recurrent painful rash, without fever, over a period of 8 weeks.

Meningococo A vacuna

Meningococo B (ver también Temas A-Z)

Muy interesantes datos a nivel global de la incidencia de enfermedad invasiva por Meningococo B. Sobre todo datos de países desarrollados. En general, ha habido una disminución bastante importante en los últimos años en estos países

Meningococo B vacuna (ver también Temas A-Z)

En diciembre de 2013 la FDA autorizó el uso de la vacuna antimeningococica frente al serogrupo B ( 4CmenB) en circunstancia especial para controlar un brote en una Universidad de Estados Unidos. Se cuantifico la repuesta producida por la vacuna. Los dato sugieren que la vacunación pudo frenar el brote pues los antigenos expresados en esas cepas causantes del brotes estaban muy relacionados con los incluidos en la vacuna. Se incluye 499 participantes que recibieron 2 dosis de la vacuna.

Children with complement deficiency respond less well to immunization with 4CMenB than healthy children in the control category; surveillance for vaccine failures is required to determine the significance of this.

La vacuna meningocócica del grupo B 4CMenB está indicada para la inmunización activa de individuos a partir de los dos meses de edad frente a la enfermedad meningocócica invasora por Neisseria meningitidis del serogrupo B. Aunque está recomendada, actualmente no se encuentra incluida dentro del calendario de vacunación infantil. En menores de dos años las reacciones locales más frecuentes son dolor y eritema en el sitio de inyección y las sistémicas la aparición de irritabilidad y fiebre, en general de corta duración. En la ficha técnica de la vacuna no se indica como efecto secundario específico la artritis. No obstante, hasta marzo de 2017 se han documentado en la base de datos europea de informes de presuntas reacciones adversas 29 casos de artritis u otra patología similar. A continuación, presentamos las características clínicas y analíticas de dos nuevos casos de artritis en probable relación con la vacuna.

Meningococo C vacuna (Ver Temas A-Z)

More than half of Australian adolescents have inadequate serological protection against MenC disease and low natural immunity to Men A, W and Y.

Meningococo vacuna ACWY

Resumen: sobre 48.899 individuos de esa edad vacunados no encuentran efectos indeseables en número superior al esperado en comparación con otras vacunas, salvo para la parálisis facial que se dio significativamente más en vacunados que recibieron la vacuna MenACWY asociada a otras vacunas (asociación que no se dio cuando se ponía de forma aislada)

Metapneumovirus

Las infecciones respiratorias agudas son una de las principales causas de morbilidad en niños1. En los últimos años, gracias al progreso de las tecnologías de diagnóstico molecular se han descrito nuevos virus implicados en estas infecciones, siendo uno de estos el metapneumovirus humano (MPVh)2.

Aunque es el causante del 6-14% de los ingresos por infección de vías respiratorias en niños3,4, menos frecuente que los principales causantes de hospitalización (VRS, parainfluenza), se le atribuyen hasta un 20% de estas infecciones virales en niños5,6.

El presente trabajo aporta datos basados en una amplia muestra de pacientes que exclusivamente corresponden a menores de 14 años. Con la hipótesis de mayor sintomatología obstructiva y gravedad de la infección por MPVh en los lactantes7,8, se decidió dividir la muestra en pacientes mayores y menores de 2 años, encontrando en estos últimos mayor afectación de las vías bajas y, por tanto, mayor necesidad de tratamiento broncodilatador, corticoideo y oxigenoterapia9.

En contra de lo esperable, se objetivó mayor empleo de pruebas complementarias en los pacientes mayores, que podría explicarse por más enfermedad de base y cuadros febriles9. Además, por presentar más condensaciones parenquimatosas suponemos un empleo superior de antibioterapia, a pesar de no existir diferencias en los parámetros de infección, apoyando el origen vírico.

La inmunofluorescencia directa realizada permite alcanzar un diagnóstico definitivo en menos de 24h, sin embargo, no existe un test de diagnóstico rápido como el utilizado en otras infecciones, como las causadas por el virus de la gripe o el estreptococo del grupo A, que permita la toma de decisiones en urgencias o en el momento del ingreso hospitalario y que, de existir, podría disminuir el empleo de técnicas diagnósticas y de tratamientos innecesarios como hemos visto que se producen.

En ambos grupos fue preciso el ingreso en unidad de cuidados intensivos de un número significativo de pacientes, por lo que el MPVh debe ser considerado en el diagnóstico etiológico de las infecciones respiratorias de los pacientes que precisan ingreso hospitalario.

Miasis

Micobacterias (ver también Temas A-Z)

Eighty-five children were diagnosed with culture-confirmed nontuberculous mycobacterial cervical lymphadenitis within the MYCOMED surveillance network from 2004 to 2013. The mean incidence sharply increased from 0.57 to 3.7 per 100,000 children per year, after the discontinuation of mandatory bacillus Calmette and Guérin immunization in 2007. Cases were documented as Mycobacterium avium (62.3%), Mycobacterium intracellulare (15.3%) and Mycobacterium lentiflavum (12.9%). Outcome was favorable in all, with or without surgery or antimycobacterial treatment.

Conclusión. M. lentiflavum debe ser considerado como un importante patógeno emergente causante de linfadenitis cervical en población pediátrica.

Las medidas de control del ganado y la pasteurización de los productos lácteos han hecho que la enfermedad tuberculosa por Mycobacterium bovis sea infrecuente en nuestro medio. El diagnóstico de esta entidad requiere un alto índice de sospecha, fundado en una historia clínica detallada y pruebas complementarias oportunas. La presentación más frecuente es extrapulmonar, principalmente como linfadenitis, por lo que ante una adenopatía de mala evolución se recomienda remitir al paciente para estudio y valorar la realización de punción aspiración con aguja fina para examen citológico y cultivo. Presentamos un caso de linfadenitis por M. bovis en una niña de siete años que respondió adecuadamente al tratamiento médico.

La afectación ganglionar por Mycobacterium tuberculosis puede ocurrir tras una diseminación linfohemática a partir de una afectación primaria pulmonar, o por primoinfección extrapulmonar, cuya puerta de entrada son las mucosas o contacto con objetos contaminados. Se presenta el caso de un niño de diez años, nacido en España, afecto de adenitis tuberculosa en la región inguinal, cuya infección se produjo tras una herida en el pie ocurrida en una playa de Brasil. Tras el inicio de la terapia antituberculosa desarrolló una escrófula que requirió desbridamiento quirúrgico, con buena evolución posterior.

Lymphadenitis was the most common NTM disease manifestation and not associated with comorbidity. NTM bacteremia was always associated with a central line and catheter removal with cure. We were unable to assess the added value of various antibiotic regimens.

Micosis cutánea (ver también tiña y Temas A-Z)

Adolescente de 13 años que consulta por lesión cutánea dolorosa en gemelo izquierdo de un mes de evolución, sin respuesta a tratamiento con amoxicilina-clavulánico oral. Afebril en todo momento. Como antecedentes de interés refiere vivir en entorno rural y tener contacto habitual con caballos, gallinas y perros.

An 8-year-old aboriginal boy living in Gua Musang, Malaysia, presented with a 2-year history of a round, concentric, and scaly rash on his trunk. The rash was itchy and progressively spread to involve approximately 80% of the body surface area. His 32-year-old mother and 1-year-old sister had similar lesions. His history was otherwise unremarkable. Dermatologic examination revealed generalized concentric, annular, scaly, lamellar plaques with an overlapping-ring appearance over his trunk (Figure 1), limbs, and palmoplantar surfaces. The face, scalp, hair, and nails were spared

Neonato de 3 semanas de vida, llevado al pediatra con tres lesiones grandes lesiones en cuero cabelludo que habían aparecido en la primera semana de vida. Las lesiones eran anulares con bordes papulares y pustulosos elevados y áreas centrales hiperqueratósicas planas . La madre,originaria de Somalia, tenía lesiones cutáneas similares en el tronco. Muestra de raspado de cuero cabellludo fue cultivado en agar dextrosa de Sabouraud y crecieron colonias de color amarillo con hifas radiantes . PCR realizada extraído identifica ADN de Trichophyton soudanense.

We report a case of cutaneous cryptococcosis due to Cryptococcus neoformans in a pediatric patient with hyper IgM syndrome with scalp lesions that resembled tinea capitis on gross examination and mimicked juvenile xanthogranuloma on histologic examination. This case highlights the importance of considering cutaneous cryptococcosis in patients with hyper IgM syndrome.

Micosis invasiva

Micosis ungueal (ver Temas A-Z)

Microbioma (ver Temas A-Z)

  • Trasplante de microbiota fecal en niño con enfermedad inflamatoria intestinal de inicio muy precoz. An Pediatr (Barc) 2018;89:184-6
    La disbiosis intestinal subyacente en los pacientes con enfermedad inflamatoria intestinal (EII) ha dirigido en parte las opciones terapéuticas. El trasplante de microbiota fecal (TMF),de un donante sano al tracto intestinal de un paciente receptor, ha mostrado ser eficaz en la infección recurrente Clostridium difficile en adultos y pacientes pediátricos.
    Se trata de un niño de 6 años y 7 meses de (madre E,de Crohn), diagnosticado a los 2 años de edad de enfermedad inflamatoria no clasificada (EIInC) por episodios recurrentes de diarrea sanguinolenta, anemia e hipoalbuminemia. El despistaje de inmunodeficiencias y de enfermedades inflamatorias monogénicas negativas y la investigación de procesos infecciosos ha sido repetidamente negativa para tuberculosis y CMV a excepción de 3 episodios de diarrea sanguinolenta por Clostridium difficile.  El paciente fracasa a la terapia convencional . Se acuerda con la familia realizar ileostomía disociada programando antes del cierre de la ileostomía, el TMF a través del estoma inferior.
    procedimiento: heces frescas del donante emitidas 3h antes, conservadas a temperatura ambiente en contenedor estéril. , Se administró por sondaje del estoma inferior de la ileostomía 50ml de la suspensión fecal mediante jeringa estéril. Se sometió 20 días después a una segunda infusión de suspensión fecal procedente del mismo. El procedimiento fue muy bien tolerado por parte del paciente. El interés del caso radica por un lado en la realización de ileostomía disociada en un niño afecto de colitis grave y la utilización de TMF con idea de ampliar el beneficio terapéutico. Aunque no existe consenso, parece que la vía de infusión por colonoscopia es superior al enema y a la ruta nasogástrica y nasoentérica, no solo por la aceptación por parte del paciente sino por conseguir que el colon entero sea infundido
    Tras 2 infusiones la situación clínica mejoró de forma muy satisfactoria, probablemente por adición de efectos beneficiosos (diversión ileal y el TMF). Son escasas las publicaciones pediátricas sobre TMF en niños con colitis por EII con resultados controvertidos. Lamentablemente no podemos describir datos satisfactorios evolutivos en nuestro paciente. Ignoramos el número de infusiones de solución fecal que hubiera necesitado este paciente. Es urgente la ejecución de estudios aleatorizados en niños que ayuden a despejar las numerosas dudas que tenemos en la actualidad

Miocarditis

Deportista de 15 años que acude a Urgencias por presentar durante un entrenamiento dolor torácico opresivo irradiado a brazo izquierdo de una hora de evolución, acompañado de náuseas y mareo. Afebril. Pruebas complementarias: ECG: elevación del segmento ST en la cara diafragmática e infradesnivelación en cara lateral; CK 3312 UI/l, troponina T 9,12 µg/l, GOT 408 UI/l. Ecocardiograma y radiografía de tórax normales. El diagnóstico final fue de miocarditis aguda mediante RM, con serología positiva para Mycoplasma pneumoniae. Evolución: se permite el deporte de competición a partir de los 6 meses, aconsejándose controles cardiológicos semestrales, permaneciendo la paciente asintomática hasta la fecha.

Evidence from one trial does not support the use of IVIG for the treatment of adults with presumed viral myocarditis. The only paediatric trial had high risk of bias but suggested that benefit may be seen in the select group of children beyond the neonatal period who have viral encephalitis with myocarditis. Until higher-quality studies have demonstrated benefit in a particular group of patients, IVIG for presumed viral myocarditis should not be provided as routine practice in any situation. Further studies of the pathophysiology of myocarditis would lead to improved diagnostic criteria, which would facilitate future research.

Molluscum

A three-month old infant, with no relevant history, born by vaginal delivery with no complications, was seen in the emergency department as she had a lesion on her scalp which was detected by her parents 4–5 weeks ago, and which had grown progressively since then. The patient did not have a fever or general symptoms and no lesions were observed at other sites. The parents denied previous wounds or lesions in the area. In the emergency department, a fungal and bacterial culture was performed with a negative result, and treatment was started with corticosteroids and topical antifungals with no improvement. It was therefore decided to refer the patient to the Dermatology department. In the consultation, during the physical examination, we observed a verrucous plaque formed by multiple grouped papules of follicular distribution, some of which had a cystic appearance, measuring around 2 cm in diameter in the right parieto-occipital region (Fig. 1). As viral plaque warts vs congenital molluscum contagiosum infection was suspected, a small area was shaved. A physical examination of the mother’s genitalia was performed. She did not have any lesions at the time.

To assess the effects of specific treatments and management strategies, including waiting for natural resolution, for cutaneous, non-genital molluscum contagiosum in people without immune deficiency.

We searched the literature to July 2016. We included 22 trials (total of 1650 participants). Twenty of the studies evaluated topical treatment, and two studies evaluated treatment taken by mouth (oral). Comparisons included physical therapies, as well as topical and oral treatments. Most studies were set in hospital outpatient or emergency departments, and were performed in North America, the UK, Asia, or South America. Participants were of both sexes and were mainly children or young adults. Follow-up duration varied from 3 to 28 weeks after randomisation. Only five studies had longer than 3 months' follow-up.

Five studies reported commercial funding, three studies obtained medication for free from pharmaceutical companies, 12 studies did not mention the source of funding, one study reported charity funding, and one study reported they had had no financial support.

No single intervention has been shown to be convincingly effective in the treatment of molluscum contagiosum. We found moderate-quality evidence that topical 5% imiquimod was no more effective than vehicle in terms of clinical cure, but led to more application site reactions, and high-quality evidence that there was no difference between the treatments in terms of short-term improvement. However, high-quality evidence showed a similar number of general side effects in both groups. As the evidence found did not favour any one treatment, the natural resolution of molluscum contagiosum remains a strong method for dealing with the condition.

A 5-year-old boy presented with a 2-week history of a left, painful red eye despite treatment with chloramphenicol drops. Examination revealed conjunctival ulceration associated with localized injection but no follicular reaction (Figure, A). No eyelid or facial cutaneous lesions were present. Conjunctival swabs were negative.

Mordeduras (ver Infecciones cutáneas en Temas A-Z)

Mononucleosis (ver también Temas A-Z)

El virus de Cytomegalovirus, de Epstein Barr y el virus de la varicela-zoster son herpesvirus frecuentes, adquiridos con frecuencia en la infancia, que establecen una infección latente persistente y son susceptibles de afectar el desarrollo del sistema inmune. El estudio pone de manifiesto grandes diferencias de incidencia entre los británicos blancos y los niños paquistaníes en el Reino Unido y ha identificado factores de riesgo clave para la infección en cada grupo, que sugieren que los mecanismos de transmisión deben de ser investigados más a fondo.

Se revisan 7 estudios que incluyen a 362 pacientes. Los estudios son heterogéneos: 4 comparan corticoides vs placebo, 1 corticoides vs aspirina y 2 corticoides en combinación con antivirales.

En 2 de los estudios muestran mejoría a corto plazo en la odinofagia comparado con placebo. También mejora la odinofagia entre los días 2º y 4º de evolución en los estudios que los administran asociados a corticoides.

Sin embargo los autores concluyen que no existe suficiente evidencia para justificar su uso y que no se analizan los efectos secundarios/complicaciones a largo plazo.

Socioeconomic position and factors related to lifestyle explain only a part of the large ethnic differences in EBV and HSV-1seroprevalences, whereas they do not explain ethnic differences in CMV seroprevalences in childhood.

Mujer de 22 anos, ˜ alérgica a la penicilina y fumadora activa sin otros antecedentes, que ingresó en nuestro hospital por un cuadro compatible con MI (malestar general, fiebre, mialgias y odinofagia). En la EF presentaba adenopatías cervicales, ictericia, esplenomegalia e hipertrofia amigdalar con necrosis. Analíticamente destacaba hipertransaminasemia, leucocitosis en sangre periférica a expensas de linfocitos y elevación de la PCR (316 mg/l). Los hemocultivos, las serologías fuerno negativas a excepción de anticuerpos IgM para el VEB fueron positivos (IgG negativos) y existía una alteración del cociente CD4/CD8 (20/57%). Inmunoglobulinas normales y una ecografía abdominal confirmó la esplenomegalia. A los 7 días del ingreso, por fiebre persistente, disfagia progresiva y aparición de edema en la zona submandibular y cervical anterior se realizó una ecografía y (TAC) cervical que objetivó amígdalas hipertróficas y colecciones hidroaéreas en la zona laterocervical anterior y supraclavicular con extensión a tejido graso subcutáneo y espacios profundos.

Mosquitos (Ver Temas A-Z)

A propósito de los brotes de Dengue en Francia (2015) y de Chukungunya en Italia. Autochthonous outbreaks of chikungunya and dengue during the past decade showed that continental Europe is vulnerable to Aedesalbopictus–borne infections. Ae. albopictus has spread geographically, resulting in more people exposed to risk. Timely application of adequate mosquito suppression measures may delay, or even prevent, the vector population from crossing the potential epidemic abundance threshold should a pathogen be introduced. Health authorities should be on alert to detect early cases to prevent autochthonous outbreaks

Mucormicosis

La mucormicosis se ha convertido en una enfermedad fúngica invasiva rara pero frecuentemente fatal. Afecta principalmente a niños con enfermedades malignas. Se presenta como enfermedad pulmonar, de tejidos blandos, senos paranasales o enfermedad diseminada y es altamente letal. La evolución mejora cuando se combina el tratamiento antifúngico y la cirugía.

Muerte súbita

Conclusions Our findings suggest that there is considerable interoffice variability with testing for infectious diseases in SUIDs. This appeared to be largely the result of a perceived lack of testing utility rather than a lack of test availability. Evidence-based practice guidelines regarding the interpretation of microbial testing results, as well as common testing protocols/algorithms, may lead to more accurate and standardized data, thus improving SUID investigation and surveillance.

Mycoplasma (ver también Temas A-Z)

This study included children hospitalized with M. pneumonia  pneumonia between 2010 and 2015. At the time of pneumoniadiagnosis, a nasopharyngeal aspirate was analyzed for respiratory viruses by reverse transcription-polymerase chain reaction (RT-PCR). The clinical manifestations and laboratory findings were reviewed from medical records.

Of the 286 children with M. pneumoniae pneumonia, 84 (29.4%) had a co-detected respiratory virus, with the highest co-detection rate in young children (51.9% of children <2 years; P = 0.002). In children <2 years, with and without co-detected virus, wheezing occurred in 35.7% and 15.4%, respectively. Among the 202 children without any virus detected, only 6.4% were <2 years. These young children showed fewer median days of fever than the children ≥2 years (8 vs. 11 days; P = 0.022). Children ≥2 years tended to have accompanying skin rashes (21.7% vs.7.7%; P = 0.310) and elevated liver enzymes (21.7% vs. 0%; P = 0.075) more frequently than children <2 years. Only 53.8% of the patients <2 years were treated with macrolide compared with 94.1% of the patients ≥2 years (P < 0.001).

The clinical manifestations of M. pneumoniae pneumonia in young children are milder than those in older children. A high prevalence of co-detected respiratory virus in young children suggests that virus might play a role in making pneumonia clinically apparent in this age group.

Con la aparición de la resistencia a los macrólidos, se han planteado preocupaciones acerca de la eficacia de los macrólidos para el tratamiento de la neumonía por Mycoplasma pneumoniae (MP) en niños. Este estudio tuvo como objetivo determinar el efecto de la resistencia a los macrólidos sobre el resultado de los niños hospitalizados con neumonía por MP. Demostró que la duración de la fiebre en la neumonía por MP se determinó por los hallazgos radiológicos no por la presencia de resistencia a los macrólidos. Los resultados destacan la necesidad de futuros estudios para evaluar el beneficio terapéutico de los macrólidos en el tratamiento de niños con neumonía por MP

Mycoplasma pneumoniae is a common cause of community-acquired pneumonia and may cause life-threatening disease in children. We identified 30 (0.3%) confirmed M. pneumoniae cases by clinical and laboratory criteria in 11,526 pediatric intensive care unit admissions. Outcomes were comparable to patients admitted with other infections (n=3005; P > 0.1). Our findings indicate that empiric antimicrobial coverage for M. pneumoniae infection in pediatric intensive care unit is rarely needed

A 33-week-old gestational age male infant was admitted to the neonatal intensive care unit for severe respiratory distress syndrome. He was born vaginally after spontaneous preterm labor without maternal fever, genitourinary tract infection, or biological sign of infection. An initial absolute neutrophil count was 45 000/mm3 and C-reactive protein peaked at 44 mg/L on day 2 of life. The initial hemoglobin value was 100 g/L. He rapidly developed refractory hypoxemia with pulmonary arterial hypertension and hemodynamic failure that required high-frequency oscillatory ventilation, surfactant therapy, inhaled nitric oxide, red blood cells transfusion for neonatal anemia, hemodynamic support with volume expansion, and norepinephrine infusion. Empirical broad-spectrum antibiotherapy was initiated including amoxicillin, cefotaxime, and amikacin…

The oropharyngeal swab specimen was superior to the nasopharyngeal swab specimen for the detection of Mycoplasma pneumoniae in children with lower respiratory tract infection. The oropharyngeal loop-mediated isothermal amplification had 100% sensitivity and specificity compared with polymerase chain reaction testing, whereas the oropharyngeal rapid antigen detection test using immunochromatographic assay had relatively low sensitivity (66%) and reasonable specificity (90.7%).

El diagnóstico de neumonía adquirida en la comunidad (NAC) causado por Mycoplasma pneumoniae (Mp) en los niños se ha visto obstaculizado por la dificultad en obtener suero convaleciente y limitaciones de tiempo. En este estudio se investigaron los dos métodos de diagnóstico que tenían como blanco, respectivamente, a los anticuerpos de MP y al ADN de MP. En algunos casos de NAC infantil, el diagnóstico de laboratorio de MP fue discordante entre la serología y el método PCR múltiple. Comparado con el test de aglutinación en suero, el GeXP mostró un desempeño mayor sensibilidad y fiabilidad, en comparación con método serológico. Además, el empleo de la PCR múltiple podría proporcionar más información sobre los patógenos asociados para la evaluación clínica de la NAC.

Neumococo (ver también Temas A-Z)

Durante las últimas décadas, Streptococcuspneumoniae ha desarrollado resistencia significativa a muchas clases de fármacos antimicrobianos. Se examinaron los factores de riesgo potenciales para la colonización de la nasofaringe por Streptococcuspneumoniae y para el transporte de cepas resistentes a fármacosen niños, en el distrito de Nicosia en Chipre.En análisis multivariableencuentran que la asistencia a la guardería, tener hermanos en la familia y ambos padres originarios de Chipre, aumenta estadísticamente el riesgo de colonización por neumococo. La administración previa de antimicrobianos durante el último mes antes de la obtención de la muestra pareció ser el factor de riesgo más consistente para transportar una cepa no susceptible de Streptococcuspneumoniae a penicilina o eritromicina

  • Distribution of serotypes and patterns of antimicrobial resistance among commensal Streptococcus pneumoniae in nine European countries. BMC Infectious Diseases201818:440

Este artículo presenta la distribución de los serotipos y la resistencia antimicrobiana en cepas comensales de S. pneumoniae cultivadas a partir de portadores sanos mayores de cuatro años en nueve países europeos, así como el impacto de la vacunación neumocócica en en el estado de portador neumocócico. Se encontró una gran variación en la distribución de serotipos en los países participantes y se observó una diferencia en la resistencia a los antimicrobianos, incluida la resistencia a múltiples fármacos, entre estos serotipos. El principal hallazgo fue que la vacunación neumocócica se asoció con un alto riesgo de transporte de serotipos no PCV10.

En conclusión, la vacunación neumocócica se asocia con un mayor riesgo de colonización de serotipos no PCV10 y la resistencia antimicrobiana es independiente del país y la vacuna utilizada. Los serotipos 14 (PCV-7), 15A (serotipo sin vacuna) y 19A (PCV-13) tuvieron la mayor proporción de resistencia antimicrobiana y resistencia a múltiples fármacos. La aparición de nuevos serotipos y la prevalencia relacionada de la resistencia a los antimicrobianos podría justificar a corto plazo, una evaluación y ajuste continuo de las vacunas disponibles, para incluir los serotipos recién emergidos. A largo plazo, la implementación de nuevas vacunas que podrían cubrir todos los serotipos neumocócicos, como las vacunas de células enteras, podría ser útil.

  • Resistant Streptococcus pneumoniae strains in children with acute otitis media– high risk of persistent colonization after treatment. BMC Infectious Diseases201818:478

En este estudio se evaluan la relación entre 55 cepas neumocócicas obtenidas de nasofaringe / orofaringe y líquido del oído medio de 62 niños, entre 1 y 16 años, durante la OMA (incluida la OMA con insuficiencia de tratamiento / recurrente, y visitas posteriores al tratamiento), según sus características fenotípicas y genotípicas realizadas mediante análisis de serotipo, patrones de susceptibilidad a antibióticos y tipificación de secuencias multilocus. Los hallazgos parecen confirmar informes recientes que muestran que la terapia con antibióticos en la OMA induce la selección de S. pneumoniae preexistente resistente a los antibióticos nasofaríngeos. Se demostró que el tiempo de tratamiento demasiado corto en niños con OMA bilateral, pero no con β-lactámicos, tiene un impacto en la colonización neumocócica persistente después del tratamiento.

La alta prevalencia persistente de cepas de S. pneumoniae resistentes a los antibióticos en niños con OMA después de la finalización de la terapia parece confirmar que la erradicación fallida de bacterias puede considerarse como un factor de riesgo de recurrencia.

A few previous studies have reported an increased risk of invasive pneumococcal disease (IPD) in children born preterm, but this has not been investigated in a cohort study. The impact of 7-valent pneumococcal conjugate vaccine (PCV7) on IPD incidence rates in preterm children is unknown.

Data from the Medical Birth Registry of Norway (2002–2010) were linked to other national registries. In total, 628,138 children were included in our study and followed until 2 years of age. Incidence rate ratios (IRRs) and confidence intervals (CIs) were estimated with Poisson regression.

We identified 411 cases of IPD. We observed higher rates of IPD in preterm than in full-term children for the intervals 0–23, 0–5 and 6–23 months of age, IRRs = 1.83 (95 % CI: 1.36–2.47), 2.95 (95% CI: 1.44–6.06) and 1.69 (95% CI: 1.22–2.34), respectively. The risk for IPD was reduced in the PCV7-period (2007–2010) compared with that of the pre PCV7-period (2002–2005) for children 6–23 months of age, IRRs = 0.20 (95% CI: 0.08–0.53) for preterm children and 0.28 (95% CI: 0.21–0.38) for full-term children, but not for those 0–5 months of age, IRRs = 1.94 (95% CI: 0.48–7.80) and 0.71 (95% CI: 0.38–1.33).

Preterm children had an increased risk of IPD. After introduction of PCV7, the rate of IPD was reduced among preterm and full-term children from 6 months of age.

Children with SCD remain at increased risk of IPD despite national newborn screening, early penicillin prophylaxis and high pneumococcal vaccine uptake. They are also more likely to die of their infection compared with their peers without SCD. Most IPD cases are now due to serotypes not covered by PCV13. Healthcare professionals need to work more closely with families with SCD and local communities to emphasise the importance of penicillin prophylaxis, explore barriers, allay misguided beliefs and facilitate rapid access to healthcare.

Los menores de 2 años con mayor depresión del sensorio al ingreso, especialmente cuando requieren soporte ventilatorio prolongado, tienen un mayor riesgo de mala evolución.

Pneumococcus was a recognized pathogen among neonates in all development regions of the world. The burden of neonatal IPD, particularly in the least-developed UN country stratum, requires substantial further evaluation.

Of an unselected cohort of children with rIPD at least 11% were C2 deficient. Data suggest that screening for complement deficiencies and deficient antibody response to pneumococcal vaccines in patients with more than 1 episode of IPD is warranted.

Neumococo vacuna (ver también Temas A-Z)

We report substantial declines in all-cause pneumonia hospitalizations and related costs after introduction of pneumococcal conjugate vaccines in Ontario, Canada. We observed reduced hospitalizations in both vaccinated and unvaccinated age groups, supporting the presence of indirect effects of vaccination.

Resumen: compara una pauta de vacuna neumocócica conjugada 13-valente 1+1(n=107) frente a la actual 2+1 (n=106) en niños de Reino Unido. Analizando los valores de IgG específicas de serotipo (concentraciones geométricas medias en microgr/mL) un mes después de finalizada la pauta 2+1 o 1+1, para 9 de los 13 serotipos los títulos son iguales o superiores en el caso de la pauta 1+1. Los títulos fueron mejores para la pauta 2+1 en los serotipos 6A, 6B, 18C y 23F. Plantea que en poblaciones con un programa ya implantado de esta vacuna e inmunidad de grupo demostrada, podría ser suficiente una pauta 1+1.

The 10-valent pneumococcal conjugate vaccine (PHiD-CV10) was introduced in Iceland in 2011, without catch-up. The aim of this study was to estimate vaccine impact (VI) on acute otitis media (AOM).

In this whole-population study, all primary care visits due to AOM from 2005 to 2015 in children <3 years of age were included. Birth cohorts were grouped as vaccine noneligible (VNEC) or vaccine eligible (VEC). Crude incidence rates (IRs) were compared between the VNEC and VEC. A Cox regression model for repeated events was used to model the individual-level data. VI was calculated as (hazard ratio [HR] – 1) × 100%.

Included were 53150 children, with 140912 person-years of follow-up and 58794 AOM episodes. Both IR and the mean number of episodes differed significantly between VNEC and VEC; 43 compared to 38 episodes per 100 person-years and 1.61 episodes per child compared to 1.37. IR was significantly reduced in all age brackets, with the largest reduction in children <4 months of age (40% [95% confidence interval {CI}, 31%–49%). The VI on all-cause AOM was 22% (95% CI, 12%–31%). The impact was mediated through its effect on the first (HR, 0.84 [95% CI, .82–.86]) and second (HR, 0.95 [95% CI, .93–.98]) episodes.

Conclusions

The impact of PHiD-CV10 on all-cause AOM was considerable, mediated mainly by preventing the first two episodes of AOM. A decrease in the IR of AOM in children too young to receive direct vaccine protection was demonstrated, suggesting herd effect.

Our nationwide study shows that ambulatory visits for OM have declined following the introduction of PCV7 and PCV13. Future research on the evolving microbiology of OM and continued monitoring of the epidemiology of pneumococcal disease are needed.

Tapping into the nationally representative databases from the National Center for Health Statistics at the US Centers for Disease Control and Prevention, Kawai et al from Boston queried the number of otitis media associated ambulatory visits in children up to 18 years of age over the years 1997 to 2014. This interval spans years before universal use of pneumococcal conjugate vaccine (PCV) (before 2000), during PCV7 use, and since PCV13 use beginning in late 2010 in children 2 months through 59 months of age. A strength of the study is that the databases include 3 types of ambulatory physician visits: in office practices, hospital-associated outpatient departments, and emergency departments. The results are only broad brush strokes as no attempt was made to assess criteria or providers' clinical acumen to diagnose/code otitis media, whether visits were at the time of diagnosis or for follow up, and did not take in to account changing national recommendations for management that included dropping follow up visits for uncomplicated acute otitis media. The results, however, represent real world incidence and are in line with smaller (less representative samples) that did include more granular data.
Almost 25 000 otitis media related visits were identified over the study period. Between the pre-PCV7 and post-PCV13 period, annual physician office visits for those under 2 years of age declined most dramatically (ie, by 51%, CI 42% to 58%; from 826 to 387 visits per 1000 children under 2 years of age). Declines occurred across all ambulatory settings. An equally important finding was decline across demographics of sex, race/ethnicity, age, health insurance status, and across geographic regions. Without debate, PCV7 and PCV13 have all but eliminated the primary “bad actor” pneumococci of previous severe infection that led to the most “problematic” cases as well as protracted middle ear inflammation that facilitated recurrent episodes of acute otitis media. PCVs also have all but eliminated dread pneumococcal invasion of the bloodstream and central nervous system. With these helpful data from Kawai et al in mind, providers should have greatly reduced prescribing of antibiotics in ambulatory settings and parents should expect receiving many fewer prescriptions.

Background: The 10-valent pneumococcal conjugate vaccine (PHiD-CV10) was introduced in Iceland in 2011, without catch-up. The aim of this study was to estimate vaccine impact (VI) on acute otitis media (AOM).

Conclusions: The impact of PHiD-CV10 on all-cause AOM was considerable, mediated mainly by preventing the first two episodes of AOM. A decrease in the IR of AOM in children too young to receive direct vaccine protection was demonstrated, suggesting herd effect.

We observed a reduction in pHNIs incidence after PCV program implementation.

Background. Antibiotic-nonsusceptible invasive pneumococcal disease (IPD) decreased substantially after the US introduction of the pediatric 7-valent pneumococcal conjugate vaccine (PCV7) in 2000. However, rates of antibiotic-nonsusceptible non-PCV7-type IPD increased during 2004–2009. In 2010, the 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7. We assessed the impact of PCV13 on antibiotic-nonsusceptible IPD rates.

Methods. We defined IPD as pneumococcal isolation from a normally sterile site in a resident from 10 US surveillance sites. Antibiotic-nonsusceptible isolates were those intermediate or resistant to ≥1 antibiotic classes according to 2012 Clinical and Laboratory Standards Institute breakpoints. We examined rates of antibiotic nonsusceptibility and estimated cases prevented between observed cases of antibiotic-nonsusceptible IPD and cases that would have occurred if PCV13 had not been introduced.

Results. From 2009 to 2013, rates of antibiotic-nonsusceptible IPD caused by serotypes included in PCV13 but not in PCV7 decreased from 6.5 to 0.5 per 100 000 in children aged <5 years and from 4.4 to 1.4 per 100 000 in adults aged ≥65 years. During 2010–2013, we estimated that 1636 and 1327 cases of antibiotic-nonsusceptible IPD caused by serotypes included in PCV13 but not PCV7 were prevented among children aged <5 years (−97% difference) and among adults aged ≥65 years (−64% difference), respectively. Although we observed small increases in antibiotic-nonsusceptible IPD caused by non-PCV13 serotypes, no non-PCV13 serotype dominated among antibiotic-nonsusceptible strains.

Conclusions. After PCV13 introduction, antibiotic-nonsusceptible IPD decreased in multiple age groups. Continued surveillance is needed to monitor trends of nonvaccine serotypes. Pneumococcal conjugate vaccines are important tools in the approach to combat antibiotic resistance.

High rate of PCV13 immunization was associated with decreased incidence of bacteremic CAP; this incidence increased when rate of immunization fell. Empyema (but not parapneumonic pleural effusion) was associated with bacteremia.

Vaccine failures occurring with 13-valent pneumococcal conjugate vaccine (PCV13) in 3 pediatric hospitals in Barcelona (2012–2013) are described. PCV13 vaccine failure was defined as the occurrence of an invasive pneumococcal infection in children properly vaccinated by PCV13. Among 84 patients with invasive pneumococcal infection, 32 had received at least one dose of PCV13. Seventeen of them had invasive pneumococcal infection produced by a PCV13 serotype. Among those, 9 patients were considered to have a PCV13 vaccine failure. Serotype 3 was isolated in 6 patients, serotype 19A in 2 and serotype 6B in 1.

Serotype replacement was observed post-PCV7 vaccination with a concomitant, not previously recognized, increased nasopharyngeal density.

Serotypes 35B, 23B, 21 and 15A/B/C rapidly emerged as NP colonizers in the early PCV13 era. Genetically divergent strains with ST558 and ST62 emerged. Resistance to common antibiotics declined after the introduction of PCV13.

PCV13 reduced PCV13-specific and 6C carriage among children <5 years of age. Low pre-PCV13 carriage prevalence of PCV13-specific types limited confirming this reduction for adults.

Conjugate vaccines have reduced pneumococcal disease in vaccinated children and unvaccinated adults, but non-vaccine serotypes are of concern, particularly if antibiotic resistant. We reviewed Streptococcus pneumoniae collected via: (i) the British Society for Antimicrobial Chemotherapy (BSAC) surveillances from 2001–2014; (ii) Public Health England’s (PHE) invasive isolate surveillance from 2005–2014 and (iii) referral to PHE for resistance investigation from 2005–2014. Serotype 15A increased in all series, with many representatives showing triple resistance to macrolides, tetracyclines and penicillin. 15A was consistently among the 10 most prevalent serotypes from 2011 in PHE and BSAC invasive isolate/bacteraemia surveillance but never previously; 26–33% of these invasive 15A isolates had triple resistance. BSAC respiratory isolates were only serotyped in 2013/14 and 2014/15 (October to September); 15A was most prevalent serotype in both periods, comprising 9–11% of isolates, 38–48% of them with triple resistance. Serotype 15A represented 0–4% of S. pneumoniae referred to PHE for reference investigation annually until 2008 but rose to 29% (2013) and 32% (2014). Almost all multidrug-resistant 15A isolates were sequence type (ST) 63 variants, whereas susceptible 15A isolates were clonally diverse. The rise of serotype 15A suggests that pneumococcal conjugate vaccines will need ongoing adaptation.

We collected cases of pneumococcal meningitis vaccine breakthrough (VBT) and vaccine failure (VF) from 2003 to 2013 after the implementation of pneumococcal conjugate vaccines (PCVs) in France. VBT accounted for 3.2% of the cases (PCV7 era: 24 of 943, PCV13 era: 15 of 290) and VF 0.6% (PCV7 era: 6 of 943, PCV13 era: 2 of 290). VBT and VF are rare and occur in most cases in children younger than 2 years. The serotype 19F was the most frequent cause even after the introduction of PCV13.

The 13-valent PCV catch-up program was associated with a significant decrease in serotype 19A IPD incidence in 2013, primarily in children eligible for the 13-valent PCV immunization. Continued surveillance is necessary to assess the further impact of the national catch-upprogram on pediatric IPD epidemiology in Taiwan.

Se revisan 7 ensayos randomizados. No se demuestra que la vacunación antineumocócica durante la gestación, reduzca el riesgo de enfermedad neumocócica en el lactante.

Conclusion: Both formulations of PCV15 display acceptable safety profiles and induce IgG and OPA responses to all vaccine serotypes.

PHiD-CV and DTPa-IPV-Hib were immunogenic and well tolerated when coadministered as a 3-dose primary vaccination course.

Our study results suggest that PHiD-CV10 immunization according to a 3 + 1 or 2 + 1 schedule initiated before 12 months of age may reduce the frequency of TTPs, although the primary analysis did not reach statistical significance

Our study also confirmed that a small group of patients with recurrent upper respiratory tract infections are unable to develop a normal response to pneumococcal and other bacterial polysaccharides despite vaccination with the newer conjugated vaccines. This immunodeficiency has been named selective antibody deficiency with normal immunoglobulins or impaired polysaccharide responsiveness. These patients did well after administration of intravenous IgG

Pneumococcal infections are a significant cause of morbidity and mortality, and are one of the 10 leading causes of death worldwide. Children under 2 years have a higher incidence rate, followed by adults over 64 years. The main risk group are individuals with immunodeficiency, and those with anatomical or functional asplenia, but can also affect immunocompetent persons with certain chronic diseases. Significant progress has been made in the last 10 years in the prevention of these infections. Until a few years ago, only the 23-valent non-conjugate pneumococcal vaccine was available. Its results were controversial in terms of efficacy and effectiveness, and with serious limitations on the type of immune response induced. The current possibility of using the 13-valent conjugate vaccine in adults has led to greater expectations in improving the prevention of pneumococcal disease in these age groups.

Neumonias (ver también Temas A-Z)

Todos los estudios encuentran que la ecografía torácica (ET) es una buena alternativa a la realización de radiografía de tórax (RT) en niños con sospecha de neumonía en los que se plantea una prueba de imagen, y que un resultado en la ET compatible con NAC podría evitar la realización de la RT. En el caso de que la ET no mostrara imágenes de consolidación compatibles con NAC, si la sospecha clínica es alta, podría valorarse la realización en este momento de una RT buscando neumonías alejadas de la pleura que escaparían al diagnóstico ecográfico o bien adoptar una decisión diagnóstica basada exclusivamente en la información clínica.

Conclusions: While pediatric pneumonia-specific risk scores have been developed and validated, it is yet unclear if implementation is feasible, what impact, if any, implemented scores may have on child outcomes, or how broadly scores may be generalized. To increase the feasibility of implementation, future research should focus on developing scores based on routinely collected data

Las coinfecciones son comunes en la neumonía adquirida en la comunidad infantil (NAC). Sin embargo, su patrón etiológico y su impacto clínico no son concluyentes. El patógeno implicado se identificó en el 70.1% (593 de 846) de los pacientes. Los patógenos más comúnmente detectados fueron virus respiratorio sincicial (VSR) (22.9%), rinovirus humano (RVH) (22.1%), M. pneumoniae (15.8%). Se identificó coinfección en 34.6% (293 de 846) de los pacientes. La mayoría de estos (209 [71.3%] de 293) fueron infecciones bacterianas y virales mixtas. La edad <6 meses (odds ratio: 2,1; IC 95%: 1,2-3,3) y la admisión en UCIP (odds ratio: 12,5; IC 95%: 1,6-97,4) se asociaron con la infección mixta. Los pacientes con infección mixta tuvieron una tasa más alta de admisión en la UCIP. La alta carga de infección mixta en la NAC de la infancia subraya la necesidad de mejorar los diagnósticos sensibles, económicos y rápidos para identificar con precisión los patógenos en la neumonía

We included 17 studies evaluating systemic corticosteroid therapy (given intravenously or by tablets) for people with pneumonia (2264 participants; 1954 adults and 310 children). We included 12 new studies in this update and excluded one previously included study. All included studies evaluated people who had acquired pneumonia in the community (community-acquired pneumonia (CAP)) being treated in the hospital; no studies assessed people who had developed pneumonia while in hospital or who were on breathing machines (mechanically ventilated).

Corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death. Corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP. Corticosteroid therapy was associated with more adverse events, especially hyperglycaemia, but the harms did not seem to outweigh the benefits.

 

Revisión sistemática (RS) y metanálisis (MA). El objetivo es estimar la validez de los síntomas y signos clínicos en niños para el diagnóstico de neumonía confirmada radiológicamente. Se seleccionaron estudios de diagnóstico de neumonía en niños y adolescentes hasta los 19 años (MeSH (Medline) y Emtree (Embase). No existía ningún síntoma que de forma aislada se asociara con fuerza a la neumonía. En dos estudios que incluían adolescentes el dolor torácico. La tos, la dificultad para respirar, los vómitos y la diarrea no se asociaron con un aumento en la probabilidad de neumonía. La hipoxemia moderada (saturación de oxígeno ≤96% ) y el aumento del trabajo respiratorio (quejido, aleteo o tiraje) fueron los signos más asociados a la neumonía.

Así concluyen que ningún hallazgo por separado diferencia de forma fiable la neumonía de otras causas de enfermedades respiratorias infantiles. La hipoxemia y el aumento del trabajo respiratorio son signos más válidos que la taquipnea y los hallazgos auscultatorios. No obstante los revisores del artículo apuntan que si basamos el diagnóstico de neumonía exclusivamente en criterios clínicos, estamos asumiendo cierta proporción de sobretratamientos y diagnósticos perdidos. Sería conveniente contar con más estudios que analicen el rendimiento clínico de la aplicación en paralelo o en serie de estos síntomas y signos en nuestra práctica clínica.

Población de estudio: niños menores de dieciocho años, hospitalizados con el diagnóstico de neumonía adquirida en la comunidad, entre enero de 2010 y junio de 2012. Los criterios de inclusión fueron niños ingresados con síntomas y signos de infección aguda, de enfermedad respiratoria aguda y evidencia radiológica de neumonía. Se excluyeron los niños con hospitalización reciente, inmunosupresión grave, fibrosis quística, traqueostomía o con un diagnóstico alternativo evidente.
Conclusión: se presentan tres modelos de riesgo para poder estimar con precisión el riesgo de neumonía grave en niños, lo que permitirá mejorar el tratamiento y el pronóstico en esta población

Conclusiones de los autores del estudio: se presentan tres modelos de riesgo para poder estimar con precisión el riesgo de neumonía grave en niños, lo que permitirá mejorar el tratamiento y el pronóstico en esta población.

Comentario de los revisores: el estudio propone una herramienta, simple y de fácil aplicabilidad, para predecir el curso clínico de la neumonía que aún debe ser validada internacionalmente.

After the introduction of PCV13, the hospitalization rates of all pneumococcal pneumonia and complicated pneumonia among 8 children’s hospitals significantly decreased. PCV13 serotype pneumonia cases also decreased; however, they continued to cause a significant proportion of pneumococcal pneumonia in 2011–2014.

Resumen: estudio de cohortes retrospectivas para comprobar la adecuación de la prescripción de amoxicilina, macrólidos y antibióticos de amplio espectro en 10,414 niños (0-14 años)con neumonía adquirida en la comunidad en Pensylvania (USA). 41% recibieron amoxicilina, 42,5% macrolidos y 17% antibióticos de amplio espectro. Se trató significativamente más con macrólidos a los mayores de 5 años, si habían recibido previamente otro antibiótico y si tenían seguro privado.

The publication of the Pediatric Infectious Diseases Society/Infectious Diseases Society of America guideline was associated with sustained increases in the use of penicillins for children hospitalized with pneumonia. Local implementation efforts may have enhanced guideline adoption and appeared more relevant than hospitals’ organizational readiness to change.

Question Among children with suspected community acquired pneumonia (CAP), what is the diagnostic accuracy of clinical exam, compared with chest radiography, in diagnosing CAP.

Design Systematic review.

Setting Thirty-five percent of the 23 studies were conducted in the US and Canada.

Participants Children, age less than 5 years old through 21 years old.

Intervention Clinical exam.

Outcomes Infiltrate on chest radiography.

Main Results No single sign or symptom (including auscultation, fever, and tachypnea) was strongly associated with CAP. Most associated with CAP were hypoxemia (≤96%): likelihood ratio (LR), 2.8 (95% CI, 2.1-3.6), and increased work of breathing: LR, 2.1 (95% CI, 1.6-2.7).

Conclusions Clinical signs and symptoms were not strongly associated with CAP diagnosis.

Commentary This systematic review emphasizes the challenges in diagnosing and studying pediatric CAP. Important methodological limitations of this review include substantial heterogeneity, use of a limited reference standard (ie, chest radiography) in defining pneumonia, and moderate strength of evidence, with most studies having an evidence level of 3 out of 5. Although the authors conclude that an oxygen saturation ≤96% and increased work of breathing are most associated with pneumonia, LR's for these signs did not exceed 3. The authors chose to highlight findings with positive LR (LR+) ≥2 or negative LR (LR−) ≤0.5. These values generate small shifts in pretest to posttest probability, whereas LR+ ≥ 5/LR− ≤ 0.2 generate moderate shifts and LR+ ≥ 10/LR− ≤ 0.1 generate large, often conclusive, shifts in pretest to posttest probability.1 None of the findings in this review generated moderate or large shifts from pretest to posttest probabilities. Interestingly, common findings typically thought to be important in the diagnosis of pneumonia (eg, magnitude of hypoxia, tachypnea, rales) were not associated with radiographic pneumonia. A recent meta-analysis of 18 studies of children <5 years had largely similar results, finding that tachypnea, chest indrawing, and grunting were most associated with radiographic pneumonia, but none with a LR+ >2.2 Both reviews conclude that no single clinical feature is sufficient to diagnose pneumonia in children. Neither review evaluated whether combinations of findings increase diagnostic accuracy. These findings suggest that improved methods for diagnosing pneumonia, and perhaps more importantly, which children require antimicrobial therapy, are necessary.

Background: Pneumonia is a major cause of mortality in children. The objective of this study was to construct a prognostic scale for estimation of mortality applicable to children with community-acquired pneumonia (CAP).

Methods: This observational study included patients younger than 15 years with a diagnosis of CAP who were hospitalized between 2004 and 2013. A point-based scoring system based on the modification of the PIRO scale used in adults with pneumonia was applied to each child hospitalized with CAP. It included the following variables: predisposition (age <6 months, comorbidity), insult [hypoxia (O2 saturation < 90), hypotension (according to age) and bacteremia], response (multilobar or complicated pneumonia) and organ dysfunction (kidney failure, liver failure and acute respiratory distress syndrome). One point was given for each feature that was present (range, 0–10 points). The association between the modified PIRO score and mortality was assessed by stratifying patients into 4 levels of risk: low (0–2 points), moderate (3–4 points), high (5–6 points) and very high risk (7–10 points).

Results: Eight hundred sixty children hospitalized with CAP were eligible for study. The mean age was 2.8 ± 3.2 years. The observed mortality was 6.5% (56/860). Mortality ranged from 0% for a low PIRO score (0/708 pts), 18% (20/112 pts) for a moderate score, 83% (25/30 pts) for a high score and 100% (10/10 pts) for a very high modified PIRO score (P < 0.001).

Conclusion: The present score accurately discriminated the probability of death in children hospitalized with CAP, and it could be a useful tool to select candidates for admission to intensive care unit and for adjunctive therapy in clinical trials.

We included 17 studies evaluating systemic corticosteroid therapy (given intravenously or by tablets) for people with pneumonia (2264 participants; 1954 adults and 310 children). We included 12 new studies in this update and excluded one previously included study. All included studies evaluated people who had acquired pneumonia in the community (community-acquired pneumonia (CAP)) being treated in the hospital; no studies assessed people who had developed pneumonia while in hospital or who were on breathing machines (mechanically ventilated).

Corticosteroid therapy reduced mortality and morbidity in adults with severe CAP; the number needed to treat for an additional beneficial outcome was 18 patients (95% CI 12 to 49) to prevent one death. Corticosteroid therapy reduced morbidity, but not mortality, for adults and children with non-severe CAP. Corticosteroid therapy was associated with more adverse events, especially hyperglycaemia, but the harms did not seem to outweigh the benefits.

Actualización en el manejo de la neumonía adquirida en la comunidad en niños sanos, fuera del período neonatal. Resume las recomendaciones de las directrices de la Sociedad Británica de Cirugía Torácica. Directrices internacionales similares, incluidas las de la Organización Mundial de la Salud y la Sociedad de Enfermedades Infecciosas de América, presentan algunas variaciones en el tratamiento, probablemente dependientes de la disponibilidad de fármacos, coste y patrones de resistencia de los antibióticos.

We describe the demographic, clinic and radiologic features of nontuberculous cavitary pulmonary diseases in 42 patients with a mean age of 91.1 ± 6.8 months. Infectious etiology was the most common cause (64%), including necrotizing pneumonia (n = 15), ruptured hydatid cyst (n = 5), lung abscess (n = 5) and fungal infection (n = 2). Other causes were bronchiectasis, congenital anomalies, foreign body aspiration, sarcoidosis and tumor.

Interpretation Current tachypnoea-based algorithms significantly overdiagnose pneumonia in children and underdiagnose wheezy diseases. Diagnostic accuracy can be improved by various combinations of clinical variables, but the best single diagnostic predictor is auscultation. Simple criteria can also be defined that reliably detect which tachypnoeic children are at high risk of death or deterioration. Management plans based on these protocols could reduce unnecessary antibiotic use, improve the management of wheezy diseases and reduce mortality by earlier identification of high-risk children

En niños mayores de 6 meses, el tratamiento de la NAC con 5 días de amoxicilina a 80mg/kg/día en 3 dosis no es inferior a la misma pauta durante 10 días. Un tratamiento corto de 3 días sí que se asocia a mayor tasa de fallos terapéuticos.

We conducted this review to determine if there are any differences in treatment outcomes between short- (two to three days) and long-course (five days) intravenous antibiotics (alone or combined with oral antibiotics) for children aged two months to 59 months with severe pneumonia.

We identified no randomised controlled trials comparing a short course (two to three days) of intravenous antibiotics compared to a long course (five days) for severe pneumonia in children aged two months to 59 months that met our inclusion criteria.

Aunque se trata de un estudio en pacientes hospitalizados, aporta interesantes reflexiones sobre uso racional de antibióticos y resistencias bacterianas.

Our findings suggest that children diagnosed with CAP in the outpatient setting and treated with beta-lactam or macrolide monotherapy have the same likelihood to fail treatment regardless of age.

We examined the association between baseline peripheral white blood cell count and C-reactive protein (CRP) values with outcomes among 153children hospitalized with pneumonia. In multivariable analyses, CRP, but not white blood cell count, was significantly associated with both fever duration and hospital length of stay. For every 1mg/dL increase in CRP, length of stay increased by 1 hour.

Evolution of Streptococcus pneumoniae toward increased fitness in their interaction with host and exaggerated IL-8 expression may be responsible for the increase of necrotizing pneumococcal pneumonia.

Over recent years non-culture techniques such as specific viral and bacterial nucleic acid amplification, serology and antigen detection have considerably developed and been applied within research studies to clinical samples, significantly increasing pathogen detection in pneumonia. There are promising signs of improved diagnostic yields for pneumococcal pneumonia when using molecular techniques to detect pneumococcal gene sequences in blood or by combining serum biomarkers with rapid pneumococcal urinary antigen testing. Pathogens have traditionally been difficult to detect in pneumonia and treatment is usually successful with empiric antibiotics. However, directed antibiotic treatment has significant benefits in terms of antibiotic stewardship and these new technologies make this goal a possibility, though not yet a reality.

A 4-year-old girl attends with a 3-day history of cough, breathlessness and fever. She is started on antibiotics but fails to improve over the subsequent 48 hours. A chest X-ray and ultrasound of the thorax reveals a large, loculated pleural effusion amenable to drainage.

In this trial, DXM seemed to be a safe and effective adjunctive therapy for parapneumonic pleural effusion.

Nuestros resultados coinciden con los de otros estudios recientes que han observado una buena evolución en niños tratados solo con antibióticos y cuestionan la necesidad del drenaje en muchos de los niños que presentan un DPC. Son necesarios ensayos clínicos para identificar las circunstancias en las que se puede obtener un beneficio del drenaje en el DPC.

La Proadrenomedulina y la copeptina son péptidos sintetizados en las células endoteliales y la glándula pituitaria, respectivamente. Estos nuevos biomarcadores parecen útiles para predecir la gravedad y las complicaciones de la neumonía grave en adultos, pero muy pocos estudios han explorado el valor predictivo de estos marcadores en los niños. El objetivo de este estudio fue evaluar la precisión diagnóstica de ambos para predecir complicaciones en una cohorte de niños con neumonía adquirida en la comunidad y tomar la decisión de ingreso o la elección de la vía de administración de los antibióticos.

Neutropenia

Should a 3-year-old immunocompetent child with a fever, upper respiratory tract infection and an incidental finding of moderate neutropenia (patient) be treated for suspected neutropenic sepsis (intervention)? Is neutropenia predictive of serious bacterial infection (SBI) in an immunocompetent child (outcome)?

Background: Mutations within the ELANE gene, which encodes human neutrophil elastase, are the most common genetic causes of severe congenital neutropenia (SCN). No cases of SCN have been previously described from a Chinese population. Herein, we describe the clinical, hematologic and molecular characteristics of 7 Chinese SCN cases with novel ELANE mutations.

Methods: Seven Chinese pediatric patients (4 males and 3 females) with suspected SCN were enrolled in this study. Clinical data, peripheral blood, bone marrow and immune function were evaluated for SCN. ELANE genomic DNA and cDNA sequences from patients and potential carriers were analyzed using polymerase chain reaction (PCR) and direct sequencing.

Results: All the7 patients experienced recurrent infection (soft tissue, lung, oral cavity) during a period of 120 days. Noninfectious conditions such as anemia and osteopenia were found in most patients, and absolute peripheral neutrophil counts varied. DNA and cDNA sequencing demonstrated that the patients harbored a range of heterozygous ELANE gene mutations, including substitution, deletion, insertion and frame shift alterations. All the mutations had not been reported previously; however, no mutation carriers were identified among the parents or siblings, even in a family with 2 affected offspring.

Conclusion: SCN cases were identified for the first time in China, and all patients carried novel ELANE mutations. Granulocyte-colony stimulating factor (G-CSF) was an effective treatment for most of the SCN patients and prevented life-threatening bacterial infections.

Chemokines may play an important role in the pathogenesis of severe neutropenia in patients with primary HHV-6B infection.

Nilo

El virus WN afecta desde 2004 a caballos y aves desde 2004. En 2016 se diagnostican 3 casos confirmados de meningoencefalitis por este virus. Ocurre en periodo estival y en la provincia de Sevilla

Norovirus

NoV causes moderate to severe disease similar to RV in young children. This information should be useful for future evaluations of an eventual introduction of NoV vaccines in national immunization programs.

Los norovirus (NoV) son la causa más frecuente de gastroenteritis aguda en todo el  mundo entre las personas de todas las edades y la principal causa de brotes de enfermedades gastrointestinales en diferentes escenarios. El objetivo del estudio es comprender la situación epidémica del NoV y la distribución de los genotipos, lo que ayudará a determinar la utilidad de futuras vacunas.

The burden of NoV disease in children in the EU is substantial, and will grow in relative importance as rotavirus (RV) vaccines are rolled out in the EU. This burden of disease is comparable with the burden of RV disease in the EU before RV vaccine introduction. More country-specific studies are needed to better assess this burden and guide the potential introduction of a vaccine against NoV at the national level.

Aparte de en gastroenteritis, raramente se ha visto implicado al norovirus en trastornos cutáneos. Presentamos el caso clínico de un lactante de nueve meses de edad que presentó lesiones maculares generalizadas mientras cursaba una gastroenteritis con detección de virus en heces positiva para norovirus.

Orquiepididimitis

We presente a neonatal epididymo-orchitis (EO: 19-day-old male was brought to the Emergency Department with an erythematous and firm swelling of his left scrotum associated with irritability and fever that had begun five hours before. He had been born healthy at 38 weeks of gestational age and prenatal ultrasounds were normal. Clinical examination revealed a firm and erythematous left hemiscrotum. Doppler ultrasound findInge were compatible with bilateral EO, mainly in the left hemiscrotum with a right hydrocele and a left pyocele. Laboratory examinations showed a WBC of 13,700 mm–3 (neutrophils 55%), CRP 132 mg/L and procalcitonin 4.5 ng/mL. Urine and cerebrospinal fluid (CSF) analysis were normal. He was admitted and empirical treatment with intravenous ampicillin and cefotaxime was started. After Escherichia coli was isolated in urine and blood cultures, ampicillin was discontinued. CSF culture was sterile. Renal ultrasound was normal. Fever resolved within 24 h. A new scrotal ultrasound after nine days of treatment showed improvement in inflammatory changes and pyocele resolution. He was discharged after ten days of intravenous cefotaxime. Compared with testicular torsion,the majority of cases of EO present with fever, increased acute phase reactants and increased blood flow.2

Hematogenous spread appears to be the causative mechanism in majority of cases but Direct extension from a urinary tract infection has been described . uropathy can predispose to EO. Testicular involvement is commonly preceded by signs of severe infection and scrotal inflammation usually develops after an initial clinical improvement. The most commonly isolated bacteria was E. coli in five patients. Most of the cases presented suppurative complications (pyoceles and abscesses), which were drained in all cases. In the reviewed cases, blood cultures were usually positive and drainage fluid culture was the only positive sample in 2/11 newborns.

Osteomielitis (ver también Temas A-Z)

Use of the appropriate PCR assays demonstrated that K kingae currently is the major bacterial cause of pediatric osteoarticular infection, especially in children <4 years of age in whom K kingae is more common than S aureus. PCR assays should be used in routine microbiologic laboratory evaluation to improve diagnostic performance. However, despite the use of molecular methods, there are many osteoarticular infections in which no microorganism is detected, which suggests that these infections may be caused by other as yet unrecognized fastidious microorganisms.

A risk prediction model, utilizing information available shortly after hospitalization, allows early identification of children at greatest risk of developing complicated osteomyelitis

El objetivo es determiner la incidencia de infección ósteoarticular en una región de Francia y describir los datos clínicos, de laboratorio y radiológicos.

One of the most common indications for a prolonged course of intravenous (IV) antibiotics in children is osteomyelitis. These children often improve rapidly after the first few days of treatment, and then need to either take up a hospital bed, or return frequently for ambulatory injections, with all the cost and disruption which that implies. There has been a trend towards an earlier switch to oral antibiotics for some time, as advocated in a review in this journal. A large group of researchers in the US set out to compare outcomes in children who received either continuing…

Skull base osteomyelitis is a rare condition in childhood and can be described according to whether it is associated with spread of infection from the middle ear (otogenic) or not (nonotogenic). Early recognition of this serious disease and prompt treatment are key to preventing extension to adjacent vascular and nervous system structures. Diagnosis can be challenging due to the variable presentation of the disease and potentially subtle radiological appearances. We present 2 cases of nonotogenic skull base osteomyelitis in childhood both affecting the clivus and review the 6 casespreviously described. Both children presented with fever, headache and neck stiffness and responded well to medical management alone; detailed imaging was key to making a diagnosis.

Otitis externa (ver TemasA-Z)

  • Images in paediatrics: A child with a painful swollen earArch Dis Child 2016; 101: 859  A previously healthy 2-year-old boy presented to the emergency department with a 1-day history of pain, swelling and redness of his left auricle, which spared his earlobe (figure 1). There was no reported preceding trauma, fever or otorrhea, and no history of otitis media or change in hearing. On examination, there was erythema, oedema and warmth with tenderness on moving the auricle but no fluctuance …

Otitis media aguda (ver también Temas A-Z)

This review includes evidence up to 4 December 2017. We included five randomised controlled trials with a total of 805 children with recurring acutemiddle ear infections. All studies were performed before the introduction of vaccination against pneumococcus, a bacterium that commonly causes ear infections. Surgical removal of the adenoids was not performed in both groups in any of the trials.

Key results

We primarily looked at the difference in the proportion of children who had no further acute middle ear infections at three to six months follow-up (intermediate-term), and who had a persisting perforation (hole) in the ear drum. We also looked at some other outcomes, including the proportion of children who had no further episodes of acute middle ear infection.

Grommets versus active monitoring

We found low-quality evidence that fewer children who were treated with grommets had further episodes of ear infection at six and 12 months follow-up than those managed with active monitoring; three and eight children needed to be treated with grommets to benefit one, respectively. The number of ear infections at six and 12 months follow-up was also lower in the grommets group; the difference was, however, at best modest with around one fewer episode at six months and a less noticeable effect by 12 months (low to very low-quality evidence). Children treated with grommets did not have better quality of life at four or 12 months follow-up (low-quality evidence).

Grommets versus antibiotic prophylaxis

It is uncertain whether or not grommets are more effective than antibiotic prophylaxis; we found very low-quality evidence that fewer children who were treated with grommets had further ear infections at six months than those receiving antibiotic prophylaxis (preventative antibiotics); five children needed to be treated with grommets to benefit one. The number of ear infections at six months, however, did not significantly differ between children treated with grommets and those receiving antibiotic prophylaxis (very-low quality evidence).

Grommets versus placebo drugs

We found very low-quality evidence that fewer children who were treated with grommets had further ear infections at six months than those receiving placebodrugs; three children needed to be treated with grommets to benefit one. The number of ear infections at six months was also lower in the grommets group; the difference was however at best modest with around one fewer episode (very low-quality evidence).

Negative effects of grommets were not systematically reported in the studies. Two studies reported on the number of children with a persistent perforation of the ear drum; this occurred in 0% (0/54) and 4% (3/76) of children receiving grommets, respectively (low-quality evidence).

Quality of evidence

We judged the quality of the evidence on the benefits and harms of placement of grommets in both ears for children with recurring acute middle ear infections to be low to very low due to study limitations (risk of bias) and the small to very small sample sizes of included studies (leading to imprecise effect estimates). This means that the findings of this review should be interpreted with caution since the true effects of grommets in this group of children may be different than the numbers presented.

A 4-year-old boy presents to your clinic with his mother. Mum tells you that his left ear has been discharging for 5 days now and thinks it may be infected. On examining the child’s ear you notice purulent discharge within the left ear canal and a grommet in-situ. You wonder whether oral or topical antibiotics may be appropriate in this case.

Question. In children with tympanostomy tubes (patient) that develop ear discharge, are topical antibiotics (intervention) superior to systemic antibiotics (comparison) when treating otorrhoea (outcome)?

Cost-Effectiveness of Watchful Waiting in Acute Otitis Media. Pediatrics. 2017;139:e20163086.

El empleo apropiado de la actitud expectante para el manejo de la otitis media aguda podría simultáneamente mejorar los resultados de salud y ahorrar costes a la sociedad. En contraposición, los autores interpretan que esta actitud podría suponer un aumento de las visitas, requiriendo educación adicional de los padres y del personal sanitario.

We included two studies involving 252 children with AOM aged from three months to six years receiving hospital ambulatory care who were treated with intramuscular ceftriaxone, and who were then randomised to the corticosteroid group (corticosteroid and corticosteroid plus antihistamine) or the placebo group (antihistamine and double placebo). In one study, children also had a needle aspiration of middle ear fluid. Both studies were at unclear risk of bias for allocation concealment, and unclear to high risk of bias for selective reporting.

One study (N = 179) included pain as an outcome, but we were unable to derive the proportion of children with persistent pain at Day 5 and Day 14. Reduction of overall or specific symptoms was presented as improvement in clinical symptoms and resolution of inflamed tympanic membranes without the need for additional antibiotic treatment: at Day 5 (94% of children in the treatment group (N = 89) versus 89% in the placebo group (N = 90); risk ratio (RR) 1.06, 95% confidence interval (CI) 0.97 to 1.16) and Day 14 (91% versus 87%; RR 1.05, 95% CI 0.95 to 1.17). Low-quality evidence meant that we are uncertain of the effectiveness of corticosteroids for this outcome.

The second study (N = 73) reported a reduction of overall or specific symptoms without additional antibiotic treatment during the first two weeks as a favourable outcome. Children in the treatment group had more favourable outcomes (adjusted odds ratio 65.9, 95% CI 1.28 to 1000; P = 0.037), although the numbers were small. We were unable to pool the results with the other study because it did not report the proportion of children with this outcome by treatment group. Only one study reported adverse effects of corticosteroids (e.g. drowsiness, nappy rash), but did not quantify incidence, so we were unable to draw conclusions about adverse effects. Neither study reported a reduction in overall or specific symptom duration.

Estudio en niños con diferentes casos de OMA de etiología neumocócica, en los que se encontró una alta frecuencia de cepas resistentes a diversos antibióticos. El 73,3% de las cepas neumocócicas aisladas se obtuvieron de pacientes con fracaso del tratamiento y OMA recurrente. El tratamiento con antibióticos, que ocurre en el 80% de las consultas por OMA, se considera un factor de selección de cepas inicialmente no susceptibles, lo que facilitaría la colonización con nuevas cepas o el desarrollo de resistencia durante la terapia.

Concluyen que la alta prevalencia de cepas de S. pneumoniae resistentes a los antibióticos en niños con OMA después de la finalización de la terapia parece confirmar que el fracaso en la erradicación de bacterias puede considerarse como un factor de riesgo de recurrencia de la infección.

Otitis media (OM) poses a high disease burden on Bangladeshi children, but little is known about its etiologies. We conducted a surveillance study in the largest pediatric hospital to characterize pathogens responsible for OM.

In the outpatient ear–nose–throat department of Dhaka Shishu Hospital, which serves 0 to 18-year-old children, we collected ear swabs from OM children with otorrhea from April 2014 to March 2015. We cultured all specimens for bacterial pathogens and assessed serotype and antimicrobial susceptibility ofStreptococcus pneumoniae (Spn) and Haemophilus influenzae (Hi) isolates.

We recorded 1111 OM episodes; 88% (981/1111) involved otorrhea, and we collected samples from 91% (891/981) of these children. Fifty-one percent (452/891) were culture positive (contaminants excluded), with Hi (21%, 187/891) and Spn (18%, 164/891) most commonly detected. Overall, 45 distinct single and mixed pathogens were revealed. Dominant pneumococcal serotypes were 19A, 19F, 3 and 14; 98% of Hi isolates were nontypeable. Pneumococcal conjugate vaccine (PCV)10 and PCV10 + 6A serotypes accounted for 8% and 9% of all OM and 46% and 49% of pneumococcus-positive cases, respectively, and were more likely to be nonsusceptible to at least 1 antibiotic (erythromycin and/or trimethoprim-sulfamethoxazole) than nonvaccine serotypes (91% vs. 77%). Staphylococcus aureus (9%, 83/891) and Pseudomonas aeruginosa (4%, 38/891) were also found.

Nontypeable Hi (NTHi) and Spn are predominant causes of OM in Bangladesh. PCV10, introduced in March 2015, is likely to reduce pneumococcal and overall OM burden. Data collected post-PCV10 will provide comprehensive insight into the effects of this vaccine on these pathogens.

Background: Acute otitis media is a leading cause of childhood morbidity and antibiotic prescriptions. We examined etiologic changes in acute otitis media after introduction of 13-valent pneumococcal conjugate vaccineas routine immunization for Japanese children in 2014. Serotypes, resistance genotypes, antibiotic susceptibilities and multilocus sequence typing of pneumococcal isolates were also characterized.

Methods: Otolaryngologists prospectively collected middle ear fluid from 582 children by tympanocentesis or sampling through a spontaneously ruptured tympanic membrane between June 2016 and January 2017. Causative pathogens were identified by bacterial culture and real-time polymerase chain reaction for bacteria. Serotypes, resistance genotypes, sequence types and susceptibilities to 14 antimicrobial agents were determined for pneumococcal isolates.

Results: At least 1 bacterial pathogen was identified in 473 of the samples (81.3%). Nontypeable Haemophilus influenzae (54.8%) was detected most frequently, followed by Streptococcus pneumoniae (25.4%), Streptococcus pyogenes (2.9%) and others. Pneumococci of current vaccine serotypes have decreased dramatically from 82.1% in 2006 to 18.5% (P < 0.001). Commonest serotypes were 15A (14.8%), 3 (13.9%) and 35B (11.1%). Serotype 3 was significantly less frequent among children receiving 13-valent pneumococcal conjugate vaccine compared with 7-valent pneumococcal conjugate vaccine (P = 0.002). Genotypic penicillin-resistant S. pneumoniaeaccounted for 28.7%, slightly less than in 2006 (34.2%; P = 0.393); the penicillin-resistant serotypes 15A and 35B had increased. Serotypes 15A, 3 and 35B most often belonged to sequence types 63, 180 and 558.

Conclusions: Our findings are expected to assist in development of future vaccines, and they underscore the need for appropriate clinical choice of oral agents based on testing of causative pathogens.

Prevention of acute otitis media (AOM), and especially recurrence and biofilm formation, by pneumococcal conjugate vaccines has been hypothesized to be due to prevention of early episodes triggering the vicious cycle. We tested the specific role of vaccine-type pneumococcal AOM in this hypothesis.

In the phase III randomized, double-blind Finnish otitis media Vaccine Trial conducted in 1995-1999, children received pneumococcal conjugate vaccine 7 or hepatitis B vaccine as control at 2, 4, 6, and 12 months of age and were followed for AOM. Myringotomy with middle ear fluid aspiration was performed in AOM, and samples were cultured. We compared control-vaccinated children with confirmed vaccine-type or 6A-AOM with those with AOM due to other confirmed etiology within 2-6 months of age (early AOM) and followed for subsequent AOM from 6-24 months of age.

Eight hundred thirty-one children were enrolled in the Finnish otitis media control arm. Before 6 months of age, 34 children experienced vaccine-type-AOM, and 40 children experienced AOM of other bacterial etiology. The subsequent AOM incidences were 1.9 (95% CI, 1.5-2.4) and 2.1 (1.7-2.5) in these subgroups, respectively. However, the subsequent incidences were lower if no bacteria were detected at AOM (1.5, 1.2-1.8) or if there was no early AOM (1.1, 1.1-1.2).

Early vaccine-type AOM was not associated with a higher risk of subsequent AOM compared with AOM due to other confirmed bacterial etiology. These data do not support any specific role of vaccine-type pneumococcus in the hypothesis.

Background Clinical practice guidelines focusing on judicious use of antibiotics for childhood acute otitis media (AOM) have been introduced in many countries around the world.

Objective To systematically review the effects of these guidelines on the prescription of antibiotics and analgesics for children with AOM.

Methods Systematic searches of PubMed, Embase and Cochrane Library from inception to 6 June 2017 using broad search terms. Studies specifically aimed at evaluating the effects of introduction of national AOM practice guidelines on type of antibiotic and/or analgesic prescriptions were included, irrespective of design, setting or language. The Risk Of Bias In Non-randomized Studies of Interventions tool was used to assess risk of bias.

Results Of 411 unique records retrieved, seven studies conducted in six different countries (France, Italy, Spain, Sweden, UK and USA (twice)) compared data before and after guideline introduction. All studies had an observational design, using longitudinal data of children aged under 15 years (n=200–4.6 million) from either routine care, insurance databases or electronic surveys. Risk of bias of all studies was judged serious to critical.

Of the five studies reporting on antibiotic prescription rates, three showed a decline of 5%–12% up to 3 years after guideline introduction and two found no or negligible effect. In one US study, the initial 9% decline decreased to 5% after 4–6 years. The recommended first choice antibiotic was prescribed more frequently (9%–58% increase) after guideline introduction in four out of five studies reporting on this outcome. Analgesic prescription rates for AOM were reported in one US study and increased from 14% to 24% after guideline introduction.

Conclusion Based upon what is published, the effects of introduction of national clinical practice guidelines on antibiotic and analgesic prescribing for children with AOM seem modest at the most.

Records of children 6-36 months of age with AOM visiting a university-affiliated pediatric emergency department between 2014 and 2016 were reviewed for the treatment given: watchful waiting versus antibiotics. If antibiotics were prescribed, the type and duration were recorded. We evaluated appropriate and inappropriate treatment rates of eligible AOM cases, in respect to the local guidelines, which encourage watchful waiting in most mild-moderate cases.

Out of 1493 AOM visits, 863 (57.8%) were boys, with a median age of 14.9 months (interquartile range, 9-19). The overall pre-visit antibiotic rate was 24.1%, but among those children examined by a physician, this rate was 95.2%. Amoxicillin was the most common antibiotic, administered in 66.3% of the cases. Only 21 children (5.8%) had been treated with antibiotics for ≥7 days before their visit, and were considered as treatment failure. Antibiotic therapy upon discharge was recorded in 1394/1449 visits (96.2%), again with amoxicillin as the most common antibiotic therapy, in 80.8% of the cases. In these visits, the average duration of antibiotic treatment was 8.29 days. Appropriateness of treatment (watchful waiting or antibiotics) could be analyzed in 1134 visits; 20.9% were considered as inappropriate. Of them, 98.3% were prescribed with the wrong antibiotic type and duration.

Adherence rate to the local guidelines treatment recommendations for uncomplicated AOM was high, as measured by whether appropriate treatment was given and type and duration of antibiotics.

Resumen: en este estudio de cohorte prospectivas de 615 niños cuyos diagnósiticos de otitis se confirmaron por timpanocentesis, se comprueba la evolución en la etiología tras la introducción de las vacunas hepta y tridecavalente (disminuye S.pneumoniae aunque persiste en un buen porcentaje y toma más protagonismo H.Influenzae no encapsulado). Como factores predisponentes se confirman el sexo masculino, la asistencia a guardería y los antecedentes familiares de OMA. LA lactancia materna durante los primeros 6 meses de vida se confirma como factor protector para la OMA

Background: Streptococcus pneumoniae is a common cause of community-acquired alveolar pneumonia (CAAP) and acute otitis media (AOM) in children. Romania has high rates of S. pneumoniae antibiotic resistance. The pneumococcal conjugated vaccines (PCVs) are not being used routinely in this country. The aims of the study were as follows: 1) to compare pneumococcal antibiotic resistance patterns in AOM and CAAP in children from central Romania and 2) to compare differences in the distribution of pneumococcal serotypes isolated from the middle ear fluid (MEF) of children with AOM and from the nasopharynx (NP) of children with CAAP.

Methods: Children younger than 5 years old with AOM or with radiologically confirmed CAAP were prospectively enrolled. Samples from MEF and NP were evaluated for antibiotic susceptibility and serotyping.

Results: Eighty-eight children with CAAP and 68 with AOM were enrolled. Of the MEF and CAAP isolates, 64 (94.1%) and 79 (89.7%) were penicillin nonsusceptible, respectively. The pneumococcal serotypes distribution in AOM was similar to those in CAAP except for serotype 19F, which was more common in AOM. Overall, 89.7% and 85.8% of all serotypes in AOM and CAAP patients, respectively, were covered by 13-valent PCV.

Conclusions: MEF and NP-CAAP S. pneumoniae isolates were similar in regard to serotype distribution and antibiotic resistance. S. pneumoniae antibiotic resistance rates were extremely high. Thirteen-valent PCV has the potential to reduce both the burden of disease as well as the rates of antibiotic-resistant S. pneumoniae in both diseases.

In 177 children living in an area with high 13-valent pneumococcal conjugate vaccine 13 coverage, who had acute otitis media complicated with spontaneous tympanic membrane perforation, Streptococcus pneumoniae was identified in the middle ear fluid of 48 (27.1%) subjects, with 37 (77.1%) cases caused by nonpneumococcal conjugate vaccine 13 serotypes.

Guidelines for AOM from developing and developed countries are similar in many aspects, with variation in specific recommendations, due to local epidemiology and healthcare accessibility. Formulation of regional guidelines may help reduce AOM burden.

Resumen: la menor edad, y el mayor grado de abombamiento de la membrana timpánica fueron los factores que más se asociaron a fallos del tratamiento en la OMA

The association between earlier age of first AOM and recurrent AOM as well as total health care use during childhood is particularly strong before 9 months of age.

  • Most cases of otitis media should not be treated with antibiotics, says NICEBMJ 2017;358:j4398

Una nueva guía del Instituto Nacional para la Excelencia en Salud y Atención expone que la mayoría de los casos de otitis media en niños, pueden ser manejados con paracetamol o ibuprofeno en lugar de antibióticos. La guía, que continua en proyecto, dice que la mayoría de los niños con síntomas tienen menos dolor en 24 horas y que los antibióticos no ayudan. La evidencia demuestra que los antibióticos producen poca diferencia en cuánto al tiempo que duran los síntomas o la proporción de niños cuyos síntomas mejoran. También hay evidencia de que los antibióticos producen poca diferencia en la proporción de niños con infecciones recurrentes, pérdida de audición o perforación del tímpano, mientras que las complicaciones agudas, como la mastoiditis, son poco frecuentes tanto si se administran antibióticos o no. La guía da la opción de una "prescripción en diferido", si los síntomas empeoran o no mejoran después de tres días. www.nice.org.uk/guidance/indevelopment/gidapg10001

In children younger than 2 years of age with acute otitis media and no recent antibiotic exposure, immediate amoxicillin seems to be the most cost-effective initial treatment. The 5 treatment regimens, listed in order from least effective to most effective were DP, watchful waiting, immediate cefdinir, immediate amoxicillin, and immediate amoxicillin/clavulanate. Listed in order from least costly to most costly, the regimens were DP, immediate amoxicillin, watchful waiting, immediate amoxicillin/clavulanate, and immediate cefdinir. The incremental cost-utility ratio of immediate amoxicillin compared with DP was $101.07 per quality-adjusted life-day gained. The incremental cost-utility ratio of immediate amoxicillin/clavulanate compared with amoxicillin was $2331.28 per quality-adjusted life-day gained.

In this volume of The Journal, Shaikh et al1 report “bang for the buck” rankings for 5 management options for acute otitis media (AOM). Two aspects should interest readers: (1) “cost-utility analysis,” a complex but increasingly used method to judge whether the balance between benefits and adverse events justify the overall socioeconomic and treatment costs, and (2) confirmation of AOM guideline recommendations based on decades of increasingly rigorous science.

This review summarizes a prospective, longitudinal 10-year study in Rochester, NY, with virtually every clinically diagnosed acute otitis media (AOM) confirmed by bacterial culture of middle ear fluid. Children experiencing 3 episodes within 6 months or 4 episodes in 12 months were considered stringently defined otitis prone (sOP). We found stringent diagnosis compared with clinical diagnosis reduced the frequency of children meeting the OP definition from 27% to 6% resulting in 14.8% and 2.4% receiving tympanostomy tubes, respectively. Significantly more often respiratory syncytial virus infection led to AOM in sOP than non-otitis-prone children that correlated with diminished total respiratory syncytial virus-specific serum IgG. sOP children produced low levels of antibody to Streptococcus pneumoniae and Haemophilus influenzae candidate vaccine protein antigens and to routine pediatric vaccines. sOP children generated significantly fewer memory B cells, functional and memory T cells to otopathogens following nasopharyngeal colonization and AOM than non-otitis-prone children and they had defects in antigen-presenting cells.

Establecen 3 periodos (pre PCV, PCV7 y PCV13). Comparan la incidencia de neumococos, Hi no tipables, Moraxella catarrhalis, Streptococcus pyogenes, y cultivos negativos

CONCLUSIONES:

Los episodios de OMA descienden substancialmente tanto en las formas neumocócicas como en las no neumocócicas, después de la introducción de la PCV7 PCV13. La reducción en las formas no neumocócicas podría explicarse a la prevención en las formas tempranas.

Maternal use of antibiotics during pregnancy is associated with an increased risk of otitis media and VT insertions in the offspring. Antibiotics late in pregnancy mainly contributed to these effects, pointing toward potential transmission of an unfavorable microbiome from mother to child.

We reviewed the evidence about the effectiveness and safety of xylitol to prevent acute middle ear infection (acute otitis media; AOM) in children up to 12 years old. We identified five clinical trials that involved 3405 children, mostly from the same research group. Four trials were conducted in Finland and enrolled healthy children (three trials) or children with an acute respiratory infection (one trial). The fifth trial was conducted in the USA and enrolled otitis-prone children who were recruited from attendance at general medical practices.

Xylitol, administered in chewing gum, lozenges or syrup, can reduce the occurrence of AOM among healthy children with no acute upper respiratory infection from 30% to 22%.There is moderate quality evidence showing that the prophylactic administration of xylitol among healthy children attending daycare centres can reduce the occurrence of AOM. There is inconclusive evidence with regard to the efficacy of xylitol in preventing AOM among children with respiratory infection, or among otitis-prone children. The meta-analysis was limited because data came from a small number of studies, and most were from the same research group.

Se revisan 10 ensayos clínicos controlados y randomizados, en los que se compara la incidencia de OMA en los vacunados frente al virus influenza frente los no vacunados o que reciben placebo. Incluyen pacientes de edades comprendidas entre los 6 meses y 6 años. Encuentran una pequeña reducción en la incidencia de OMA en los vacunados (4%) y una disminución en la prescripción de antibióticos en los vacunados de un 15%.La vacuna no está justificada según los datos actuales en la prevención de OMA.

S. pneumoniae, the leading bacterial AOM pathogen in Moscow children, is characterized by a substantial rate of antibiotic nonsusceptibility and clonality. A polysaccharide conjugate vaccine with expanded coverage seems to fit the current AOM pneumococcal serotype distribution in Russia better.

First-year day care attendance is a major risk factor for AOM symptom episodes among infants in the community. This adjusted effect estimate is higher than previously reported and is age-dependent. AOM prevention strategies in day care facilities should therefore focus in particular on the youngest age groups.

Spn and Hflu remain the leading otopathogens in all populations examined. While associated with overlapping symptoms and severity, they exhibit some differences in their likelihood to cause disease in specific subpopulations.

We estimated the MID for change in AOM-SOS scores in young children and described use of the MID as an added metric in interpreting results from a clinical trial of antibiotic efficacy.

High-throughput, quantitative polymerase chain reaction assays were used to detect 13 common respiratory viruses from nasopharyngeal specimens collected during 2028 visits from 362 infants followed from near birth up to 12 months of age. Specimens were collected at monthly interval (months 1–6 and month 9) and during upper respiratory tract infection (URTI) episodes. Subjects were followed closely for acute otitis media (AOM) development.

Conclusions. Compared to symptomatic infection, asymptomatic viral infection in infants is associated with young age, male sex, low viral load, specific viruses, and single virus detection. Asymptomatic viral infection did not result in AOM.

In summary, this large study of asymptomatic respiratory viral infections in the first year of life showed rhinovirus to be the most commonly detected virus. Asymptomatic viral infection was more common in young infants and did not lead to AOM development.

Los autores analizan si los cultivos nasofaríngeos recogidos en las visitas de niño sano o al inicio de otitis media aguda (OMA) podrían predecir los otopatógenos y su susceptibilidad a los antibióticos de los cultivos del líquido del oído medio obtenido por timpanocentesis. Observan una mayor correlación de los cultivos nasofaríngeos al inicio de la OMA, pero esta es demasiado baja para poder recomendarlos como sustituto del cultivo del líquido del oído medio, considerado el patrón oro.

En Israel la vacuna conjugada 7V se introdujo en el calendario vacunal nacional en Julio de 2009 y fue cambiándose progresivamente en Noviembre de 2010 por la 13V. El objetivo es fue estimar la influencia de esta medida sobre las OMAs neumocócicas y sobre el total de las OMAs  en las que se realizó cultivo. Reducción muy importante  (85-96%) de los serotipos de neumococo incluidos en la vacuna 13V como causa de otitis media. Incremento no significativo de los serotipos no vacunales. Reducción del 77% de la incidencia de las OMA producidas por neumococo y un 60% en el total.

Expansion of contents of pneumococcal vaccine administered to children is followed by not-fully-predictable changes in nasopharyngeal pneumococcal colonization. Continued surveillance is required to help inform future vaccine development.

This review reveals that antibiotics have no early effect on pain, a slight effect on pain in the days following and only a modest effect on the number of children with tympanic perforations, contralateral otitis episodes and abnormal tympanometry findings at two to four weeks and at six to eight weeks compared with placebo in children with AOM. In high-income countries, most cases of AOM spontaneously remit without complications. The benefits of antibiotics must be weighed against the possible harms: for every 14 children treated with antibiotics one child experienced an adverse event (such as vomiting, diarrhoea or rash) that would not have occurred if antibiotics were withheld. Therefore clinical management should emphasise advice about adequate analgesia and the limited role for antibiotics. Antibiotics are most useful in children under two years of age with bilateral AOM, or with both AOM and otorrhoea. For most other children with mild disease in high-income countries, an expectant observational approach seems justified.

Estas conclusiones son tomadas después de revisar 13 ensayos clínicos controlados, que incluyen en total más de 3000 pacientes con sus correspondientes OMAs en los que se compara tto atb vs placebo o vs actitud expectante

Lo mejor…no parece haber más complicaciones en el grupo de los no tratados aunque no se afirma este hecho con rotundidad.

S. pneumoniae was a leading cause for AOM in children in Suzhou, China. Antibiotics resistance rates of S. pneumoniae were high and mainly due to the spread of CC271 clonal complex.

Antibiotic-glucocorticoid eardrops are clinically superior and cost less than oral antibiotics and initial observation in children with tympanostomy tubes who develop otorrhea

Resumen: El tratamiento antibiótico tópico se mostró eficaz en la otitis media supurada en niños con miringotomía y drenajes en un ECA de alta calidad. Sin embargo actualmente no existe suficiente evidencia para aconsejar el uso de antibióticos tópicos en niños con otitis media aguda supurada causada por perforación espontánea del tímpano.

Otitis media crónica

Otitis serosa (ver TemasA-Z)

This review presents evidence of both benefits and harms associated with the use of oral antibiotics to treat children up to 16 years with OME. Although evidence indicates that oral antibiotics are associated with an increased chance of complete resolution of OME at various time points, we also found evidence that these children are more likely to experience diarrhoea, vomiting or skin rash. The impact of antibiotics on short-term hearing is uncertain and low quality evidence did not show that oral antibiotics were associated with fewer ventilation tube insertions. Furthermore, we found no data on the impact of antibiotics on other important outcomes such as speech, language and cognitive development or quality of life.

Even in situations where clear and relevant benefits of oral antibiotics have been demonstrated, these must always be carefully balanced against adverse effects and the emergence of bacterial resistance. This has specifically been linked to the widespread use of antibiotics for common conditions such as otitis media.

PANDAS

The sudden onset of new neuropsychiatric symptoms in children is often a challenge for both parents and physicians. For the physician, there is a broad differential diagnosis to consider, and decisions must be made about the selection of diagnostic studies as well as the choice of therapy.1 In addition, there is often a belief that, even without a documented etiology, an immediate pharmacologic treatment targeted toward an undiagnosed biological etiology will prevent worsening symptoms or permanent sequelae. Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection (PANDAS)2 and Pediatric Acute-onset Neuropsychiatric Syndrome (PANS)3 are 2 entities that have received much attention in recent years, with claims that 1% of children may be affected.4 PANDAS was initially proposed 2 decades ago as a poststreptococcal autoimmune condition similar to Sydenham chorea, whereas PANS is a broader diagnosis without a single defined etiology or mechanism. In this commentary, we review updated information on PANDAS and PANS clinical symptoms, presumed etiologic associations, proposed autoimmune mechanisms, diagnostic testing, and recommended treatments. Our goal is to provide current information that will permit a clear and balanced approach when dealing with these controversial diagnoses.

Los trastornos neuropsiquiátricos son entidades clínicas difíciles de identificar y manejar en la población infantil. Alteraciones conductuales en el niño pueden ser vistas en contextos clínicos diversos y atribuirse a diferentes causas.

Son procesos conocidos para el pediatra de Atención Primaria el trastorno de hiperactividad con déficit de atención y el trastorno obsesivo compulsivo (TOC), pero existen otros cuadros menos frecuentes, como el que se describe. El paciente presenta una alteración compatible con lo que se ha definido como síndrome neuropsiquiátrico autoinmune pediátrico asociado a la infección por estreptococo o pediatric autoimmune neuropsychiatric disorders associated with streptococccal infections (PANDAS).

En el artículo se revisa esta entidad clínica. En la práctica hay pacientes con sintomatología superponible al PANDAS en los que no se demuestra la etiología autoinmune ni la infección por estreptococo. Para incluirlos se ha descrito un cuadro clínico denominado: trastorno neuropsiquiátrico agudo en la infancia y adolescencia o pediatric acute onset neuropsychiatric syndrome (PANS).

Parásitos (ver entidades individuales y Temas A-Z)

La malaria es potencialmente mortal y precisa un diagnóstico y un tratamiento urgentes. En zonas endémicas se está reduciendo su incidencia y mortalidad. La clínica es inespecífica, por lo que en malarias importadas es vital el antecedente de estancia en una zona malárica. La terapia de elección en Plasmodium falciparum son los tratamientos combinados con artemisininas, la cloroquina en la mayoría de los no P. falciparum y el artesunato intravenoso si existen criterios de gravedad.

Las infecciones humanas por protozoos intestinales son de distribución mundial, con una alta morbimortalidad global. Producen diarrea y a veces enfermedad invasiva, aunque la mayoría son asintomáticas. En nuestro medio, las poblaciones de mayor riesgo son los niños —incluyendo adoptados en el extranjero—, inmunodeprimidos, viajeros, inmigrantes y personas en contacto con animales o que practican sexo oral-anal. El examen microscópico diagnóstico tiene baja sensibilidad, mejorando con métodos de detección de antígenos o moleculares. Recientemente están apareciendo resistencias a los antiparasitarios.

Chagas disease, leishmaniasis, onchocerciasis and lymphatic filariasis are all vectorborne neglected tropical diseases (NTDs) that are responsible for significant disease burden in impoverished children and adults worldwide. As vectorborne parasitic diseases, they can all be targeted for elimination through vector control strategies. Examples of successful vector control programmes for these diseases over the past two decades have included the Southern Cone Initiative against Chagas disease, the Kala-azar Control Scheme against leishmaniasis, the Onchocerciasis Control Programme and the lymphatic filariasis control programme in The Gambia. A common vector control component in all of these programmes is the use of adulticides including dichlorodiphenyltrichloroethane and newer synthetic pyrethroid insecticides against the insect vectors of disease. Household spraying has been used against Chagas disease and leishmaniasis, and insecticide-treated bed nets have helped prevent leishmaniasis and lymphatic filariasis. Recent trends in vector control focus on collaborations between programmes and sectors to achieve integrated vector management that addresses the holistic vector control needs of a community rather than approaching it on a disease-by-disease basis, with the goals of increased efficacy, sustainability and cost-effectiveness. As evidence of vector resistance to currently used insecticide regimens emerges, research to develop new and improved insecticides and novel control strategies will be critical in reducing disease burden. In the quest to eliminate these vectorborne NTDs, efforts need to be made to continue existing control programmes, further implement integrated vector control strategies and stimulate research into new insecticides and control methods.

Parechovirus

Introducción: Los parechovirus humanos (HPeV) son virus de la familia Picornaviridae, a los que se atribuyen cuadros de fiebre sin foco (FSF), sepsis clínica, gastroenteritis, meningitis o encefalitis fundamentalmente en lactantes pequeños.
métodos: Estudio multicéntrico prospectivo, llevado a cabo en 12 hospitales a nivel nacional, entre 2013-2015, en niños<3 años con FSF, sepsis clínica o patología neurológica. Se realizó determinación de HPeV mediante RT-PCR en suero, heces o LCR.
Resultados:Se analizan 47 infecciones por HPeV de un total de 850 muestras, siendo HPeV-3 el más frecuente , con predominio en mayo y julio, con una distribución bienal. El 57% eran neonatos y solo 2>3 meses. Todos los pacientes presentaron fiebre, el 45% irritabilidad, el 18,6% exantema y el 14% diarrea. No se observa ninguna alteración específica en las pruebas bioquímicas. El diagnóstico final más frecuente fue FSF (61%) seguido de sepsis clínica (29%). Aunque un 29% de los niños precisaron ingreso en cuidados intensivos, solo un paciente presentó secuelas.
Conclusiones: Los HPeV circulan en nuestro país, afectando fundamentalmente a lactantes < 2 meses y se asocian a FSF y sepsis clínica, con un predominio en primavera y verano. Sería de interés implementar las técnicas moleculares de diagnóstico en todos los hospitales.

HPeV is an important cause of febrile illness in infants and can have severe clinical presentations. Early diagnosis may help reduce antimicrobial use, unnecessary investigations and prolonged hospitalisation. While prognosis remains favourable, some infants will develop long-term complications-paediatricians should ensure appropriate follow-up after discharge.

Aunque los HPeV están asociados a diarrea, fiebre neonatal y enfermedades del SNC, la mayoría son infecciones asintomáticas5. En muchos casos, los niños asocian un exantema eritematoso al inicio o evolución del cuadro infeccioso6. En el periodo neonatal, no obstante, puede producirse, como ocurrió en nuestro caso, síndrome sepsis-like e incluso afectación aguda a nivel de SNC

Conclusions: We found an HPeV infection rate of 13% in infants being tested for late onset sepsis. HPeV should be considered as a possible cause of sepsis-like symptoms in preterm infants.

 Los síntomas observados en niños con infección por el Parechovirus Humano,varían ampliamente desde infecciones gastrointestinales leves o asintomáticas hasta infecciones más severas del sistema nervioso central o cuadros sepsis-like. Muchas de estas asociaciones son, sin embargo, sólo sugestivas. En este estudio, se examina la relación entre Parechovirus Humano y otitis media aguda, infecciones respiratorias de vías bajas e infecciones del sistema nervioso central.

One-month-old infant was admitted to the paediatric unit with high fever (38.5°C) and irritability. He was otherwise healthy and born at term. His parents reported contact with a cousin with high fever. The physical examination was unremarkable except for tense fontanelle. Suspecting infection, an antibiotic (amoxicillin) and antiviral (ganciclovir) therapies were started. However, the blood count, the C-reactive protein and the cerebrospinal fluid analysis were normal,

Parotiditis (Ver Temas A-Z)

El comité asesor de vacunas de USA tras los brotes de paperas que han ocurrido en los estados unidos desde 2015 recomienda la administración de una tercera dosis de triple vírica para la población que este en riesgo de contraer paperas durante un brote de la enfermedad.

Esta población la definirían las autoridades de salud pública y serían los residentes en instituciones cerradas incluidos universidades, colegios y comunidades cerradas. La tercera dosis no esta recomendada para la población general. Recomendación de octubre 2017

El objetivo final es mejorar la protección contra la enfermedad y contra sus posibles complicaciones en la población expuesta durante un brote epidémico.

  • Influenza-Associated Parotitis During the 2014–2015 Influenza Season in the United States, ClinicalInfectiousDiseases, Volume 67, Issue 4, 1 August 2018, Pages 485–492, https://doi.org/10.1093/cid/ciy136

Duringthe 2014–2015 influenza season in theUnitedStates, 256 cases of influenza-associatedparotitiswerereportedfrom 27 states. Weconducted a case-control study and laboratoryinvestigation to further describe thisrareclinicalmanifestation of influenza.

Methods

DuringFebruary 2015–April 2015, weinterviewed 50 cases (withparotitis) and 124 illcontrols (withoutparotitis) withlaboratory-confirmed influenza; participantsresided in 11 states and werematchedbyage, state, hospital admission status, and specimencollection date. Influenza viruseswerecharacterizedusing real-time polymerasechainreaction and next-generationsequencing. Wecompared cases and controlsusingconditionallogisticregression. Specimensfromadditionalreported cases werealsoanalyzed.

Results

Cases, 73% of whomwereaged<20 years, experiencedpainful (86%), unilateral (68%) parotitis a median of 4 (range, 0–16) daysafteronset of systemicorrespiratorysymptoms. Cases were more likelythancontrols to be male (76% vs 51%; P = .005). Wedetected influenza A(H3N2) viruses, geneticgroup 3C.2a, in 100% (32/32) of case and 92% (105/108) of control specimenssequenced (P = .22). Influenza B and A(H3N2) 3C.3 and 3C.3b geneticgroup virus infectionsweredetected in specimensfromadditional cases.

Conclusions

Influenza-associatedparotitis, as reportedhere and in prior sporadic case reports, seems to occurprimarilywith influenza A(H3N2) virus infection. Because of thedifferentclinical and infection control considerationsformumps and influenza virus infections, werecommendcliniciansconsider influenza in thedifferentialdiagnosesamongpatientswithacuteparotitisduringthe influenza season.

El estudio del brote ha determinado el virus de la parotiditis genotipo G1 como agente causal. La detección precoz y el aislamiento, incluso para casos vacunados con resultados IgM negativos, son fundamentales para prevenir casos en el ámbito escolar. Los datos del estudio de cohortes descartan como determinantes del brote los fallos vacunales prevenibles relacionados con la fabricación, refrigeración o manipulación. La estimación puntual de la efectividad vacunal se encuentra por debajo de lo esperado.

A 6-day-old boy presented with restlessness and swelling of the right pre-auricular area. The patient was born by spontaneous vaginal delivery after a full-term gestation with birth weight of 3805 g. On examination, vital signs and weight were normal, and his temperature was 37.5°C. He had a firm, erythematous, and tender swelling of the right pre-auricular area that extended to the angle of the mandible. Purulent material was expressed

Parvovirus (ver también Temas A-Z)

Resumen: La principal manifestación de la primoinfección por parvovirus B19 suele ser el eritema infeccioso, leve y de resolución espontánea. En ocasiones puede presentarse de forma atípica, con artropatía, citopenias o distrés respiratorio, y conlleva un difícil diagnóstico. Describen un caso de una niña de un mes y medio con edema agudo de pulmón y otra de 11 años con fiebre de 13 días de evolución y trombopenia. En ambas se resolvió sin complicaciones

A 2-year-old boy was admitted to the emergency department with acute swelling of both lower extremities. Two weeks prior, he had a fever of a duration of 3 days, which was followed by erythema on the cheeks and extremities. Physical examination revealed edematous erythema on both lower extremities with small vesicles, dominant on the left leg (Figure, A). Laboratory data showed a total white blood cell count of 8.2 × 109 /L and a C-reactive protein level of 3.2 mg/L. Initially, the patient received intravenous cefazolin for suspected bacterial cellulitis. However, the erythema and edema of the left leg progressed and multiple bullae developed 2 days after admission (Figure, B). The bullae spontaneously ruptured and resolved within 1 week (Figure, C). The lesions spared the palms and soles. Parvovirus B19 infection was suspected from his clinical course, and parvovirus B19 IgM on the day of admission was positive. Parvovirus B19 DNA was detected by real-time polymerase chain reaction from the swab specimen of fluid obtained from the bullae. The patient recovered without complications and had no further episodes within 1 year of follow-up.

A 4-year-old girl was referred for an evaluation of a 2-week history of swelling and pain localized on the lower leg associated with a slightly reticular erythematous rash (Figure, A and B). One week previously, she presented with the clinical signs typical of erythema infectiosum, with a red rash on her face, which spread down to the trunk, arms, and legs, without any further symptoms or fever. The rash began to resolve gradually with a reticular appearance. The swelling and pain started during the disappearance of the reticular macular rash.

PVB19 can cause a devastating myocarditis in children. Children with fulminant myocarditis, ST segment changes or a short prodrome have the worst outcome. Transplantation may be considered, but is rarely required in the acute period if mechanical circulatory support is utilised. If the initial presentation is survived, recovery of the myocardium can occur even in those who had fulminant myocarditis.

PCR (ver Marcadores)

Petequias

  • The “Petechiae in children” (PiC) study: evaluatingpotentialclinicaldecision rules forthemanagement of feverishchildrenwith non-blanchingrashes, includingthe role of point of caretestingforProcalcitonin&Neisseriameningitidis DNA – a studyprotocol. BMC Pediatrics 2018;18:246

Los niños que se presentan en los Departamentos de Emergencia (DE) con una erupción que no desaparece en el contexto de una enfermedad febril, si bien la mayoría tiene una enfermedad viral autolimitada, esta combinación de características representa potencialmente una infección bacteriana grave invasiva, incluida la septicemia meningocócica. La escasez de pruebas diagnósticas definitivas crea incertidumbre diagnóstica para los médicos; Un enfoque seguro exige que los niños sin enfermedad invasora a menudo sean admitidos y tratados con antibióticos de amplio espectro. Por el contrario, una cohorte de niños todavía experimenta una mortalidad y morbilidad significativas debido a un diagnóstico tardío. El tratamiento actual se basa en evidencia que es anterior a (i) la introducción de vacunas meningocócicas B y C y (ii) disponibilidad de pruebas como laprocalcitonina (PCT) y PCR de Neisseriameningitidis.

El estudioPiC proporcionará información importante para los responsables de políticas con respecto al valor de pruebas como la PCT o detección de ADN bacteriano y sobre la utilidad y el costo de las estrategias de diagnóstico emergentes. El estudio también identificará qué elementos de las GPC existentes pueden merecer la inclusión en cualquier estudio futuro para elaborar las reglas de decisión clínica para esta población.

PFAPA (ver también Temas A-Z)

El síndrome de fiebre periódica, estomatitis aftosa, faringitis y adenitis cervical (PFAPA) es el tipo más común de fiebre recurrente en la infancia. Fue descrita en 1987 por Marshall et al.1, y se caracteriza por episodios de fiebre de 3-6 días de duración, que se repiten a intervalos regulares cada 3-8 semanas. Generalmente se inicia antes de los 5 años y remite, sin secuelas, entre los 9-11 años, con un pronóstico final excelente. Se diagnostica en función de una serie de criterios clínicos que se recogen en la tabla 12.

We reviewed the medical records of patients with periodic fever, aphthosis, pharyngitis, and adenitis (PFAPA) to investigate the clinical course, treatment response, and association with MEFV gene mutation. Familial Mediterranean fever should be considered in patients with PFAPA who do not respond to adenotonsillectomy.

Tonsillectomy was an effective treatment for patients with regularly recurring fever episodes who failed to meet the classic Thomas criteria. We suggest that PFAPA syndrome should be suspected and tonsillectomy considered in children with a late onset of symptoms (>5 years of age) or when fever is the only symptom during the episodes.

Resumen: cierto porcentaje de casos de PFAPA parecen ser familiares, lo que sugiere una predisposición genética hereditaria y/o factores ambientales implicados. En padres y hermanos de pacientes con PFAPA hay mayor prevalencia de faringitis recurrentes y estomatitis aftosas que en controles, lo que sugiere que pueda haber diferentes fenotipos de PFAPA con penetrancia variable.

Picadura

A boy aged 8 years presented with recurrent erythematous streaks on the anterior chest.

The first episode occurred in spring with a pruritic linear eruption on the left side after an insect bite at night. The lesion extended from the area of the bite towards the left axillary fold (figure 1A). He was in excellent general condition …

Pielonefritis (ver también ITU en Temas A-Z)

El 44% de las gammagrafías-DMSA de pacientes de uno a 36 meses hospitalizados por PNFA desarrolla cicatrices renales a los 6 meses. Estas se relacionaron con las recurrencias y el RVU grave, pero no con la bacteriología y los reactantes inflamatorios.

Valoran el papel de PCT, PCR y VSG para diferenciar PNA vs cistitis, con el fin de evitar la realización de DMSA en fase aguda. Se recopilan 6 estudios con la PCT, 13 para la PCR y 6 para la VSG. Se concluye que la VSG no es un buen marcador; la PCR puede ayudar a descartar PNA si es inferior a 20 mg/L. El mejor marcador de PNA es la PCT, si bien el escaso número de estudios y la hetoregenicidad de los mismos no permite que se puedan sacar conclusiones firmes.

Piojos (ver también Temas A-Z)

La pediculosis capitis es la infestación pediátrica más frecuente. Generalmente se considera una infestación banal y no se comentan las posibles complicaciones clínicamente relevantes. Se presenta el caso de una adolescente con historia de astenia, anemia moderada, importante adenopatía cervical y eosinofilia, finalmente achacada a la infestación por el parásito, no sospechada de entrada.

Piomiositis

Se presenta el caso de un niño de ocho años que desarrolla una piomiositis de los músculos obturador interno y externo, coincidiendo con una faringoamigdalitis estreptocócica. Inicialmente presenta solo dolor en miembro inferior izquierdo, siendo diagnosticado de contractura del bíceps femoral. Pocos días más tarde comienza con odinofagia, exantema cutáneo escarlatiniforme, fiebre y exudado amigdalar. Llama la atención la persistencia de dolor intenso en la pierna izquierda, dolor lumbar bajo y signo de Lassègue positivo, por lo que se realiza una resonancia magnética en la que se observa la piomiositis. Se realiza una revisión de los casos de piomiositis descritos recientemente, observándose un aumento de la incidencia en nuestro entorno. Se compara la clínica con dichos casos para intentar identificar signos clínicos que puedan ayudar a un diagnóstico precoz del proceso.

Pitiriasis versicolor

Caso clínico de interés por lo atípico e infrecuente de su presentación.

Polio (Ver Temas A-Z)

CDC y OMS notifican la interrupción de la transmisión del virus de la polio 3 y esto hace suponer que este virus ha sido erradicado. Sin embargo no se puede considerar formalmente erradicado hasta que hayan pasado tres años desde el último aislamiento.

A pesar de que para la OMS la polio debería haber sido erradicada en el año 2000 –gracias a la vacunación y a los recursos institucionales, públicos y privados, destinados a tal fin– en 2013 la enfermedad siguió siendo endémica en tres países, Afganistán, Pakistán y Nigeria y se describieron casos en otros cinco. La circulación de poliovirus tipo 1 salvaje en Israel, Gaza y Cisjordania y los casos de Siria fueron una llamada de atención, como en su momento lo fueron los virus derivados de la vacuna oral que siguen siendo un problema. Los viajes «desde» y «a» zonas endémicas son un factor a tener en cuenta en la exportación de los virus y su difusión cuando llegan a zonas con carencias vacunales. Los conflictos bélicos, las persecuciones, la intolerancia, la incultura y la proliferación de grupos y movimientos «antivacunación» son en gran parte la causa de la ausencia y del abandono de la vacunación. En 2014 la situación se ha complicado, tanto que el Comité de Emergencias de la OMS se reunió en mayo para abordar el problema. Es necesario conocer la enfermedad y su agente causal, en el primer caso porque habrá que pensar en ella a la hora de hacer un diagnóstico diferencial de la parálisis flácida y seguir vacunando y en el segundo porque será imprescindible seguir buscando en muestras ambientales el virus de la polio, del que se desconocen muchos aspectos, pues es un modelo para el estudio de otros muchos virus.

En este artículo se describen dos casos de polio en un niño de 4 años y otro de 10 meses, por el virus vacunal tipo 1 en Ucrania. La Organización Mundial de la Salud ha advertido que este brote es probable que se propague debido a las bajas coberturas vacunales en la población infantil de este país, aunque considera que la probabilidad de propagación internacional es baja.

Polio vacuna

Resumen: En este trabajo se expone la estrategia a seguir para el cese de la administración de la vacuna oral de la polio y sustitución por la vacuna inyectable. Por un lado representa la única forma de eliminar los riesgos asociados al uso de la OPV, pero a su vez, está asociada a diversos retos y riesgos. En zonas con coberturas muy bajas se requerirán dosis adicionales de OPV por medio de estrategias intensivas de inmunización antes de la interrupción y sustitución de la misma.

Prescripción

This is the first study to systematically look at drug use in children in France. Over a 1 year period, 84% of French children had a prescription for at least one drug; drug use was age-dependent, with 97% of children under the age of 2 years having at least one prescription and with the rate of drug use declining significantly with age. The median number of drugs prescribed per child over this year was 5.

Background and objective To provide an overview of drug use in outpatient children in France, a population-based study using a national reimbursement claims database representative of 90% of the French population was conducted.

Design Cross-sectional study performed between January and December 2011 using the EGB database (Echantillon Généraliste de Bénéficiaires), a 1/97th sample of the national healthcare insurance system beneficiaries. Drug use in children <18 years old was estimated through reimbursements for prescribed drugs excluding vaccines. Prevalences of use were calculated for different levels of the Anatomical Therapeutic Chemical classification by considering as users children who had at least one reimbursement during the study period.

Results In 2011, 133 800 children were included in the study. The overall prevalence of drug use was 84% and the median number of different drugs per child was 5. Drug use was greatest in children aged <2 years. The most widely used drugs were paracetamol, systemic anti-infectives, nasal corticosteroids and decongestants, and anti-histamines. 21% children <2 years received domperidone.

Conclusions There is widespread use of medicines that are unlikely to be effective and may have significant toxicity in French children. Irrational use of medicines appears to be greatest in children aged 5 years and under.

Probióticos (ver también Temas A-Z)

The aim of this study was to examine effectiveness of oral probiotic Streptococcus salivarius K12 in preventing group A streptococcus pharyngitis in 5- to 14-year-old children at high risk of acute rheumatic fever. New Zealand has high rates of acute rheumatic fever among Māori and Pacific children. Children were already enrolled in a school-based Ministry of Health throat swabbing and treatment program. Children self-identified and reported sore throats daily and were swabbed twice weekly.

A total of 1314 children were quasirandomized (based on odd or even birthdates) to receive either K12 (2.5 × 10 9 cfu per lozenge) or placebo lozenges and continued observed daily treatment (in the school week, during school time) for one school year.

A total of 801 children (61.0%) reported a sore throat on one or more occasions resulting in 2927 pharyngeal swabs. Of these swabs, 1525 (52.1%) were taken from 411 children receiving K12 and 119 (7.8%) of these were positive for group A streptococcus on routine culture. In addition, 1402 (47.8%) swabs were taken from 390 children receiving placebo and 124 (8.8%) were positive. Overall there was a nonsignificant 11.2% relative reduction in positive swabs among children receiving K12. This relative reduction was greater for older children, 7–9 years of age, 15.6%, and for children 10 years and older, 30.2%.

S. salivarius K12 had modest nonsignificant effects on culture-positive sore throats when given at school, during the school day. Based on our pragmatic trial, the routine use of this probiotic in the prevention of pharyngitis associated with GAS detection is not supported.

Probiotics can be defined as “live microorganisms that, when administered in adequate amounts, confer a health benefit on the host.”1 They are marketed either as food supplements, typically added to yogurt or to infant formula, or as pharmaceuticals. Components of probiotics consist of single or multiple strains of bacteria (often Lactobacillus or Bifidobacterium species) or fungi (often Saccharomyces boulardii). These strains are usually of human origin1 and are very rarely pathogenic, even in the immunocompromised host. The organisms in probiotics do not always survive storage. Although they would no longer qualify as “probiotics,” some believe that even nonviable microorganisms may still confer benefit.1 The limitation of interpreting and comparing the results of studies of probiotics is that efficacy may vary depending upon the strain(s) present, the quantity of live and dead organism(s), the other ingredients present, the method of manufacture, the lot chosen and the storage conditions. There is a hypothesis that probiotics may decrease the incidence or severity of respiratory tract infections (RTIs) in adults and children.2

No beneficial effect of LP299V compared with placebo was observed for the incidence of loose/watery stools, mean number of loose/watery stools, or the incidence of abdominal symptoms. LP299V had a satisfactory safety profile.

The health benefits of probiotics have been the subject of extensive research. Still, some questions are being repeatedly asked: should one use or not use probiotics? If yes, how and when should probiotics be used? The purpose of this review is to summarise current evidence on specific probiotics’ efficacy and safety to help healthcare professionals make evidence-based decisions on the indications for using specific probiotic strains or combinations in children. To identify relevant data, searches of MEDLINE and the Cochrane Library databases were performed in July 2015 to locate randomised controlled trials or their meta-analyses published in the last five years. The MEDLINE database also was searched for evidence-based clinical practice guidelines, developed by scientific societies. Considering that probiotics have strain-specific effects, the main focus was on data on individual probiotic strains, not on probiotics in general.

Resumen: ensayo clínico randomizado en el que en niños que asisten a guardería, un tratamiento durante 6 meses con Bifidobacterium animalis lactis y Lactobacillus rhamnosus no disminuye los días de falta a guardería por enfermedad.

Daily supplementation of children's diet with yogurt containing probiotic bacteria BB-12 and inulin significantly reduced days of fever and improved social and school functioning. The increased frequency of bowel movements may be explained by an accelerating effect of BB-12 and inulin on intestinal transit. Further research on the possible benefits of synbiotics on children's health is advised.

Procalcitonina

La meningitis bacteriana es una emergencia pediátrica con alta mortalidad y morbilidad que requiere un diagnóstico y tratamiento rápidos. A menudo es difícil de diferenciar clínicamente entre meningitis bacteriana y no bacteriana. Este estudio se realizó para evaluar la PCT sérica como un marcador para diferenciar la meningitis bacteriana y no bacteriana en niños y evaluar su eficacia. La sensibilidad y especificidad de la PCT sérica en el diagnóstico de meningitis bacteriana a un nivel de corte de 0,5 ng / ml fueron 95.45% y 84.61% con un valor del área bajo la curva ROC de 0,991 (P<0,001) en comparación con el recuento total de leucocitos y la citoquímica del LCR.

Conclusiones: PCT sérica tiene una alta sensibilidad y especificidad para el diagnóstico temprano de meningitis bacteriana en niños. Por lo tanto, puede ser un complemento útil en la diferenciación de la meningitis bacteriana y no bacteriana para el manejo rápido y mejor de los niños.

Queratolisis punctata

A 16-year-old male presented with asymptomatic, malodorous erosions and pits on the soles of both feet of approximately 10 months' duration. Soaking of the feet in water tended to exacerbate the appearance. The patient was very active in sports activities and had a history of wearing athletic shoes for long periods of time. Physical examination showed multiple yellowish crateriform pits on the heels and a macerated area with a large erosion on the arch of the left foot (Figure). The feet were hyperhidrotic and malodorous.

Quinolonas

Las fluoroquinolonas (FQ) se recetan cada vez más a los niños, a pesar de estar autorizadas solo para un número limitado de indicaciones pediátricas. En este estudio multicéntrico retrospectivo de utilización de fármacos, analizamos las indicaciones de las prescripciones de FQ sistémicas en niños hospitalizados y la idoneidad de la dosis prescrita.

Conclusión: FQ a menudo se prescribieron fuera de ficha técnica y no se guiaron por los hallazgos bacteriológicos en nuestra población de estudio. Los errores de dosificación fueron comunes, particularmente en bebés y niños en edad preescolar. Las prescripciones de FQ para niños deben mejorarse mediante equipos de administración de antimicrobianos pediátricos específicos. Además, los estudios farmacocinéticos deberían optimizar las recomendaciones de dosificación para niños.

Quiste hidatídico

Rabia (ver también Temas A-Z)

Refugiados (ver también Temas A-Z)

Ricketsiosis

Presentamos una serie retrospectiva de casos pediátricos diagnosticados de rickettsiosis durante los años 2013-2014. Se incluyeron un total de 8 pacientes, 2 de ellos diagnosticados de fiebre botonosa mediterránea y 6 de linfadenopatía por picadura de garrapata, identificándose en 3 de ellos Rickettsia slovaca, Rickettsia sibirica mongolitimonae y Rickettsia massiliae. Se describen la etiología, las características clínicas y el tratamiento realizado en cada uno de ellos.

Rinovirus

Resumen: datos claros sobre la importancia del virus en la patología de la primera infancia. Se estiman una media anual de 3,5 infecciones anuales por  preescolar, 47% de infecciones en niños asociadas a OMA, y 61% de infecciones asociadas a prescripción de antibióticos. La prevalencia de rinovirus a los 2,13 o 24 meses de edad varió de 14 al 24%. 9% de niños asintomáticos fueron positivos para rinovirus.

A significant temporal association was observed between HRV circulation and K kingae osteoarticular infection, strengthening the hypothesis of a role of viral infections in the pathophysiology of K kingae invasive infection.

RVs are highly prevalent during the first year of life, and most infections are asymptomatic. Frequency of RV infectionsis associated with environmental factors, while respiratory symptoms during RV infections are linked to host determinants like infantage, maternal atopy or premorbid lung function

Rotavirus

Estudio prospectivo, multicéntrico y observacional durante la temporada invernal de octubre a abril de 2014 en algunas zonas de España (Cataluña, País Vasco, Andalucía) para estimar la frecuencia y características de la gastroenteritis aguda (AGE) y la Gastroenteritis por rotavirus (RVGE) en niños menores de 3 años que buscan atención médica en centros de atención primaria y de urgencias. Los resultados recomiendan que la vacunación rutinaria contra el rotavirus en lactantes ≤ 3 años de edad podría reducir considerablemente la grave carga de esta enfermedad infantil potencialmente grave

Rotavirus vacuna (ver también Temas A-Z)

El rotavirus es la causa de gastroenteritis más frecuente en niños. Casi todos los niños tendrán por lo menos un episodio de infección por rotavirus al cumplir los 5 años. El virus típicamente afecta a los bebés y niños pequeños, causando diarrea y algunas veces vómitos, dolor abdominal y fiebre. La mayoría de los niños se recuperan en casa en unos cuantos días, pero aproximadamente uno de cada cinco necesitará ver a su médico, y uno de cada diez acaba ingresado en el hospital como resultado de complicaciones. Un número muy pequeño de niños fallece por la infección por rotavirus al año.

En julio del año 2013, el NHS introdujo un programa de vacunación infantil contra la infección por rotavirus. (RotarixR) El objetivo de este estudio fue el de investigar la reducción de la incidencia de diarrea infecciosa en niños en los 2 años posteriores a la introducción de la vacuna, y calcular los ahorros probables debidos a la reducción en el número de visitas al NHS.

Encuentran que se han reducido las tasas de diarrea infecciosa un 15%, con una reducción del 41% entre febrero y abril, cuando la incidencia de rotavirus es tradicionalmente más alta. Se constata una disminución del número de visitas tanto a consultorios de MG, hospitales y servicios de urgencias, con un ahorro estimado de 12,5 millones de libras en el periodo revisado tras la introducción de la vacuna. Estos hallazgos preliminares sugieren que el programa de vacunación ha reducido de manera exitosa la carga sobre el NHS tanto en entornos de Atención Primaria como secundaria.

Resumen: Se analiza la efectividad en prevenir ingresos hospitalarios por rotavirus, de las dos vacunas frente al rotavirus, en una población pediátrica en la Comunidad Valenciana. Su alta efectividad, mayor del 85%, es un argumento a favor de su inclusión en el calendario vacunal oficial. Adicionalmente informan de la seguridad y de la duración de la protección, de la importancia de evaluar los riesgos-beneficios en esa población para informar de tales deliberaciones y de la calidad de los datos procedentes de la base de datos del SIV (Sistema de Información de Vacunas) de Valencia, a pesar de no ser una vacuna incluida en el calendario oficial.

Conclusions. Syndromic surveillance revealed a marked decline in gastroenteritis, coinciding with the introduction of the new rotavirus vaccine program in England. The largest reduction in disease was observed in infants, although some impact was also demonstrated in children aged 1–4 and 5–14 years, suggesting possible herd protection in older age groups. This study was limited to the first postvaccine year, and further analysis is required to assess the longer-term impact of the vaccine.

This meta-analysis showed a similar increased risk of intussusception, during the first 7 days after administration of dose 1 and, to a lesser extent, dose 2, for both currently available rotavirus vaccines. This suggests that intussusception may be a class effect of currently available oral rotavirus vaccines.

Conclusions Risk of intussusception increases about 8-fold during 1-7 days after receipt of first dose RV1 in infants of Chinese, Malay, and Indian ethnicity in Singapore, Asia. High vaccine coverage program in Singapore would be beneficial with only a low risk of excess intussusception. The relative risk of intussusception post-RV1 vaccination is not higher in Asia despite differences in background intussusception incidence compared with US and Australia, or older age of vaccination.

We documented at a population-level a small increased risk in intussusception hospitalizations post-introduction of the newrotavirus vaccines.

Our results show that rotavirus vaccination may have a significant impact in the decrease in seizure-related hospitalizations inchildhood. This additional benefit of rotavirus vaccination seems more marked in the youngest infants.

Rubeola (ver también Temas A-Z)

Rubeola congénita (ver también Temas A-Z)

Salmonella

Resumen: se describe un brote de gastroenteritis causada por Salmonella poona en una guardería infantil en la ciudad de Valladolid (España) en los primeros tres meses del año 2011.

Resultados: se encontraron 13 casos, de edades comprendidas entre los cinco meses y los cinco años, tres de los cuales fueron asintomáticos. La tasa de ataque global en la guardería fue del 28,2%, no encontrándose diferencias significativas entre las diferentes aulas. Todas las salmonelas aisladas excepto dos fueron enviadas al Centro Nacional de Microbiología (CNM) para su caracterización, identificándose todas ellas como Salmonella poona 13,22:z:1,6, idéntica a la aislada en el brote nacional.

Conclusiones: parece evidente que el brote ocurrido en la guardería fue producido por el mismo microorganismo que el que causó el brote supracomunitario y que la fórmula láctea implicada en dicho brote fue el vehículo de transmisión que permitió la introducción del microorganismo en la guardería, propagándose por otras vías entre los alumnos de la misma.

Eight multistate outbreaks associated with small turtles were investigated during 2011–2013. Children <5 years and Hispanics were disproportionately affected. Prevention efforts should focus on patient education targeting families with young children and Hispanics and enactment of state and local regulations to complement federal sales restrictions.

En vista de estos resultados de CMI, azitromicina podría resultar un tratamiento útil en la GEA por SNT, aunque sería deseable el establecimiento, por parte de comités internacionales, de puntos de corte clínicos para Salmonella enterica y azitromicina.

Sarampión (ver también Temas A-Z)

  • Measles outbreak hot spots are in US states where parents can optout of vaccinationsBMJ 2018;361:k2655

El porcentaje de niños estadounidenses que no han sido vacunados ha aumentado desde 2009. La Encuesta Nacional de Inmunización de 2015 encontró que solo el 72.2% de los niños pequeños de entre 19 y 35 meses fueron vacunados completamente de acuerdo con las pautas de práctica."Un movimiento social de oposición a la vacuna contra la salud pública ha estado creciendo en los Estados Unidos en los últimos años; posteriormente, los brotes de sarampión también han aumentado ".

  • European countries are urged to carryout catch-up campaigns as measles outbreaks continueBMJ 2018;361:k1771

Los países europeos deberían llevar a cabo campañas de actualización de vacunación dirigidas a adolescentes y jóvenes para frenar los brotes de sarampión en todo el continente, dijo el Centro Europeo para la Prevención y Control de Enfermedades.El informe anual del centro muestra que hasta el 80% de los adolescentes y adultos jóvenes que contrajeron sarampión en 2017 no habían sido vacunados. Una evaluación de riesgo rápida realizada por el centro encontró que los trabajadores de la salud no vacunados se vieron afectados en los últimos brotes.

Whatisalreadyknownaboutthistopic? Measlesoccurssporadically in Israel and can be importedbytravelers. Measlesoutbreaksoccurred in 15 Europeancountriesdurngthesummerof 2017.

What is added by this report?DuringJuly and August 2017, ninemeasles cases occurredamongvaccinatedIsraelisoldiers. TheprimarypatienthadrecentlytraveledtoEurope. Allother cases occurred in hisdirectcontacts. Allpatientshadmildillness; no tertiary cases occurred.

What are theimplicationsforpublichealth practice? Modifiedmeaslesmightnot be suspected in personswithdocumentationofvaccination. In outbreaksettings, healthcareprovidersshouldmaintain a highindexofsuspicionformeasles, even in vaccinatedpatients, and conduct a thoroughepidemiologic and laboratoryinvestigationofsuspectedmeasles cases.

Sólo se encuentra un pequeño ensayo que  incluye a 85 niños. La administración de Zn (oligoelemento carencial en paises en desarrollo) no parece influir en la evolución del sarampión.

Responding to 1 measles case cost the pediatric clinic more than $5000, despite isolating the patient promptly after examination. Documentation of employee immunity, vaccination of eligible patients and strict infection control precautions might reduce ambulatory costs associated with measles containment.

Subacute sclerosing panencephalitis (SSPE) is a fatal complication of measles infection. We present a case of a fully vaccinated 3-year-old boy who was diagnosed with and treated for autoimmune encephalitis before arriving at a diagnosis of SSPE. We discuss the challenges of diagnosing SSPE in developed countries.

Sarna (Ver Temas A-Z)

Es un artículo que pone de relieve la necesidad de herramientas diagnósticas más fiables e identificar nuevas terapias para el tratamiento y profilaxis de la sarna, dada la resistencia emergente de los ácaros de la sarna y los efectos secundarios de los fármacos actuales.

Fifteen studies (1896 participants) comparing topical permethrin, systemicivermectin, or topical ivermectin met the inclusion criteria. Overall, the riskof bias in the included trials was moderate: reporting in many studies was poor. Nearly all studies were conducted in South Asia or North Africa, where the disease is more common, and is associated with poverty.

We found that for the most part, there was no difference detected in the efficacy of permethrin compared to systemic or topical ivermectin. Overall, few and mild adverse events were reported. Our confidence in the effect estimates was mostly low to moderate. Poor reporting is a major limitation.

Adverse events in participants treated with topical ivermectin were rare and of mild intensity and comparable to those with systemic ivermectin. For this comparison, it is uncertain whether there is any difference in the number of participants with at least one adverse event (very low-certainty evidence). No participants in the topical or systemic ivermectin group stopped participating in the study because they experienced an adverse event (moderate-certainty evidence).

It is uncertain whether topical ivermectin and permethrin differ in the number of participants with at least one adverse event (very low-certainty evidence). We found no studies comparing one dose versus two doses of systemic ivermectin that assessed safety outcomes

Una causa infrecuente a considerar en el diagnóstico diferencial de los exantemas neonatales.

A 4-year-old girl with a medical history of Trisomy 21 presented with a diffuse, pruritic, scaly rash affecting her entire body. The rash began on her scalp as small areas of scaling and crusting then spread to her hands and feet. She had multiple visits to the emergency department with each exacerbation of rash and had been prescribed medications that included ketoconazole, permethrin, and triamcinolone. She was also evaluated previously by a dermatologist and was diagnosed with psoriasis. Of the 9 relatives with whom she had lived, each had received intermittent treatment for scabies over a period of 3 years.

Sepsis (ver también Temas A-Z)

Question Among newborns, what is the clinical benefit of an early-onset sepsis (EOS) risk calculator, compared with national guidelines, in reducing antibiotic use?

Design Cohort.

Setting Kaiser Permanente Northern California (KPNC).

Participants Neonates, 35 weeks of gestation or older.

Intervention EOS calculator or national guidelines.

Outcomes Empiric antibiotic use.

Main Results Fewer babies in the EOS calculator group experienced blood culture use: adjusted number needed to treat (aNNT) 13 (95% CI, 8 to 42), and less empirical antibiotic administration in the first 24 hours: aNNT, 56 (95% CI, 44 to 77) with no difference between 24 and 72 hours after birth and no clinical outcome differences.

Conclusions An EOS calculator reduced neonatal blood culture and empiric antibiotic use.

Commentary A liberal threshold for initiating antibiotic therapy in neonates, based on early-onset sepsis (EOS) risk factors with poor predictive value, has led to overuse of antibiotics in non-infected neonates. This contrasts starkly with the low prevalence of EOS. Antibiotic overuse early in life may have severe short-term and long-term adverse consequences.1, 2 This large cohort study from KPNC investigated clinical management of term and near-term infants with suspected or proven EOS over a 6-year period. The remarkable 50% relative reduction in antibiotic use after introduction of an EOS-calculator was not followed by a delay in therapy for infected infants or an increase in readmissions. It is evident that not only the EOS-calculator but also a bundle of co-interventions including improved patient monitoring was implemented, most likely at the same time. Moreover, the KPNC-staff must have undergone rigorous training in order to use the EOS-calculator and follow the bundle of interventions appropriately. The authors are to be congratulated for this very successful approach. The use of an EOS calculator has the potential to reduce antibiotic overuse, especially in areas where maternal risk factors, earlier, may have been over-emphasized. However, similar results may be achieved with different approaches. We recently presented data from a population-based study of 168,000 term infants in Norway over a 3-year period. In our setting, with a tradition of not recommending therapy based on risk factors alone, the proportion of term infants receiving antibiotic therapy in the first week of life was 2.3% and mortality was low.3

As part of the development of new sepsis guidelines in response to the national Commissioning for Quality and Innovation (CQUIN) and new National Institute for Health and Care Excellence (NICE) guidelines on sepsis in Paediatrics, we undertook a retrospective audit comparing the new guidelines to previous cases that had attended the emergency department (ED). NICE guidelines indicate that screening is necessary to detect sepsis but it gives no suggestion on how to differentiate septic children from children who have an infection. The new NICE guideline indicates that having one risk factor should trigger sepsis screening but we felt that this would over treat and potentially cause harm and trigger unnecessary investigations.

We report a high burden of sepsis in neonates with considerable mortality and morbidity. EOS, hospital-acquired LOS, and community-acquired LOS affect specific patient subgroups and have distinct clinical presentation, pathogens and outcomes.

Use of quality improvement methodologies to improve the management of paediatric sepsis in the emergency department was associated with a reduction in hospital length of stay.

Shigella

En octubre de 2012 se detectó un brote de gastroenteritis aguda por Shigella sonnei en una escuela del norte de España que afectó a 112 personas: el 63,7% fueron escolares y docentes y el 35,7% convivientes. El origen fue un niño enfermo con antecedente de viaje a país endémico, y el desencadenante, las deficiencias higiénicas existentes en uno de los aseos de la escuela. La aplicación de estrictas medidas de higiene fueron determinantes para el control del brote.

Sibilancias

A 3-year-old girl presents to the emergency department with a severe wheeze and tachypnoea. Her mother reports that she experienced coryzal symptoms a few days prior to the onset of the wheeze and that she previously had three similar wheezing episodes that were also triggered by viral upper respiratory tract infections in the past year. Each wheezing episode lasts 2–4 days and have all been clinically severe, requiring medical attention. Between upper respiratory tract infections, she is asymptomatic with no wheeze, and she has no history of atopy.

She has viral induced wheeze (also known as episodic viral wheeze (EVW)) and is usually managed with an inhaled short-acting beta-2 agonist and inhaled or oral corticosteroids. Having heard that there are some concerns over corticosteroids causing stunted growth, her physician wonders if a leukotriene receptor antagonist (LTRA), such as Montelukast, which does not suppress growth, would be effective at preventing wheezing episodes.

Background: Susceptibility to rhinovirus (RV)-induced early wheezing episode has been recognized as an important risk factor for asthma, but the data on different RV species are limited. Our aim was to investigate the risk for recurrences in first-time wheezing children with special focus on RV species.

Conclusions: RV causes reinfections with different strains in small children after the first wheezing episode. Both RV-A and RV-C affected children have an increased risk for recurrence, especially RV associated, and initiation of regular controller medication than those with other viruses.

Pediatric Infectious Disease Journal . 36(2):179-183

Abstract:

Background: We sought to know more about how 14 common respiratory viruses manifest clinically, and to identify risk factors for specific virus-induced acute respiratory tract infections (ARTIs) in children younger than 3 years old and for wheezing at 36-month follow-up.

Methods: We retrospectively studied the clinical records for 273 full-term children (median age, 2.9 months; range, 0.26–39; boys, 61.2%) hospitalized for ARTIs, whose nasopharyngeal specimen tested positive for a respiratory virus and 101 children with no history of respiratory diseases (median age, 8 months; range, 0.5–36.5; boys, 58.4%). At 12, 24 and 36 months after children’s discharge, all parents were interviewed by telephone with a structured questionnaire on wheezing episodes.

Results: The most frequently detected viruses were respiratory syncytial virus in bronchiolitis, human rhinovirus in pneumonia and human bocavirus in wheezing. Multivariate analysis identified, as risk factors for virus-induced ARTIs, the presence of siblings [odds ratio (OR): 3.0 (95% confidence interval [CI]: 1.8–5.2)], smoking cohabitants (OR: 2.3 (95% CI: 2–4.2)] and breastfeeding lasting less than 3 months [OR: 0.5 (95% CI: 0.3–0.9)]. The major risk factor for respiratory syncytial virus–induced ARTIs was exposure to tobacco smoke [OR: 1.8 (95% CI: 1.1–3.2)]. Risk factors for human rhinovirus–induced ARTIs were attending day-care [OR: 5.0 (95% CI: 2.3–10.6)] and high eosinophil blood counts [OR: 2.6 (95% CI: 1.2–5.7)]. The leading risk factor for recurrent wheezing was exposure to tobacco smoke [OR: 2.5 (95% CI: 1.1–15.6)].

Conclusions: Each respiratory virus leads to a specific clinical manifestation. Avoiding exposing children to tobacco smoke might restrict viral spread from sick parents and siblings to younger children, prevent severe respiratory diseases, and possibly limit sequelae.

Backgrounds: Respiratory tract infections (RTIs) are a common cause of morbidity and mortality in young children and can be associated with wheeze. Vitamin D can have a protective role against RTI.

Materials and Methods: A systematic search of PubMed, Embase and the Cochrane library was performed. Titles and abstracts were evaluated, and selected articles were reviewed by 2 authors. We included randomized controlled trials (RCTs) investigating the effect of vitamin D supplementation during pregnancy on RTIs or wheeze in children of 5 years of age or younger. Observational studies on the association between serum 25-hydroxyvitamin D during pregnancy, or at birth, and RTIs and/or wheeze were included. The protocol was registered on PROSPERO (Registration number: CRD42015019183).

Results: Of 4 RCTs, 1 showed a protective effect of a high daily dose (2000 IU) of vitamin D during pregnancy on offspring RTI doctor visits (P = 0.004; the RCT also included 800 IU/d supplement to the infants until 6 months). Meta-analysis of 3 RCTs showed a reduced relative risk for offspring wheeze when mothers were supplemented with vitamin D during pregnancy [relative risk: 0.81 (95% confidence interval: 0.68–0.97), P = 0.025]. In 3 of 4 strong-quality, and 5 of 10 moderate-quality observational studies, an inverse association between pregnancy and cord 25-hydroxyvitamin D and subsequent wheeze and/or RTI was seen.

Conclusion: Growing evidence supports a preventive role of vitamin D during pregnancy on offspring wheeze and/or RTI. Recommendations in future intervention studies may need to exceed current recommendations of vitamin D supplementation during pregnancy to show benefit against childhood wheeze or infections.

Resumen: En la sección Researchs News, la autora describe el estudio publicado en JAMA sobre los beneficios del uso de Azitromicina en los episodios de sibilancias recurrentes en niños. Se hace eco de la advertencia por parte de otros investigadores de los riesgos que esto podría conllevar, sobre todo con respeto al incremento de las resistencias bacterianas a los macrólidos

Conclusions Intraobserver variation is modest, and interobserver variation is large for most clinical findings in children with dyspnoea. The measurement error induced by this variation is too large to distinguish potentially clinically relevant changes in dyspnoea after treatment in two-thirds of observations. The poor interobserver reliability of clinical dyspnoea assessment in children limits its usefulness in clinical practice and research, and highlights the need to use more objective measurements in these patients.

The relationship between viral infection, host immune response in infants with respiratory syncytial virus (RSV) bronchiolitisand subsequent wheezing is discussed. We measured RSV-RNA load and interferon-λ1-3 expression in the nasopharyngeal washings from 68 infants hospitalized for RSV bronchiolitis, and wheezing was assessed 36 months after the first episode ofbronchiolitis. Higher RSV-RNA load and higher interferon-λ2/3 levels were found in children with recurrent wheezing at 36-month follow-up.

We included randomised controlled trials with a parallel-group or cross-over (for intermittent LTRA only) design. Maintenance was considered as treatment for more than two months and intermittent as less than 14 days. EVW was defined as a history of at least one previous episode of wheezing in association with a viral respiratory tract infection in the absence of symptoms between episodes. As far as possible, relevant specific data were obtained from authors of studies that included children of a wider age group or phenotype.

Authors' conclusions: In pre-school children with EVW, there is no evidence of benefit associated with maintenance or intermittent LTRA treatment, compared to placebo, for reducing the number of children with one or more viral-induced episodes requiring rescue oral corticosteroids, and little evidence of significant clinical benefit for other secondary outcomes. Therefore until further data are available, LTRA should be used with caution in individual children. When used, we suggest a therapeutic trial is undertaken, during which efficacy should be carefully monitored. It is likely that children with an apparent EVW phenotype are not a homogeneous group and that subgroups may respond to LTRA treatment depending on the exact patho-physiological mechanisms involved.

Sífilis

Conclusions: The association of congenital syphilis with all syphilis cases in women highlights the importance of reporting all cases and not just primary and secondary syphilis. The increase in congenital syphilis reinforces the recommendation for repeat maternal screening during pregnancy.

A 4-month-old boy presented with a several-week history of progressive abdominal distension and persistent nasal congestion. He was adopted and his birth mother had received limited prenatal care. Examination revealed mild nasal congestion without rhinorrhea and marked hepatosplenomegaly. Long bone films revealed multiple bony changes, including destruction of the medial metaphysis of both tibias (Wimberger sign) and diffuse tibial periosteal reactions (Figure). Wimberger sign is due to destructive metaphysitis and is highly suggestive of congenital syphilis, though it has been reported with other conditions such as osteomyelitis and neonatal hyperparathyroidism.

Sinusitis (ver también Temas A-Z)

ABS complicates 8% of URI in young children. Girls have more frequent ABS episodes than boys. Presence of rhinovirus and M. catarrhalis during URI are positively correlated with the risk for ABS complication.

A 7-year-old boy was admitted with left proptosis associated with ophthalmoplegia, as well as cellulitis of the upper and lower eyelids lasting 2 days (Figure 1). The patient's past medical history was positive for rhinosinusitis occurring the week before. Nasal endoscopy showed a mild hyperemia of nasal mucosa and poor mucosal secretion. Visual acuity was normal. Antibiotic (ampicillin and sulbactam) and steroid (dexamethasone) therapies were given intravenously. No improvements were observed after 36 hours, but his visual acuity began to impair.

A 5-year-old girl being treated with antibiotics for a recent history of presumptive acute rhinosinusitis presented with recurrence of fever, lethargy, and subacute onset of left lower extremity weakness.

Stevens-Johnson S

Fever is a symptom that often accompanies skin eruptions, especially in children. It can be a sign of an infectious condition presenting with exanthems or it may precede an exanthematous eruption. Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe reactions affecting skin and mucosa with blisters and erosions. High fever occurs in these conditions, frequently before the skin and/or mucosa is affected.

A previously healthy 15-year-old male patient presented with severe conjunctivitis and oral ulcerations 1 week after a clinically diagnosed upper respiratory infection and hand, foot, and mouth disease. He was instructed to complete a 5-day course of azithromycin and polymyxin/trimethoprim ophthalmic drops. On day 3 of treatment, his oral ulcerations and conjunctivitis worsened, leading to dysphagia, blurry vision, and eye pain. Findings of the physical examination on admission revealed a febrile patient with diffuse ulceration of oral mucosa, bilateral exudative conjunctivitis with matting purulent yellow discharge, and cobblestone appearance of conjunctivae (Figure).

STX-TMP

In immunocompromised children and adolescents without HIV infection (patient), which co-trimoxazole dosing regimen (intervention) is most effective in preventing PJP and best tolerated (outcome)?

Sweet S

A previously healthy 2-month-old girl presented with transient impaired awareness, fever, and erythematous skin lesions. The skin lesions developed at the same time as the fever. She received no medications before admission. At the hospital, she again developed transient impaired awareness with eye fixation. She was preemptively treated with antimicrobial agents and acyclovir for encephalitis.

 Termitas

A healthy 9-year-old boy presented to the emergency department with a chief complaint of pruritic lesions on the upper limbs. The parents had a single domiciled dog and denied the presence of fleas or ticks

Test rápidos (ver también Temas A-Z)

Resumen: Es un estudio español, realizado en Barcelona, en donde se analiza un nuevo test rápido para el diagnóstico de influenza. Combina la rapidez de un test antigénico de diagnóstico rápido con la sensibilidad del diagnóstico con PCR. No precisa de personal especializado para su realización, y podría ser realizado en diferentes niveles asistenciales en cualquier horario. Hecho que lo hace particularmente útil en atención primaria durante los períodos de epidemia de influenza.

Parece que la determinación de PCR en AP disminuye el uso de antibióticos (esta disminución no queda bien cualificada) pero parece aumentar los ingresos...

Revisión de diferentes test y técnicas microbiológicas para el diagnóstico rápido de enfermedades infecciosas. Algunos de los nuevos métodos disponibles son incluso capaces de detectar resistencias antimicrobianas y esto permite optimizar el tratamiento. Se describen aquellas que son ya de aplicación habitual y otras que todavía no están clínicamente validadas para una interpretación correcta de los resultados y que tendrán que correlacionarse con elgold standar actual pero con un futuro prometedor.

El uso de estos test no muestra en los estudios que se analizan una disminución en el uso de antibióticos, pero sí en la realización de otras pruebas (RX, orina)

Tétanos vacuna

  • Vaccines for women for preventing neonatal tetanus. Cochrane Database of Systematic Reviews 2015, Issue 7. Art. No.: CD002959. Se revisan 2 ensayos clínicos en donde se demuestra la efectividad de la vacunación antitétanica (al menos dos dosis de vacuna) en mujeres en edad reproductiva para la prevención del tétanos neonatal en países con alta incidencia de esta patología, demostrando un descenso de la mortalidad neonatal en los primeros 30 días de vida.

Tetraciclinas

A 6-year-old girl presents with fever, rash and arthralgia 1 week after returning from a camping trip to South Africa. After exclusion of other potential diagnoses, her rickettsia serology is found to be positive and you decide to prescribe a course of doxycycline. However, the package insert states that doxycycline is contraindicated in children <8 years of age as it ‘may cause enamel loss and staining in developing teeth’. You wonder ‘what is the risk of dental side effects?’

This study failed to demonstrate dental staining, enamel hypoplasia, or tooth color differences among children who received short-term courses of doxycycline at <8 years of age. Healthcare provider confidence in use of doxycycline for suspected RMSF in children may be improved by modifying the drug's label.

Tiña (ver Temas A-Z y micosis)

Tos

We included six randomised controlled trials involving 899 children; we added three studies (331 children) in this update.

We assessed two studies as at high risk of performance and detection bias; three studies as at unclear risk of attrition bias; and three studies as at unclear risk of other bias.

Studies compared honey with dextromethorphan, diphenhydramine, salbutamol, bromelin (an enzyme from the Bromeliaceae (pineapple) family), no treatment, and placebo. Five studies used 7-point Likert scales to measure symptomatic relief of cough; one used an unclear 5-point scale. In all studies, low score indicated better cough symptom relief.

Using a 7-point Likert scale, honey probably reduces cough frequency better than no treatment or placebo (no treatment: mean difference (MD) -1.05, 95% confidence interval (CI) -1.48 to -0.62; I² = 0%; 2 studies; 154 children; moderate-certainty evidence; placebo: MD -1.62, 95% CI -3.02 to -0.22; I² = 0%; 2 studies; 402 children; moderate-certainty evidence). Honey may have a similar effect as dextromethorphan in reducing cough frequency (MD-0.07, 95% CI -1.07 to 0.94; I² = 87%; 2 studies; 149 children; low-certainty evidence). Honey may be better than diphenhydramine in reducing cough frequency (MD -0.57, 95% CI -0.90 to -0.24; 1 study; 80 children; low-certainty evidence).

Giving honey for up to three days is probably more effective in relieving cough symptoms compared with placebo or salbutamol. Beyond three days honey probably had no advantage over salbutamol or placebo in reducing cough severity, bothersome cough, and impact of cough on sleep for parents and children (moderate-certainty evidence). With a 5-point cough scale, there was probably little or no difference between the effects of honey and bromelin mixed with honey in reducing cough frequency and severity.

Elegido por curioso...La miel se muestra superior al placebo o a no tratar en procesos catarrales leves. No es superior a dextrometorfano en casos de tos intensa.

Los ttos sintomáticos no muestran beneficios en la mayoría de los estudios vs placebo, con considerable aumento de efectos secundarios.

Tos crónica

We identified three studies as eligible for inclusion in the review. Two were in the previous review and one new study was included. We considered the older studies to be at high or unclear risk of bias whereas we judged the newly included study at low risk of bias. The studies varied in treatment duration (from 7 to 14 days) and the antibiotic used (two studies used amoxicillin/clavulanate acid and one used erythromycin).

We included 190 children (171 completed), mean ages ranged from 21 months to six years, in the meta-analyses. Analysis of all three trials (190 children) found that treatment with antibiotics reduced the proportion of children not cured at follow-up (primary outcome measure) (odds ratio (OR) 0.15, 95% confidence interval (CI) 0.07 to 0.31, using intention-to -treat analysis), which translated to a number needed to treat for an additional beneficial outcome (NNTB) of 3 (95% CI 2 to 4). We identified no significant heterogeneity (for both fixed-effect and random-effects model the I² statistic was 0%). Two older trials assessed progression of illness, defined by requirement for further antibiotics (125 children), which was significantly lower in the antibiotic group (OR 0.10, 95% CI 0.03 to 0.34; NNTB 4, 95% CI 3 to 5). All three trials (190 children) reported adverse events, which were not significantly increased in the antibiotic group compared to the control group (OR 1.88, 95% CI 0.62 to 5.69). We assessed the quality of evidence GRADE rating as moderate for all outcome measures, except adverse events which we assessed as low quality.

Evidence suggests antibiotics are efficacious for the treatment of children with chronic wet cough (greater than four weeks) with an NNTB of three. However, antibiotics have adverse effects and this review reported only uncertainty as to the risk of increased adverse effects when they were used in this setting. The inclusion of a more robust study strengthened the previous Cochrane review and its results.

2586 children were screened and 776 (30%) were ineligible; 839 children (median age=2.3 years, range=0.5 months to 14.7 years, 60% male) were enrolled over 2 years. Most children (n=627, 74.8%) had cough duration of <7 days at enrolment. At day 28, 171/839 (20.4%, 95% CI 17.7 to 23.1) children had persistent cough irrespective of cough duration at enrolment. The cough was wet in 59/171 (34.5%), dry in 45/171 (26.4%) and variable in 28/171 (16.1%). Of these 117 children , 117 (68.4%) were reviewed by a paediatric pulmonologist. A new and serious chronic lung disease was diagnosed in 36/117 (30.8%) children; 55/117 (47.0%) were diagnosed with protracted bacterial bronchitis.

Conclusions When chronic cough develops post-ARI, clinical review is warranted, particularly if parents report a history of prolonged or recurrent cough. Parents of children presenting acutely to ED with cough should be counselled about the development of chronic cough, as an underlying respiratory condition is not uncommon.

Tosferina (ver también Temas A-Z)
 

The use of RT-PCR permits improved detection and diagnosis of pertussis and a better understanding of the epidemiology of sources of infection. The complications and mortality rate of pertussis continue to be high. Household contacts are confirmed as a frequent source of infection of B pertussis in young children.

No está claro si las co-infecciones virales causan una enfermedad más grave que la Bordetella pertussis (B. pertussis ) sola. Se comparó la gravedad de la enfermedad clínica y se buscaron las diferencias clínicas y demográficas entre los lactantes con infección por B. pertussis sola y aquellos con coinfecciones respiratorias virales. En el estudio no se encontraron asociaciones entre la gravedad clínica y la tos ferina con o sin co-infecciones.

Enrolled subjects (115 case-patients; 230 control subjects) had 4396 contacts during incubation periods; 83 (72%) case-patients had ≥1 contact with prolonged (≥5 days) new cough in primary or secondary households. In multivariable analysis, the odds for pertussis were higher for infants with primary/secondary household contacts who had a prolonged new cough, compared with infants who did not. These contacts included mother [adjusted matched odds ratio (aMOR), 43.8; 95% confidence interval (CI), 6.45–298.0] and ≥1 nonmother contact (aMOR, 20.1; 95% CI, 6.48–62.7). Infants receiving breast milk with 0–1 formula feedings daily had decreased pertussis odds (aMOR, 0.27; 95% CI, 0.08–0.89), compared with those receiving more formula. Of 41 tested case-patients, 37 (90%) were seropositive.

Conclusions: Pertussis in infants was associated with prolonged new cough (≥5 days) in infants’ household contacts. Findings suggest that breastfeeding protects against pertussis and warrants recommendation with pertussis prevention strategies, which currently include pertussis vaccination of pregnant mothers and infants’ close contacts.

Infant PICU pertussis admission rates have increased in NZ despite improvements in immunization coverage. Higher rates have occurred since pertussis notification/PCR became available and since acellular replaced whole-cell vaccine. The severity of disease in infants admitted to PICU with pertussis has decreased in recent years.

The health burden of pertussis, particularly in the youngest infants, remains substantial, highlighting the need to intensify efforts to protect this most vulnerable population.

Increased cases of culture-positive hospitalized pertussis were limited to fully immunized children >6 months of age, consistent with schedule changes. Significant comorbidities were common, making a booster dose at 12-18 months of age especially important.

Timely administration of infant pertussis vaccine doses could potentially reduce subsequent pertussis cases, hospitalizations, deaths and medical costs in infants aged <1 year in the US.

La coinfección por el VRS en lactantes ingresados con tosferina aconteció en uno de cada 2 pacientes en época epidémica para el VRS, en lactantes de edad similar. La gravedad en términos de estancia, presencia de apneas e ingreso en cuidados intensivos fue semejante, pero con mayor necesidad de cuidados respiratorios y soporte nutricional.

Underreporting of symptomatic cases is important not only in adults, but also in children >1 year of age and suggests that providing clinics with free, fast laboratory diagnostic tests, together with enhanced surveillance of family contacts of any age is necessary to better determine existing cases. Enhanced surveillance may be helpful to better understand transmission patterns in the family and in the community

In this outbreak, pertussis cases among unvaccinated children represented an earlier spread of disease across local areas. Controlling outbreaks may require attention to the composition and location of the unvaccinated.

Se investigan las fuentes de contagio de tosferina en niños pequeños. En la actualidad son los hermanos los principales "contagiadores" de la enfermedad, sutituyendo a las madres desde los últimos 7 años.

Resumen: Estudio realizado en estudiantes de medicina al finalizar un brote de tos ferina. La tasa de ataque fue mayor en los estudiantes que no completaron el esquema de vacunación DTPa infantil. La efectividad estimada de la vacuna fue de 52%, inferior a la descrita en informes anteriores, probablemente a causa de la disminución de los niveles de anticuerpos en el largo período de tiempo desde la última dosis de DTPa. Estos resultados sugieren la necesidad de una vacuna de refuerzo para los adolescentes y el desarrollo de vacunas contra la tos ferina de mayor eficacia.

Conclusión: la epidemiología de los casos graves de tosferina y su impacto clínico y económico confirman la necesidad de modificar las estrategias de vacunación en España.

Conclusions: Pertussis in children sometimes mimics viral respiratory tract infections. If pertussis diagnostics are based on clinical suspicion alone, about 1 in 5 cases (19%) is missed. Despite widely accepted clinical criteria, paroxysmal cough is not a good predictor of pertussis. To prevent spreading, physicians should include B. pertussis in routine diagnostics in respiratory tract infections.

Conclusion: Household contacts play an important role in the transmission of pertussis to infants and when identified, mothers were the main sources of infection. Immunization during pregnancy has a key role in preventing infant disease through passive protection from birth and reduced maternal exposure.

In 169 Finnish infants hospitalized for bronchiolitis at age <6 months in 2008–2010, nasopharyngeal aspirates were tested by polymerase chain reaction for Bordetella pertussis and 16 viruses. Respiratory viruses were detected in 89% (71% with respiratory syncytial virus), but no infant had B. pertussis. The latter finding may reflect a positive effect from the broadening of the Finnish pertussis vaccination program in 2005.

Our data support that B. pertussis is an uncommon pathogen in U.S. children hospitalized with bronchiolitis in the winter. Making a diagnosis of pertussis can be challenging because the disease can be atypical and may not meet the Centers for Disease Control and Prevention definition of probable infection

In 2012, a pertussis outbreak in Dallas County resulted in the deaths of 4 children (3, unvaccinated; 2, <60 days of age). Despite recommendations that include immunization of women preferably during the third trimester of pregnancy or postpartum, household contacts ("cocooning"), and infants as early as 42 days of age, challenges in pertussis prevention remain.

Forty-three pertussis cases reported in May 2015 in Valencia were linked to a school outbreak where 90% of the students had been vaccinated. Cases were diagnosed upon paediatrician consultation and in hospital emergency units. Approximately half of the cases were students born in 2002, the first age cohort with complete shift to acellular pertussis vaccine. Public health intervention, visiting school premises to conduct interviews, sample collection and early antibiotic prophylaxis stopped further spread in the community.

We describe a 5-year-old, fully immunized boy with polymerase chain reaction-proven consecutive Bordetella pertussis and Bordetellaparapertussis infections causing typical whooping cough at the age of 2 and 5 years, respectively. Neither pertussis immunization nor disease provides reliable immunity against further episodes of whooping cough.

Tosferina vacuna (ver también Temas A-Z)

Resumen: estimación de que solamente un 10% de niños estarían protegidos contra tosferina, 8 años y medio después de la última dosis. Con importantes limitaciones al tratarse de un metaanálisis principalmente de estudios de casos y controles,con cluye que aunque las vacunas acelulares son seguras, la extensión de su utilización puede requerir tempranas dosis de recuerdo y estrategias que contemplen varios recuerdos, para conseguir alcanzar una buena inmunidad de grupo que controle la extensión de la enfermedad. 

Contact tracing and seroepidemiologic studies were done after a premature baby contracted pertussis in a children’s hospital. No infection source was confirmed. Four (3.5%) healthcare providers were positive for anti-pertussis IgM, while only 23% (26/113) were positive for IgG in a following survey. Pertussis vaccination for healthcare providers is needed.

 This case-control study demonstrated that maternal pertussis vaccination was highly effective in preventing laboratory-confirmed pertussis infection in infants aged <2 months during a national pertussis outbreak in England and Wales.

Conclusions. Maternal pertussis vaccination is effective in preventing pertussis infection in infants aged <8 weeks and may be considered in other countries experiencing high levels of pertussis notifications.

La vacunación con dTpa de los contactos estrechos de los lactantes (estrategia del nido o cocooning) está recomendada por los CDCs para prevenir los casos tosferina en esta población de riesgo. Este estudio trata de determinar si la implementación de un programa de vacunación de estas características en el Hospital General de Ben Taub, en Houston, redujo la incidencia de tosferina severa en lactantes pequeños. La vacunación materna postparto y la estrategia del nido no redujeron la incidencia de tosferina en niños menores de 6 meses. Deben realizarse todos los esfuerzos posibles para aumentar la cobertura vacunal con dTpa en embarazadas, en combinación con la estrategia del nido, para reducir la tosferina grave en los lactantes más pequeños.

La sección News del BMJ destaca lo escrito por Kathleen Winter y sus colegas en el MMWR de los Centros para el Control de Enfermedades y Prevención de EEUU sobre la efectividad de la inmunización de las mujeres embarazadas durante el tercer trimestre para asegurar la protección de los lactantes contra la tosferina.Parental tdap boosters and infant pertussis: a case-control study. Pediatrics. 2014 Oct; 134:713-20

Vaccination against pertussis in the second/third trimester of pregnancy or immediately postpartum significantly increased the levels of anti-PT sIgA in breast milk.

The first pertussis vaccine dose and antibiotic treatment protect against death, hospitalization, and pneumonia.

The Global Pertussis Initiative (GPI) is an expert scientific forum addressing the worldwide burden of pertussis, which remains a serious health issue, especially in infants. This age cohort is at risk for developing pertussis by transmission from those in close proximity. Risk is increased in infants aged 0 to 6 weeks, as they are too young to be vaccinated. Older infants are at risk when their vaccination schedules are incomplete. Infants also bear the greatest disease burden owing to their high risk for pertussis-related complications and death; therefore, protecting them is a high priority. Two vaccine strategies have been proposed to protect infants. The first involves vaccinating pregnant women, which directly protects through the passive transfer of pertussis antibodies. The second strategy, cocooning, involves vaccinating parents, caregivers, and other close contacts, which indirectly protects infants from transmission by preventing disease in those in close proximity. The goal of this review was to present and discuss evidence on these 2 strategies. Based on available data, the GPI recommends vaccination during pregnancy as the primary strategy, given its efficacy, safety, and logistic advantages over a cocoon approach. If vaccination during pregnancy is not feasible, then all individuals having close contact with infants <6 months old should be immunized consistent with local health authority guidelines. These efforts are anticipated to minimize pertussis transmission to vulnerable infants, although real-world effectiveness data are limited. Countries should educate lay and medical communities on pertussis and introduce robust surveillance practices while implementing these protective strategies.

CONCLUSIONS: Antenatal pertussis immunization results in high infant pre-immunization antibody concentrations, but blunts subsequent responses to pertussis vaccine and some CRM-conjugated antigens. In countries with no pertussis booster until school age, continued monitoring of protection against pertussis is essential.

Renacoq data confirmed the risk for young children and the need of timely pertussis vaccination. Parents and sibling remain the main source of infection, despite addition of boosters targeting sibling and parents. Improving vaccination coverage in adults in contact with younginfants is needed. The continuation of Renacoq surveillance will allow monitoring the impact of additional vaccination strategies.

Toxoplasmosis congénita (ver también Temas A-Z)

CONCLUSIONS: Our findings reveal that in infants with clinical and serologic findings suggestive of congenital toxoplasmosis and born to untreated mothers, CSF PCR has the potential to increase the frequency of cases in which the diagnosis is confirmed.

Se analizan 2 ECCR que incluyen un total de 5455 mujeres. El primero realizado en Canadá valora el impacto de una charla de unos 10 min sobre el toxoplasma en las clases de preparación al parto vs las que acuden a las clases habituales. El segundo realizado en Francia, valora el impacto de entregar a las mujeres un folleto informativo y una audición sobre el toxoplasma. En ambos se valora el impacto de las medidas con un cuestionario y en el segundo estudio además si se ha producido seroconversión.

Los resultados no son concluyentes y los estudios tienen una baja calidad metodológica, aunque la prevención primaria es recomendada.

Traqueitis

Tuberculosis (ver también Temas A-Z)

In this issue of Archives of Disease in Childhood, Singh et al report the impact of age and nutritional status on the population pharmacokinetic study of INH and PZA in 37 children. 

OBJECTIVES: To evaluate pharmacokinetics of first-line antitubercular drugs, isoniazid (INH) and pyrazinamide (PZA), with revised WHO dosages and to assess its adequacy in relation to age and nutritional status.

DESIGN: Observational study.

SETTING: This study was conducted at Sarojini Naidu Medical College, Agra, and National Institute for Research in Tuberculosis, Chennai.

PATIENTS: 40 subjects diagnosed with tuberculosis were registered in the study and started on daily first-line antitubercular regimen based on the revised WHO guidelines.

INTERVENTIONS: Blood samples were collected at 0, 2, 4, 6 and 8 hours from these subjects after 15 days of treatment for drug estimations.

MAIN OUTCOME MEASURE: The measurement of drug concentrations (maximum peak concentration (Cmax) and area under the time -concentration curve (AUC0-8 hours)) for INH and PZA. Appropriate statistical methods were used to evaluate the impact of age and nutritionalstatus on pharmacokinetic variables.

RESULTS: For INH, the difference in drug exposures in children <3 years (Cmax 3.18 µg/mL and AUC0-8 hours15.76 µg/mL hour) and children>3 years (Cmax3.05 µg/mL and AUC0-8 hours 14.37 µg/mL hour) was not significant (P=0.94, P=0.81, respectively). The drug levels in childrenwith low body mass index (BMI) (Cmax3.08 µg/mL; AUC0-8 hours14.81 µg/mL hour) were also comparable with their normal counterparts (Cmax3.09 µg/mL, P=0.99; AUC0-8 hours 14.69 µg/mL hour, P=0.82). PZA drug exposures obtained in children less than 3 years (Cmax29.22 µg/mL, AUC0-8 hours 155.45 µg/mL hour) were significantly lower compared with drug levels in children above 3 years (Cmax 37.12 µg/mL, P=0.03; AUC 202.63 µg/mL hour, P value=0.01). Children with low BMI had significantly lower drug concentrations (Cmax 31.90 µg/mL, AUC0-8 hours167.64 µg/mL hour) when compared with normal counterparts (Cmax 37.60 µg/mL, P=0.02; AUC0-8 hours 208.77 µg/mL hour, P=0.01).

CONCLUSIONS: The revised WHO drug dosages were found to be adequate for INH with respect to age and nutritional status, whereas PZA showed significantly lower drug levels in children <3 years and in malnourished children.

Resumen: estudio de cohortes multicéntrico para establcer el valor predictivo de la tuberculina y dos test IGRA. IGRA-based or BCG-stratified TST strategies appear most suited to screening for potential disease progression among high-risk groups. Further work will be needed to assess country-specific cost-effectiveness of each screening test, and in the absence of highly specific diagnostic tests, cheap non-toxic treatments need to be developed that could be given to larger groups of people at potential risk.

QFT-based LTBI screening was successfully introduced in our pediatric primary-care health system, and supported our programmatic goals of identifying LTBI cases while limiting unnecessary LTBI treatment courses. Increasing positive rates with age, and higher rates in the refugee/TB populations compared with CHS, add indirect evidence of adequate test sensitivity, even among young children, for whom data on interferon-gamma release assay performance are limited.

Revisión de los lactantes menores de 3 meses con tuberculosis durante el periodo 1978-2014. Se diagnosticaron 8 casos (1,4% de las tuberculosis pediátricas): 3 tuberculosis congénitas, 3 sugestivas (biopsia endometrial no realizada) y 2 posnatales. La prueba de tuberculina fue negativa en 2 casos. La rentabilidad diagnóstica del cultivo (7/7, 100%) o PCR (3/3, 100%) de aspirado gástrico fue superior a la de la baciloscopia (5/8, 62%) y el test IGRA (1/3, 33%). Tres pacientes presentaron diseminación miliar y uno falleció. En conclusión, la tuberculosis en este grupo de edad es infrecuente, grave y de difícil diagnóstico. En ausencia de contactos posnatales conocidos, se recomienda descartar tuberculosis genital materna mediante biopsia endometrial.

De los niños que mueren a causa de la enfermedad, nueve de cada 10 no habían recibido tratamiento. La mayoría de los casos, según un nuevo informe, son prevenibles, tratables y curables con medidas de salud pública simples y rentables

The number of children with adverse effects were similar in children receiving isoniazid medication as the control group in both children on ART and not on ART.

Se incluyeron 124 pacientes (56,5% hombres, edad mediana: 4,0 años). En la mitad, la TB afectó a pacientes de origen inmigrante y se diagnosticó por sospecha clínico-radiológica. La TB intratorácica fue la forma clínica predominante (91,9%), los cultivos fueron positivos en un tercio de los casos (37,9%) y sensibles a los fármacos orales de primera línea en su totalidad. El tiempo mediano (rango intercuartil) de tratamiento fue de 6 (6-9) meses; solo 10 pacientes precisaron tratamiento directamente observado y la evolución fue satisfactoria en la mayoría (98,4%). Entre los adolescentes, la TB fue más prevalente en mujeres (63,2%) e inmigrantes (68,4%), la comorbilidad al diagnóstico y las formas pulmonares cavitadas fueron más comunes y se identificó el caso índice solo en el 21,1% de los pacientes.

En el adolescente, la TB pulmonar tipo adulto es común, y a menudo asocia comorbilidad y se diagnostica más tarde, implicando un mayor riesgo de contagio a la comunidad.

Resumen: El objetivo es describir las características y resultados de los niños con presunta TB y con enfermedad TB, y evaluar el rendimiento de Xpert frente a un diagnóstico clínico de TB. A pesar del acceso a Xpert, la mayoría de los niños con presunta TB fueron tratados basándose en el diagnóstico clínico. Refleja la realidad de la práctica clínica en escenarios de recursos limitados. Los nuevos diagnósticos, como el Xpert, sirven como importantes pruebas complementarias, pero no obviarán la necesidad de clínicos perspicaces y algoritmos diagnósticos exhaustivos.

Casi 200 000 niños menores de 5 años murieron de tuberculosis (TB) en 2015, principalmente en el África subsahariana y el sudeste asiático, según el estudio “La carga mundial de la mortalidad por tuberculosis en los niños: un estudio de modelado matemático”.

Accurate and rapid diagnosis of extrapulmonary nodal tuberculosis in children is of paramount importance. This retrospective study performed at Tygerberg Hospital using data from the laboratory records between January 1, 2004 and June 30, 2014 demonstrates how since the introduction laboratory-run FNAB service; fine needle aspiration biopsy has become an acceptable and routine diagnostic procedure for triage of pediatric lymphadenopathy

Background: Isoniazid is recommended for prevention of tuberculosis (TB) in HIV-infected adults, but its efficacy in children living with HIV (CLHIV) is not known. We performed a systematic review to assess the efficacy of isoniazid for the prevention of TB in CLHIV.

Methods: We searched PubMed, Cochrane Clinical Trial Registry and Google Scholar from inception to December 2016. Any randomized controlled trial assessing the role of isoniazid for the prevention of TB in CLHIV was eligible for inclusion. The primary endpoint was TB incidence; secondary end points were mortality, overall survival and severe adverse events. Dual independent extraction of all data was performed. Data were pooled under a random effects model and summarized either as risk ratio (RR) or hazard ratio along with 95% confidence intervals (CIs).

Results: Of 931 references, 3 randomized controlled trials enrolling 977 patients met the inclusion criteria. Pooled results showed a statistically nonsignificant reduction in TB incidence (RR: 0.70; 95% CI: 0.47–1.04; P = 0.07) and mortality (RR: 0.94; 95% CI: 0.39–2.23; P = 0.88) with the use of isoniazid compared with placebo. One study was stopped early because of excess deaths in the placebo arm. However, results from subgroup analysis restricted to only completed trials did not change the overall findings.

Conclusions: Isoniazid did not reduce the incidence of TB in CLHIV. All included studies were performed in regions with high prevalence of TB making the overall generalizability limited.

The cost-effectiveness of diagnostic tools for TB in children depends on the population, natural history of untreated TB and existing diagnostic practices. In settings where the risk of TB death is high, empiric treatment of all children for TB should be considered until a more sensitive, low-cost diagnostic test is available.

Conclusions: Despite the concern about the use of QFT-IT in children because of their immature immune system, our results suggest the preferential use of QFT-IT as a support tool for diagnosis and management of TB, even in infants.

Tuberculous dacryoadenitis occurs rarely. It should be suspected in children presenting with unremitting inflammation of the lacrimal gland despite standard antibiotic and/or anti-inflammatory treatment, and a thorough systemic evaluation should be undertaken to identify a primary infectious site. We present an adolescent girl in whom bilateral dacryoadenitis was the first sign of pulmonary tuberculosis.

Conclusions: The majority of immigrant children with a positive preimmigration TST tested negative for TB infection on domestic evaluation using TST or IGRA. Inclusion of IGRA in preimmigration TB screening is likely to reduce subsequent testing, treatment and cost of evaluations among immigrant children to the US.

Resumen: Recientemente se han desarrollado test inmunológicos tales como QuantiFERON-TB Gold In-Tubo (QFT-IT) y T-SPOT®.TB que se utilizan

comúnmente para identificar la TB activa en adultos, pero se requieren más pruebas para su uso en el diagnóstico de la TB infantil. El propósito de este estudio fue evaluar de nuevo la sensibilidad y especificidad de los IGRA en la detección de TB activa confirmada microbiológicamente en niños inmunocompetentes de 0-18 años. La conclusión es que QFT-IT y T-SPOT tienen mayor especificidad que TST para la detección de casos de TB activa en niños inmunocompetentes. Sin embargo una de las limitaciones de este estudio es que hay un número pequeño de estudios centrados en niños menores de 5 años. Por lo tanto se debe tener precaución al considerar el uso preferencial de estos test en este grupo de edad.

Deworming in children with recent M. tuberculosis exposure is associated with a trend toward a negative TST result. Timing of deworming might influence interpretation of TST in settings with high burdens of tuberculosis and helminths.

Bacteriological evaluation should not be performed in the absence of any clinical indication. If drug-resistant Mycobacterium tuberculosis is detected in an asymptomatic child with a normal chest radiograph, close observation may be an appropriate strategy, especially in settings where potential laboratory error and poor record keeping are constant challenges.

In our low-prevalence region, childhood EPTB was linked to immigrant status, immune disorders and drug resistance, and presented high rate of complications. Our study underscores the relevance of improved diagnostic tools and systematic TB screening in high risk populations.

Peripheral lymphadenopathy (scrofula) is the second most common site for childhood tuberculosis. Paradoxical reactions are commonly seen even in immunocompetent children after therapy is initiated, and this can lead to draining sinus tracts. We describe a multimodal therapeutic option of antituberculosis therapy, corticosteroids and therapeutic ultrasound-guided nodal aspiration in an adolescent with massive cervical adenopathy.

A 4-year-old boy, previously healthy, had a 7-month history of a lesion on his face. He also had left-sided cervical adenopathy, with a diameter of 3.5 × 2.5 cm, which was not painful nor adherent to the overlying skin. Despite several courses of antibiotic therapy (erythromycin, amoxicillin-clavulanic acid, and cefaclor), there was no improvement. Surgical drainage of the lymphadenitis, undertaken after 14 days of illness, led to a chronic draining fistulous tract. Subsequently, he presented with 2 skin lesions, the largest being 2.5 × 2.5 cm (Figure). Tuberculin skin test was positive with an induration of 25 mm. Lymph node biopsy showed granulomatous inflammation and caseation necrosis. The exudate culture was positive for Mycobacterium tuberculosis. Radiography of the chest, computed tomography of the chest, and laboratory results were all normal. Serologic testing for the human immunodeficiency virus was negative. A 75-year-old relative with pulmonary tuberculosis was identified as the source of contagion, which had occurred approximately 6 weeks before clinical onset.

An 8-year-old boy presented with the complaint of swelling over the left side of the neck over the last 6 weeks. The swelling was gradually progressive and painless; it ruptured with thick purulent discharge 2 days before presentation. There was no history of fever, cough, or weight loss. His father had pulmonary tuberculosis and was currently receiving therapy. On examination, the patient had an ulcerative lesion of 3.2 × 2.1 cm with undermined edges and a necrotic base with surrounding induration (Figure, A). The overlying skin was excoriated and shiny. Fine-needle aspiration cytology of the left cervical lymph node (level III) showed acid fast bacilli (Figure, B). The Mantoux test with 5 tuberculin units was positive. Chest radiography and ultrasonography of the abdomen were normal. The child was started on a standard regimen of antituberculosis drugs, and he responded well over a period of 6 months.

Estudio sueco retrospectivo de los registros de pacientes inmigrantes en Suecia de países en conflicto: 1. la vacunación previa con BCG tiene un efecto sobre el diámetro de la PT y se recomienda una prueba IGRA (QFT) para diagnosticar la TB latente. Usando solo la PT para el cribado de la TB latente podría llevar a un sobrediagnóstico. 2. El diámetro de la PT fue mayor en niños con QFT positivo que en los QFT negativos pero en un paciente concreto no servía para predecir la respuesta a la prueba IGRA. 3. La Rx de torax contribuye poco al diagnóstico de la TB en los niños con QFT negativo pero no pudo ser omitida debido a la seroconversión tardía en algunos pacientes.

El objetivo de este documento técnico es revisar la mayor utilidad de los IGRAs para: incrementar la especificidad de los test cutáneos en los casos de niños que han recibido vacuna BCG (y pueden presentarse como falsos positivos en la prueba de tuberculina); usado de forma conjunta con la tuberculina incrementar la sensibilidad en el diagnóstico de las formas de infección tuberculosa latente en pacientes de alto riesgo para progresar de infección latente tbc a enfermedad tba; y ayudar en el diagnóstico de la enfermedad tuberculosa. 

Se realizaron Mantoux, QuantiFERON-TB Gold In-Tube y T-SPOT.TB  en 338 niños en riesgo de haber adquirido TBC, incluyendo 70 casos de TBC activa. En niños menores de 5 años la sensibilidad del QuantiFERON-TB Gold In-Tube fue de un 73.3% [intervalo de confianza (IC) 95%: 57.5–89.1]; y la sensibilidad del T-SPOT.TB de un 59.3% (IC 95%: 40.1–77.8); ambos inferiores a Mantoux que mostró una sensibilidad del 90.0% (IC 95%: 79.3–100). En niños mayores de 5 años la sensibilidad de QuantiFERON-TB Gold In-Tube fue de 92.5% (IC 95%: 84.4–100); la sensibilidad del T-SPOT.TB fue de 73.0% (IC 95%: 58.6–87.3) ; y la sensibilidad del Mantoux fue de 97.5% (IC 95%: 92.6–100). Las especificidades de los test fueron similares en todos los grupos de edad.

Children admitted to hospital were enrolled in a study of novel diagnostics for PTB in South Africa. Prolonged fever, CXR suggestive of TB or a positive TST were predictive of definite TB and should be considered in composite scoring systems for TB diagnosis in high HIV prevalence settings. Other commonly associated symptoms were not associated with definite TB

Tuberculosis (TB) in children can be challenging to diagnose with microbiological certainty. Younger children are unable to expectorate sputum and the bacillary load is frequently low; few children with a clinical diagnosis of pulmonary TB have this confirmed microbiologically. Similarly, confirmation of extra-pulmonary TB, using other samples, can be difficult.

La respuesta al tratamiento podría ser útil como confirmación diagnóstica en la tuberculosis pediátrica. Este estudio pretende evaluar el tiempo hasta la resolución de los síntomas en niños tratados de TBC pulmonar. 

En la mayoría de los niños, los síntomas iniciales tardan en resolverse más de 60 días tras el inicio del tratamiento. Además, puesto que el tiempo de resolución de los síntomas no difiere entre casos de TBC y no casos, la respuesta clínica al tratamiento no es un criterio diagnóstico adecuado para ser usado en ensayos clínicos de diagnóstico, tratamiento y vacunas de TBC. 

Both microbial and host factors can affect the outcome of M. tuberculosis infection in children. Future studies incorporating hostand pathogen data from different populations are warranted to develop new strategies for childhood TB control.

The objective was to assess the annual risk of tuberculosis infection by means of tuberculin skin testing (TST) in children, evaluating whether QuantiFERON-TB (QFN-G-IT) could improve the accuracy. Based on the positive TST results, the global annual incidence was estimated at 0.78%, with an increase in the prevalence from 0.64% to 1.68% in two years. However, QFN-G-IT was only positive in 6 of the 25 children with positive TST. The confirmation of the positive TST results by QFN-G-IT provided more accurate annual incidence estimation.

Un caso clínico de una enfermedad de siempre.

Background. Child tuberculosis contact screening and management can enhance case finding and prevent tuberculosis disease. It is universally recommended but rarely implemented in tuberculosis-endemic settings. The World Health Organization (WHO)–recommended symptom-based screening approach could improve implementation but has not been prospectively evaluated.

Methods. We conducted a cohort study of children who were close contacts of pulmonary tuberculosis patients in Indonesia from August 2010 to December 2012.We performed clinical assessment, tuberculin skin test, and chest radiography in all eligible children irrespective of symptoms at baseline. Mycobacterial culture and Xpert MTB/RIF assay were performed on sputum from children with persistent symptoms of suspected tuberculosis. Children were managed according to WHO guidelines and were prospectively followed for 12 months.

Results. A total of 269 child contacts of 140 index cases were evaluated. At baseline, 21 (8%) children had tuberculosis diagnosed clinically; an additional 102 (38%) had evidence of infection without disease. Of children with any tuberculosis-related symptoms at baseline, 21% had tuberculosis diagnosed compared with none of the asymptomatic children (P < .001). After 12 months of follow-up, none of the 99 eligible young child contacts (<5 years) who received isoniazid preventive therapy (IPT) had developed disease compared with 4 of 149 (2.6%) asymptomatic older children who did not receive IPT. Conclusions. Symptom-based screening is an effective and simple approach to child tuberculosis contact management that can be implemented at the primary healthcare level.

Abstract. After exposure to a teacher with multidrug-resistant pulmonary tuberculosis, 31 children developed latent infection. Twenty-six were treated with levofloxacin and pyrazinamide. Twelve required a change in therapy secondary to adverse effects. The most common adverse effects included abdominal pain, arthralgias/myalgias and elevated transaminases. All children reported at least 1 adverse effect. Fifteen children completed treatment. All adverse effects were transient.

Resumen: estudio que realiza una estimación de la incidencia global de tuberculosis resitente a isoniacida. Estima que uno de cada 8 niños tendrán enfermedad o infección tuberculosa por micobacterias resistentes a isoniacida a nivel mundial, pero llama l atención que hasta 1 de cada cuatro serán resistentes en la región europea de la OMS

A 7-month-old boy presented to the emergency department with fever of 7 days' duration. Physical examination revealed bilateral nonexudative conjunctivitis, anterior cervical lymphadenopathy, erythematous hands and feet, erythematous truncal rash, and erythema and eschar at the bacillus Calmette–Guérin (BCG) inoculation site (Figure 1; available at www.jpeds.com). He received the diagnosis of Kawasaki disease and was treated with intravenous immunoglobulin and aspirin. The symptoms of Kawasaki disease resolved after 2 days.

El objetivo de este estudio es evaluar los niveles de vitamina D en niños con TB latente y TB activa comparándolos con los niveles en controles sanos de la misma edad y grupo étnico. La hipovitaminosis D se asoció significativamente con la infección tuberculosa. Los autores consideran necesarios más estudios para evaluar el posible papel de la vitamina D en el tratamiento y prevención de la tuberculosis en los niños, sobre todo nuevos ensayos controlados y aleatorizados para comparar los resultados del tratamiento de la tuberculosis en los niños que recibieron suplementos de vitamina D, además de la terapia estándar.

We evaluated a 5-year-old boy with high-grade, intermittent fever, weight loss, and episodic nonprojectile vomiting for the previous 2 months. There was no associated abdominal pain, jaundice, chronic cough, bleeding manifestations, altered sensorium, seizures, or focal motor or visual deficits. 

A 9-year-old, fully immunized boy presented with a 2-month history of intermittent, low-grade fever followed by frontotemporal headache, vomiting, bilateral squint, drooping of the right eyelid, and double vision for the past 2 days. There were no seizures, altered sensorium, or behavioral changes. His mother had been treated for pulmonary tuberculosis 7 years previously. Examination showed pallor, cervical lymphadenopathy, bilateral papilledema, right-sided 3rd and 6th nerve palsies, meningismus, brisk muscle stretch reflexes, and bilateral Babinski sign.

Tuberculosis congénita (ver también Temas A-Z)

Tuberculosis vacuna (ver también Temas A-Z)

In France, Bacillus Calmette–Guérin (BCG) vaccination by multipuncture device was withdrawn in 2006. In 2007, universal mandatory BCG vaccination was replaced by vaccination of high-risk children. To evaluate the impact of these changes on tuberculous meningitis (TBM) epidemiology, data on culture-positive and culture-negative (or unknown microbiological result) TBM in ≤5 years olds were collected from 2000–2011.Ten culture-positive and 17 culture-negative TBM cases were identified, with an annual incidence rate ranging from 0.16 to 0.66 cases per 10 million inhabitants. The average annual numbers of TBM cases were 2.7 and 1.8 from 2000–2005 and 2006–2011, respectively. In Ile-de-France where all children are considered at risk, the overall incidence rates were 1.14 and 0.29 per million for the two periods. In other regions where only at-risk children are vaccinated since 2007, rates were 0.30 and 0.47, respectively. None of these differences were significant. Annual incidence rates for each one-year age group cohort were comparable before and after changes. Childhood TBM remains rare in France. No increase in incidence was observed after changes in BCG vaccination strategy. Ongoing surveillance should be maintained, as a slight increase in TBM in the coming years remains possible, in the context of suboptimal vaccination coverage of high-risk children.

A 12-year-old boy presented with a slowly enlarging plaque, at the site of BCG vaccination (Statens Serum Institute, Danish strain 1331), administered 14 months previously (figure 1). Mantoux testing showed a 14 mm induration and his interferon-gamma (IFN-γ) release assay was negative. Skin biopsy revealed non-caseating dermal granulomata composed of epithelioid histiocytes and Langhans-type multinucleated giant cells (figure 2). No acid fast bacilli were seen. PCR for Mycobacterium tuberculosis complex (includes M bovis) was negative. Based on a clinical diagnosis …

Úlcera

Comentario: caso de niña de 10 años que inicia úlceras gangrenosas genitales dolorosas a los 2 días de cuadro febril con odinofagia y cefalea. Ingresa para estudio y tratamiento antibiótico y antiviral hasta el resultado microbiológico, que resulta negativo. Plantean el diagnóstico diferencial y la etiología desconocida aunque se ha relacionado con varios virus.

Vacunas (ver en cada patógeno y en apartado específico)

OBJECTIVES: To assess the effectiveness and potential side effects of formula feeding to reduce pain during vaccination among infants.

STUDY DESIGN: In the setting of well-baby clinics we recruited a community-based sample of full-term born infants who were already formula fed by the choice of the parents (n=48, aged 4-10 weeks) and received their first DTaP-IPV-HepB-Hib and pneumococcal vaccinations and randomised them into two groups. To evaluate pain experienced during vaccination we compared infants who drank formula feeding before, during and after vaccination with infants who did not. Outcomes were observed cry duration and pain scores measured by means of the Neonatal Infant Pain Scale (NIPS) and the Face, Legs, Activity, Cry and Consolability (FLACC) scale. Side effects of drinking during vaccination were recorded. We performed intention-to-treat analyses using regression models, crude and adjusted for sex and age of the infant.

RESULTS: Pain at the moment of the second injection did not differ between groups. Drinking infants cried 33.5 s shorter (-56.6; -10.3). In the first minute after injection drinking infants experienced a faster pain reduction on the NIPSΔt: regression coefficient 3.86 (95% CI 2.70 to 5.02) and FLACCΔt: 4.42 (95% CI 2.85 to 5.99).

CONCLUSIONS: In line with findings of previous studies regarding breast feeding, formula feeding reduced vaccination pain in the recovery phase in full-term born infants receiving their first vaccinations between ages 4 and 10 weeks with no adverse effects. Professionals should discuss this non-costly and feasible pain-reducing intervention with parents of infants who receive vaccinations.

En España la incidencia de enfermedades inmunoprevenibles es baja. En cuanto a las coberturas vacunales, son altas en la infancia, pero en adolescentes, adultos y grupos de riesgo no siempre son adecuadas

Using 25 mm needles (either 23 G or 25 G) for intramuscular vaccination procedures in the anterolateral thigh of infants using the WHO injection technique (skin stretched flat, needle inserted at a 90° angle and up to the needle hub in healthy infants) probably reduces the occurrence of local reactions while achieving a comparable immune response to 25 G 16 mm needles. These findings are applicable to healthy infants aged two to six months receiving combination DTwP vaccines with a reactogenic whole-cell pertussis antigen component. These vaccines are predominantly used in developing countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.

Vacunas, efectos indirectos

Las vacunas vivas atenuadas (como el sarampión) podrían tener efectos no específicos beneficiosos y las vacunas inactivadas (como la DTP) podrían tener efectos nocivos no específicos. La evidencia de los efectos no específicos de las vacunas sigue siendo débil ya que la mayoría de las pruebas provienen de estudios observacionales, que son vulnerables al sesgo

Lo que añade este estudio: El sesgo vacunal saludable explica al menos en parte la menor tasa observada de ingreso hospitalario para la infección después de la vacunación triple vírica (TV); esta tasa más baja se asocia con la recepción de cualquier vacuna adicional y no específicamente con TV. Los posibles efectos no específicos de la TV, sin embargo, no se pueden distinguir de los sesgos. Los hallazgos destacan la importancia de la precaución en la interpretación de los resultados de los estudios observacionales sobre los efectos no específicos de la vacunación

A significant reduction in hospital visits because of AOM and pneumonia in children vaccinated with pneumococcal protein-conjugated vaccine-10 was established. The abrupt and significant reduction of AOM is unusually clear. This reduction was noted very early after initiation of the vaccination.

Bacille Calmette-Guerin (BCG) vaccination has been suggested to have nonspecific beneficial effects in children from developing countries, reducing morbidity and mortality caused by unrelated pathogens. Background.We aimed to assess the heterologous protective effects of BCG vaccination against respiratory infection (RI) and sepsis not attributable to tuberculosis in children born in Spain. Objective.

We conducted a retrospective epidemiological study using data from the Official Spanish Registry of Hospitalizations (CMBD-HA) to identify differences in hospitalization rates (HR) in BCG-vaccinated children (Basque Country, where neonatal BCG is part of the immunization schedule and has a 100% coverage) as compared to non-BCG-vaccinated children (from the rest of Spain, where BCG is not used). Methods.

A total of 464 611 hospitalization episodes from 1992 to 2011 were analyzed. The HR due to RI not attributable to tuberculosis in BCG-vaccinated children was significant lower compared to non-BCG-vaccinated children for all age groups, with a total preventive fraction (PF) of 41.4% (95% confidence interval: 40.3–42.5; P-value Results. <.001). According to age group, PF was 32.4% (30.9–33.9; P-value <.001) for children under 1 year old, 60.1% (58.5–61.7; P-value <.001) for children between 1 and 4 years old, 66.6% (62.8–70.2; P-value <.001) for children between 5 and 9 years old, and 69.6% (63.3–75.0; P-value <.001) for children between 10 and 14 years old. The HR due to sepsis not attributable to tuberculosis in BCG-vaccinated children under 1 year of age was also significantly lower, with a PF of 52.8% (43.8–60.7; P-value <.001).

BCG vaccination at birth may decrease hospitalization due to RI and sepsis not related to tuberculosis through heterologous protection.

Conclusions BCG vaccination at birth did not reduce the risk of hospitalisation for somatic acquired disease until 15 months of age in this Danish study population

A 12-year-old boy presented with a slowly enlarging plaque, at the site of BCG vaccination (Statens Serum Institute, Danish strain 1331), administered 14 months previously (figure 1). Mantoux testing showed a 14 mm induration and his interferon-gamma (IFN-γ) release assay was negative. Skin biopsy revealed non-caseating dermal granulomata composed of epithelioid histiocytes and Langhans-type multinucleated giant cells (figure 2). No acid fast bacilli were seen. PCR for Mycobacterium tuberculosis complex (includes M bovis) was negative. Based on a clinical diagnosis …

Vacunas (embarazo)

Resumen: Con datos del ACIP, de entre 2004 y 2014, sobre 413 034 nacidos vivos en USA, no encuentran relación entre el numero de hospitalizaciones o de muertes infantiles durante los primeros 6 meses de vida y la vacuna antigripal o la vacuna dTpa en la gestante.

To assess whether preterm infants are at increased risk of pertussis infection and whether this increased following introduction of a maternal pertussis vaccination in England, while examining characteristics of infants associated with more severe disease.

METHODS: Infants aged <60 days admitted between 1 April 2009 and 31 March 2016 with a pertussis diagnosis code were extracted from Hospital Episode Statistics (HES) data. HES data were reconciled with existing surveillance systems to capture maternal vaccination status where available. Cases were compared preimplementation and postimplementation of the maternal programme with respect to demography, preterm or full-term birth and coinfection. Survival analysis was undertaken to assess the impact of variables on duration of hospital stay.

RESULTS: The proportion of hospitalised preterm infants (138/1309, 10.6%) was higher than population estimates (7.4%), increasing from 9.8% (83/847) to 12.1% (56/462) following implementation of the maternal programme. Longer duration of hospital stay was associated with prematurity, younger age, additional respiratory illnesses and mothers unvaccinated in pregnancy. Of 13 deaths, 5 were preterm (38.5%) and 11 (84.6%) were female. A larger proportion of full-term infants' (49/188, 26.1%) mothers had been vaccinated in pregnancy than preterm infants (7/49, 14.3%), with 14.3% of mothers of full-term cases vaccinated after 35 weeks.

CONCLUSIONS: Preterm infants are over-represented in hospitalised pertussis cases and have less benefit from the maternal pertussis vaccination programme in England due to reduced opportunity for maternal vaccination.

In many high-income countries, pregnant women have long been prioritized to receive influenza vaccine, based on expected benefits to the woman and the infant. In a global evaluation based on data collected in 2014, the World Health Organization reported that 75% of high-income countries had influenza vaccine policies that targeted pregnant women. Unfortunately, most low- and middle-income countries do not use influenza vaccine. In that same World Health Organization survey, of 49 low- and middle-income countries eligible for Gavi support, only 4 (8%) had any influenza vaccine policy and only 2 (4%) targeted pregnant women.

Conclusions: This study demonstrated that Tdap during pregnancy results in higher levels of antibodies early in infancy but lower levels after the primary vaccine series.

Vaccination during pregnancy is an effective way to protect infants during the early months of life. With a continuing resurgence in pertussis, efforts should focus on maximizing Tdap uptake among pregnant women.

En un análisis secundario de un estudio randomizado se evalua el efecto de la vacuna de la gripe en las gestantes y su potencial efecto sobre la hospitalización por patología de vías aéreas inferiores por todas las causas.

Se concluye que la vacunación en el embarazo produce un descenso en las hospitalizaciones por patología de vías aéreas inferiores de cualquier etiología y por sobreinfecciones bacterianas secundarias a la gripe.

Background. Maternal immunization against pertussis is currently recommended after the 26th gestational week (GW). Data on the optimal timing of maternal immunization are inconsistent.

Methods. We conducted a prospective observational noninferiority study comparing the influence of second-trimester (GW 13–25) vs third-trimester (≥GW 26) tetanus-diphtheria-acellular pertussis (Tdap) immunization in pregnant women who delivered at term. Geometric mean concentrations (GMCs) of cord blood antibodies to recombinant pertussis toxin (PT) and filamentous hemagglutinin (FHA) were assessed by enzyme-linked immunosorbent assay. The primary endpoint were GMCs and expected infant seropositivity rates, defined by birth anti-PT >30 enzyme-linked immunosorbent assay units (EU)/mL to confer seropositivity until 3 months of age.

Results. We included 335 women (mean age, 31.0 ± 5.1 years; mean gestational age, 39.3 ± 1.3 GW) previously immunized with Tdap in the second (n = 122) or third (n = 213) trimester. Anti-PT and anti-FHA GMCs were higher following second- vs third-trimester immunization (PT: 57.1 EU/mL [95% confidence interval {CI}, 47.8–68.2] vs 31.1 EU/mL [95% CI, 25.7–37.7], P < .001; FHA: 284.4 EU/mL [95% CI, 241.3–335.2] vs 140.2 EU/mL [95% CI, 115.3–170.3], P < .001). The adjusted GMC ratios after second- vs third-trimester immunization differed significantly (PT: 1.9 [95% CI, 1.4–2.5]; FHA: 2.2 [95% CI, 1.7–3.0], P < .001). Expected infant seropositivity rates reached 80% vs 55% following second- vs third-trimester immunization (adjusted odds ratio, 3.7 [95% CI, 2.1–6.5], P < .001).

Conclusions. Early second-trimester maternal Tdap immunization significantly increased neonatal antibodies. Recommending immunization from the second trimester onward would widen the immunization opportunity window and could improve seroprotection.

CONCLUSIONS: Mothers who received seasonal TIV during pregnancy were significantly less likely to experience stillbirth compared with unvaccinated mothers. These results support the safety of seasonal influenza immunization during pregnancy and suggest a protective effect.

Resumen: los hijos de madres vacunadas durante el último trimestre de embarazo tienen más anticuerpos protectores a los 2 meses de edad que lo hijos de madres no vacunadas. A los 12 meses de edad, las tasas son similares en ambos grupos.

Resumen: Sobre la repercusión de la vacunación antigripal en embarazadas e incidencia de la enfermedad en descendientes: en los primeros 6 meses de vida, onstatan una reducción de riesgo del 64% de enfermedad tipo gripal, del 70% de gripes confirmadas mediante laboratorio, y del 81% en ingresos hospitalarios por gripe

Maternal influenza vaccination was associated with a reduction in the incidence of hospital admission for acute respiratory illness among infants <6 months of age. These data suggest that vaccination during third trimester may provide optimal benefit to the newborn.

This study demonstrated that prenatal tetanus, diphtheria, and acellular pertussis vaccination prevents pertussis in infants. It was 85% more effective than postpartum vaccination at preventing pertussis in infants <8 weeks of age; receipt at 27–36 weeks gestation was optimal.

Prenatal tetanus, diphtheria, and acellular pertussis vaccination reduces severity of disease in infants infected with pertussis; it was 58% effective (95% confidence interval, 15%–80%) in preventing hospitalization and lowered the risk of intensive care unit admission in these infants.

Vacunación internacional

La vacunación del viajero es una de las estrategias fundamentales para la prevención de las enfermedades infecciosas durante un viaje internacional. El riesgo de adquisición de una determinada enfermedad infecciosa viene condicionado en cada caso por las características del viajero y del viaje, por lo que el consejo del viajero y la indicación de las vacunas tendrán que hacerse de forma individualizada. La Organización Mundial de la Salud clasifica las vacunas que se pueden utilizar en viajeros en tres grupos.- Vacunas de uso rutinario en los programas nacionales de inmunización: Haemophilus influenzae tipo b, hepatitis B, poliomielitis, sarampión-parotiditis-rubéola, tétanos-difteria-tos ferina y varicela. - Vacunas exigidas por Ley en ciertos países para entrar en ellos: fiebre amarilla, enfermedad meningocócica y poliomielitis. –Vacunas recomendadas antes del viaje según las circunstancias: cólera, encefalitis japonesa, encefalitis por mordedura de garrapata, enfermedad meningocócica, fiebre tifoidea, gripe, hepatitis A, hepatitis B, rabia y BCG. Esta revisión tiene el propósito de introducir al lector en el campo de la vacunación internacional.

Vacunas rechazo

La contribución de las vacunas a la salud de las poblaciones es un hecho demostrado científicamente. La vacunación es la actividad sanitaria con mayor impacto en términos de años de calidad de vida ganados. Es prioritaria para mantener la salud, para eliminar determinados riesgos y para controlar situaciones de epidemia o endemia. El número de familias reticentes a vacunar a sus hijos es pequeño en nuestro país y aún lo es más el número de personas que rechazan de pleno la vacunación y son activistas antivacunas. Este poner en duda la actividad vacunal que llevan a cabo los profesionales sanitarios, es sentido por muchos como si se pusiese en duda su pericia o su integridad profesional. Esto genera sentimientos de rechazo hacia estas familias y dudas éticas en torno a las actitudes y decisiones a adoptar en estas situaciones. Se describen las circunstancias que podrían llevar a la ruptura de la relación médico-paciente, cómo prevenir esta situación y cómo afrontarla si se presentase.

There is low- to moderate-certainty evidence suggesting that face-to-face information or education may improve or slightly improve children's vaccination status, parents' knowledge, and parents' intention to vaccinate.

Face-to-face interventions may be more effective in populations where lack of awareness or understanding of vaccination is identified as a barrier (e.g. where people are unaware of new or optional vaccines). The effect of the intervention in a population where concerns about vaccines or vaccine hesitancy is the primary barrier is less clear. Reliable and validated scales for measuring more complex outcomes, such as attitudes or beliefs, are necessary in order to improve comparisons of the effects across studies.

A total of 40 interventions have been included in the catalogue of interventions, strategies and tools addressing vaccine hesitancy. Ten of these are diagnostic tools, developed to measure or monitor vaccine hesitancy. The majority (27/40) of interventions responding to vaccine hesitancy are based on dialogue, communication or information tools for parents or healthcare workers. Only one intervention is based on an advocacy campaign, another one on a reminder-recall system (using varied tools to remind patients or healthcare workers about vaccination), and finally one on a multi-component approach, using both reminder-recall tools and dialogue- based tools. No incentive-based intervention addressing vaccine hesitancy, financial or non-financial, was identified. The majority of these interventions focus on two determinants of vaccine hesitancy: misinformation (23 interventions) and/or safety issues (20 interventions). Some also target issues around trust (nine interventions), religious and philosophical views (eight interventions), and perceived benefits of or need for vaccination (five interventions). Finally, fourteen interventions aim to improve vaccine hesitancy in general, without targeting specific determinants.

Muchos países europeos han experimentado brotes de sarampión, y en algunos se están tomando medidas duras para asegurar que la aceptación de la vacunación sea suficiente para proporcionar inmunidad de rebaño. Francia e Italia con seis y 4,5 veces el número de nuevos casos de sarampión, respectivamente, en los primeros seis meses de 2017 en comparación con el mismo período de 2016, hacen obligatorias las vacunaciones infantiles recomendadas por la OMS (inmediatamente y a partir de 2018 respectivamente). Las mayores caídas en la cobertura de la vacuna contra el sarampión están en países europeos más pobres como Ucrania, Rumania y Bosnia Herzegovina en donde el compromiso con los programas de vacunación es variable. Ni la OMS ni el ECDC abogan por los programas obligatorios de inmunización que pueden polarizar puntos de vista sobre la vacunación o llevar a más personas que a buscar exenciones médicas.

The recent outbreaks of measles and other childhood infectious diseases in the US and other countries1-3 have garnered considerable public attention and prompted controversy about early childhood vaccination.4,5 A newcomer to this controversy would be forgiven for thinking that there is a scientific and ethical basis for controversy about the professional responsibilities of physicians regarding early childhood vaccination. For example, there are reports of physicians stating publicly that they have not authorized vaccination of their own children.

Vacunas seguridad

Resumen: llama la atención los pocos estudios de reinmunización en niños que han sufrido un evento adverso con una vacunación concreta. Los estudios publicados sugieren que la reinmunización con la misma vacuna es segura, pero hay que ser prudentes en esta conclusión porque los casos de efectos adversos más graves no han sido generalmente reinmunizados con la misma vacunación.

Live-attenuated influenza vaccines (LAIVs) are not licensed in children younger than 2 years of age because of a wheezing safety signal that has not been fully elucidated. In 2000, the Kaiser Permanente Vaccine Study Center conducted a placebo-controlled randomized clinical trial (RCT) of LAIV in children. As many of these children were still enrolled in Kaiser Permanente in 2014, we could assess the possible long-term association between LAIV and subsequent asthma diagnosis.

Methods:

We identified all children who were originally enrolled into the LAIV RCT at younger than 3 years of age. We followed up subjects until disenrollment from the health plan, a first diagnosis of asthma, or through the end of the study period in 2014. Asthma was defined by a first International Classification of Diseases, 9th revision, Clinical Modification code (493.*) assigned at an outpatient or emergency department encounter. We performed a survival analysis of time to first asthma diagnosis among children receiving LAIV or placebo with a Cox proportional hazards model.

Results:

We identified 1151 children in the original RCT who were 12 through 35 months of age at the time of enrollment and who had received 2 doses of LAIV or placebo. A total of 767 (66.7%) RCT participants were still Kaiser Permanente Northern California members in 2014. There was no evidence of differential dropout by treatment group. The hazard ratio for new-onset asthma for LAIV recipients compared with placebo was 1.1 (95% confidence interval: 0.88–1.41; P = 0.38).

Conclusions:

We found no evidence of increased risk of subsequent asthma diagnosis among children younger than 3 years of age who received LAIV compared with placebo.

A significant number of children with alleged vaccine injury had pre-existing neurologic or neurodevelopmental abnormalities. Among those developing chronic epilepsy, many had clinical features suggesting genetically determined epilepsy. Future studies that include genotyping may allow more specific therapy and prognostication, and enhance public confidence in vaccination

Vacunas situaciones especiales

Los niños que son sometidos a quimioterapia en el contexto de un cáncer presentan necesidades especiales de vacunación una vez finalizado el tratamiento. El objetivo de este trabajo es evaluar la adaptación de los calendarios de vacunación posquimioterapia en una población pediátrica.
Método: Estudio observacional de una cohorte retrospectiva. Se incluyeron todos los niños entre 0 y 14 años que recibieron quimioterapia en un hospital de tercer nivel entre 2009 y 2015.Se siguieron las indicaciones oficiales del Comité Asesor de Vacunas de la Asociación Española de Pediatría para estas situaciones. 
Resultados: De los 99 niños que recibieron quimioterapia, se incluyeron en el estudio 51. El 70,6% fueron varones. El 54,9% padecían un tumor de órgano sólido y el 45,1% un tumor hematológico. El 70,6% tenía registrada alguna vacuna tras el tratamiento. Las vacunas administradas con mayor frecuencia fueron: difteria-tétanos-tosferina o difteria-tétanos (54,9%), meningococo C (41,2%) y la gripe estacional (39,2%). La tasa de adaptación de calendario posquimioterapia fue del 9,8%. La vacuna frente a neumococo conjugada 7v o 13v fue administrada en el 21,6% de los niños evaluados, sin embargo, solo se completó con polisacárida 23v en el 17,6% de los casos. Ninguno recibió vacunación frente a hepatitis A. No se encontraron diferencias estadísticamente significativas entre el cumplimiento del calendario y el tipo de tumor , el sexo o la edad .Conclusión:Existe un importante margen de mejora en la adaptación de la vacunación posquimioterapia en niños con cáncer.

A 4-month-old baby girl with Down syndrome (DS) attended the General Paediatric clinic for routine follow-up. She had commenced her routine vaccination schedule. The Registrar asked, as children with DS are at increased risk of infections, should this baby have any extra vaccinations?

El sumario de evidencia de Uptodate(1) sugiere que en los bebés expuestos a anti-TNF en el útero se deberían evitar las vacunas vivas durante los primeros seis meses de vida, pero que pueden seguir el calendario de vacunación estándar en cuanto a las vacunas inactivadas. Señala específicamente que la vacuna frente al rotavirus es la vacuna viva generalmente recomendada para la administración antes de los seis meses de edad en los Estados Unidos, y que en algunos países también se administra antes de los seis meses la vacuna frente a la tuberculosis Bacille Calmette Guérin (BCG).

En el documento de consenso publicado por la “European League Against Rheumatism” (EULAR) en 2016(3) se establece de forma más genérica que los niños expuestos a productos biológicos solo antes de la semana 22 de gestación pueden recibir vacunas de acuerdo con los protocolos estándar (incluyendo vacunas vivas). Sin embargo, los niños expuestos a finales del segundo trimestre y durante el tercer trimestre del embarazo pueden seguir programas de vacunación estándar, pero no deberían recibir vacunas vivas en los primeros 6 meses de vida.

En base al calendario de vacunación infantil vigente durante el año 2018 en la Región de Murcia (ver calendario) un RN de madre con enfermedad reumática que ha estado en tratamiento con un anti-TNF durante la gestación podría comenzar la pauta de vacunación a los 2 meses de edad como es lo habitual; habría que tener en cuenta que si la madre no ha podido suspender el tratamiento con etanercept, adalimumab o infliximab durante el tercer trimestre de la gestación se deberían evitar las vacunas vivas en el RN al menos en los primeros 6 meses de vida.

Actualmente, la vacuna  frente al rotavirus (no financiada) es la única vacuna atenuada disponible en nuestro medio que se administra en los primeros seis meses de edad.

Atopic children with asthma are at increased risk from influenza, but are also more likely to be egg allergic. Egg allergy reportedly affects up to 2% of all under-5s. It's important, therefore, to remove obstacles to getting them immunised. All ‘flu vaccines licensed for children are manufactured using hen's eggs, and until now live attenuated influenza vaccine (LAIV; ‘Fluenz’) – an intranasal vaccine which families understandably find more acceptable than injections – was contraindicated in egg allergy. …

Varicela (Ver Temas A-Z)

El virus de Cytomegalovirus, de Epstein Barr y el virus de la varicela-zoster son herpesvirus frecuentes, adquiridos con frecuencia en la infancia, que establecen una infección latente persistente y son susceptibles de afectar el desarrollo del sistema inmune. El estudio pone de manifiesto grandes diferencias de incidencia entre los británicos blancos y los niños paquistaníes en el Reino Unido y ha identificado factores de riesgo clave para la infección en cada grupo, que sugieren que los mecanismos de transmisión deben de ser investigados más a fondo.

A previously healthy, unimmunized 11-month-old boy presented with acute right-sided weakness. On the day of presentation, his mother noted that his right arm and leg seemed to be weak when she woke him from his usual afternoon nap. Evaluation at an urgent care center confirmed right-sided facial weakness, decreased strength and movement of his right upper and lower extremities, and a lack of right-sided support in a sitting position. Computed tomography of the head without contrast was normal. He was transferred to a regional care center where head magnetic resonance imaging and magnetic resonance angiography demonstrated a left middle cerebral artery stroke and irregularities in the middle cerebral artery concerning for thrombus and vasculopathy (Figure, A and B). History revealed that the patient, as well as his older siblings, had primary chickenpox infection 2-3 months previously. The patient had a mild case of varicella, with a few scattered vesicular lesions which resolved without obvious sequelae. Owing to concern about varicella zoster virus (VZV) vasculopathy, he was started on high-dose intravenous acyclovir. A lumbar puncture performed 2 days after admission revealed a cerebrospinal fluid VZV DNA level of 880 copies/mL. Serum was positive for VZV IgG and negative for IgM. He received 10 days of intravenous acyclovir and was discharged home on oral valacyclovir 20 mg/kg 3 times daily. His weakness improved; however, follow-up imaging demonstrated progressive arteriopathy involving the distal left internal carotid and proximal left middle and anterior cerebral arteries.

Immunocompromised patients exposed to varicella may experience significant morbidity and a 7% mortality rate. Management and outcome of an outbreak of varicella infection among hospitalized pediatric hemato-oncology patients using the guidelines of the American Academy of Pediatrics Committee on Infectious Diseases are presented.

This retrospective study describes an outbreak of varicella infection between February 2011 and June 2011. Data were retrieved from the patients’ files. Positive polymerase chain reaction results for varicella zoster virus from vesicular skin lesions were used for the diagnosis of varicella infection.

Twelve pediatric hemato-oncology patients experienced 13 episodes of varicella infection, 11 underwent 1 episode each and 1 patient had 2 episodes. All exposed patients without immunity received varicella zoster immune globulins or intravenous immunoglobulin and were isolated as recommended by the guidelines. Infected patients received intravenous acyclovir. One patient with acute lymphoblastic leukemia at induction chemotherapy died. All the other patients survived.

Our experience in the management of hospitalized immunocompromised patients exposed to varicella was that a positive IgG serology did not confer protection after exposure to varicella infection and thus can not serve as a marker for immunity. Unlike the isolation period sufficient for immunocompetent patients, crusted lesions can be contagious and thus require extended isolation for immunocompromised patients. Patients receiving rituximab are at greater risk of having persistent or recurrent disease. Studies with a larger sample size should be performed to better assess the management of immunocompromized patients exposed to varicella.

A 2½-year-old previously well Afro-Caribbean girl presented with a 1-week history of fever and a generalised non-healing, painful and itchy ulceration on the body 3 weeks after acute varicella infection. On examination, she had multiple punched-out ulcers on her torso measuring 0.5–2 cm in diameter associated with central necrosis (figure 1). She had a normal white cell count and inflammatory markers. Her varicella

El interés radica en 1.posibilidad de sospecha de inmunodeficiencia como enfermedad de base ante varicelas graves, 2. Orientación terapeútica en estos casos y 3. Posibilidad de trasmisión vertical de HIV aún con serología materna negativa en el momento del parto

Varicela vacuna (ver también Temas A-Z)

The routine 2-dose varicella vaccination program appears to have significantly reduced the number, size and duration of varicella outbreaks in the US.

During the mature varicella vaccination program, declines in HZ incidence among children <10 years of age continued through 2010. Among the 10- to 19-year olds, the increase reported through 2006 did not continue further and lower rates than in 2006 were observed through 2010. Widespread use of varicella vaccine could reduce HZ incidence among vaccinated populations. Ongoing monitoring of HZ incidence is needed to detect and understand changes in HZ epidemiology in the varicella vaccine era.

Viajero (ver también Temas A-Z)

A chatty, 4 year-old girl is brought to the emergency department (ED) by her mother with a 3-day history of fever and loose stool. They returned from Nigeria 7 days earlier, having visited friends and relatives for the school holidays. Clinical examination is unremarkable, she is currently afebrile, and there are no signs of serious bacterial infection. A malaria blood film and histidine rich protein-2 (HRP-2) based rapid diagnostic test (RDT) are both negative. RDTs are for malaria antigens such as HRP-2 and lactate dehydrogenase (LDH).

The paediatric registrar discharges the patient but expresses concern regarding the ability of a single RDT and blood film to rule out malaria, following current guidelines, and insists she returns in 24 and 48 hours to repeat the tests. You wonder if this is really necessary.

VIH (ver también Temas A-Z)

UK guidelines for HIV post-exposure prophylaxis (PEP) in adults have recently been updated. Indications for PEP have been modified and there has been a change in the recommended antiretroviral therapy for adults to a combination of raltegravir with tenofovir and emtricitabine (Truvada). Raltegravir and tenofovir are now available in paediatric formulations and offer improved safety and tolerability over previously recommended ritonavir-boosted lopinavir with zidovudine. This guideline provides recommendations for those caring for children potentially exposed to HIV and other bloodborne viruses in primary care, emergency departments, secondary care and specialist paediatric HIV centres.

In reporting on the results of the Promoting Maternal and Infant Survival Everywhere (PROMISE) trial, Fowler et al. (Nov. 3 issue)1 highlight the various risks and benefits associated with three different antiretroviral therapy (ART) regimens in African infants with perinatal exposure to the human immunodeficiency virus (HIV). However, given the continued exposure to ART in African children in the age of “Option B+” (a program in which all pregnant and breast-feeding women with HIV-1 infection begin lifelong ART, regardless of their CD4+ cell counts), it is necessary for these trials to continue beyond the early postpartum period into early childhood. In 2014, there were approximately 1.2 million pregnant women with HIV infection in southern and eastern Africa.2

Studies have shown cardiac risks associated with in utero exposure to zidovudine3 and poor growth outcomes at 5 years of age with exposure to nevirapine or zidovudine.4 However, few studies focus on longer-term outcomes in sub-Saharan African populations, and most involve infants in the first few weeks of life or infants younger than 6 weeks of age. This needs to be changed because of the large number of children who will have prolonged exposure to ART in utero and through breast-feeding with Option B+.

Randomized-trial data on the risks and benefits of antiretroviral therapy (ART) as compared with zidovudine and single-dose nevirapine to prevent transmission of the human immunodeficiency virus (HIV) in HIV-infected pregnant women with high CD4 counts are lacking.

Antiretroviral treatment coverage for children living with HIV is low, and new efforts are underway to expand eligibility so that all children and adolescents qualify for the treatment regardless of immune suppression or clinical stage. Although recent trials provide direct evidence of the benefit of this approach in adults, no such studies have been performed in children. This report examines the available body of evidence regarding universal HIV treatment for children and adolescents and assesses the benefits and challenges both at individual patient health, as well as at programmatic level. Universal treatment eligibility for children with HIV has great potential for improved growth and neurodevelopment and fewer morbidities for children, and treatment coverage would be expected to increase through guideline simplification. However, concerns regarding toxicities, drug resistance and costs require careful planning. Successful implementation will depend on effective strategies for case-finding, treatment adherence support and program monitoring that will contribute to the growing evidence base for this pivotal pediatric HIV policy shift.

El interés radica en 1.posibilidad de sospecha de inmunodeficiencia como enfermedad de base ante varicelas graves, 2. Orientación terapeútica en estos casos y 3. Posibilidad de trasmisión vertical de HIV aún con serología materna negativa en el momento del parto

Late presentation (LP) for HIV care across Europe remains a significant issue. We provide a cross-European update from 34 countries on the prevalence and risk factors of LP for 2010–2013.

This review is an update focusing on the current status of paediatric HIV in the UK and Ireland. Successes in prevention of mother to child transmission are highlighted. The changing epidemiology of the UK cohort is summarised and the shift in emphasis of treatment guidelines beyond limiting short-term morbidity and mortality to ensuring optimal health status in adult life is discussed.

Vitamina D

We included seven studies involving a total of 1529 children (780 with pneumonia (4 studies) and 749 with severe or very severe pneumonia (3 studies)) aged under 5 years from low-income countries. In four studies, a single large dose of vitamin D was used either when the child joined the study or within 24 hours of admission to hospital; in two studies, vitamin D was used for five days; and in one study, vitamin D was used for two days. One study excluded children whose vitamin D levels were normal. One study reported the cause of children's pneumonia.

We are uncertain as to whether vitamin D has an important effect on outcomes because the results were imprecise. No major adverse events were reported. We assessed the quality of the evidence as very low to low. Several trials are ongoing and may provide additional information.

Resumen: Revisión de los estudios más recientes sobre la actividad inmunomoduladora de la vitamina D y su relación con el riesgo de infecciones del tracto respiratorio en niños. Los datos disponibles apoyan la asociación del déficit de vitamina D con el riesgo de tuberculosis pediátrica, otitis media recurrente y bronquiolitis severa, mientras que se necesitan más estudios en el caso de otras infecciones. Es muy importante definir con exactitud el déficit y la insuficiencia de vitamina D, cuando y como tratar esta condición, establecer los regímenes en función del tipo de infección respiratoria y tener en cuenta, además, los polimorfismos de los receptores de vitamina D.

Resumen: Meta-análisis con datos individuales de los participantes(10 933 participantes en 25 ensayos controlados aleatorios). Mostró un efecto protector global de la suplementación con vitamina D(NNT = 33). El beneficio fue mayor en los que recibieron vitamina D diaria (NNT = 20), y los efectos protectores contra la infección aguda del tracto respiratorio en este grupo fueron más fuertes en aquellos con un mayor déficit basal de vit D (NNT = 4) Estos hallazgos apoyan la introducción de medidas de salud pública como la fortificación de alimentos para mejorar el estado de vitamina D, particularmente en entornos donde la deficiencia profunda de vitamina D es común.

Un editorial en la misma revista: ¿Deben estos resultados cambiar la práctica clínica? Probablemente no. Los resultados son heterogéneos y no son suficientemente aplicables a la población en general. Creemos que deben ser vistos solo como la generación de hipótesis, que requieren la confirmación con ensayos bien diseñados controlados y aleatorizados que no tengan como participantes a individuos con concentraciones muy bajas de vit D. Consideramos que la evidencia actual no apoya el uso de suplementos de vitamina D para prevenir las enfermedades respiratorias, a excepción de aquellos con alto riesgo de osteomalacia, actualmente definidos como niveles de 25-hidroxivitamina D inferiores a 25 nmol / l.

 

Objectives: This study aimed to evaluate the clinical efficacy and safety of vitamin D for preventing influenza A in 400 infants in a multicenter, randomized, open, controlled clinical trial.

Methods: The infants were randomized into low-dose and high-dose vitamin D groups, and serum calcium, inorganic phosphorus and 25-hydroxyvitamin D levels were detected thrice in 4 months. Infants infected with influenza A were monitored for symptoms including fever, cough and wheezing. Pathogen levels and safety of vitamin D treatment were also evaluated.

Results: Of 121 cases in total, 78 and 43 cases of influenza A infection occurred in the low-dose and high-dose vitamin D groups, respectively. There was a significant difference between the groups (χ 2 = 14.6324, P = 0.0001). Among the cases of influenza infection, the median durations for fever, cough and wheezing were shorter in the high-dose vitamin D group than in the low-dose vitamin D group. The viral loads showed a downward trend in both groups and were significantly different between the groups at the second and third detections. Additionally, the incidences of adverse events and severe adverse events were very low and not significantly different between the 2 groups.

Conclusion: High-dose vitamin D (1200 IU) is suitable for the prevention of seasonal influenza as evidenced by rapid relief from symptoms, rapid decrease in viral loads and disease recovery. In addition, high-dose vitamin D is probably safe for infants.

Objective: To investigate the association between circulating 25-hydroxyvitamin D [25(OH)D] status at admission and disease severity among infants hospitalized for bronchiolitis and to determine whether the association differs by the form of 25(OH)D—total, bioavailable or free 25(OH)D.

Study design: We conducted a 17-center prospective cohort study of 1016 US infants <12 months old hospitalized with bronchiolitis. Vitamin D status was defined by total 25(OH)D levels, and by calculated levels of bioavailable and free 25(OH)D. Bronchiolitis severity was defined by requirement for intensive care and hospital length-of-stay (LOS). Logistic and Poisson regression were used for unadjusted and multivariable analyses.

Results: The median age of hospitalized infants was 3.2 months (IQR 1.6-6.0). The median total 25(OH)D was 26.5 ng/mL (IQR 18.0-33.1); 298 (29%) infants had total 25(OH)D <20 ng/mL. In multivariable models, infants with total 25(OH)D <20 ng/mL had higher risk of requiring intensive care (aOR 1.72, 95% CI 1.12-2.64) and longer LOS (adjusted rate ratio 1.39, 95% CI 1.17-1.65) compared with infants with total 25(OH)D ≥30 ng/mL. Infants with the lowest tertile of bioavailable 25(OH)D, compared with those with the highest tertile, had longer LOS (adjusted rate ratio 1.32, 95% CI 1.07-1.62); admission to the intensive care unit was not statistically significant in the adjusted model (aOR 1.39, 95% CI 0.96-2.64). Free 25(OH)D level was not associated with severity of bronchiolitis in either unadjusted or adjusted models.

Conclusion: In a large, multicenter cohort of US infants hospitalized for bronchiolitis, infants with total 25(OH)D <20 ng/mL had increased risk of intensive care and longer hospital LOS.

VPH (Ver Temas A-Z)

Estudian en mujeres australianas con clamidia la coinfección con virus del papiloma tipos 6, 11, 16 y 18 (los serotipos incluidos en la vacuna que allí han puesto desde el inicio en Abril de 2007). No encuentran ninguno de los cuatro tipos de VPH en mujeres vacunadas, y comprueban una importante disminución en las no vacunadas. Son datos de efectividad de la vacuna y también sugiere importante inmunidad de grupo

VPH vacuna (ver también Temas A-Z)

Results The modalities and contents of the information about HPV vaccination raise questions about the limitations of the information doctors receive. The ineluctable association between sexuality and HPV vaccination explains their reluctance to raise topics considered to be private. The reasons for HPV vaccination illustrate the difficulty of arguing in favour of it. In view of the frequent parental reluctance, which weakens the parent–physician alliance, physicians must take responsibility for defending the benefits of vaccination. They nonetheless remain citizens whose opinions may implicitly echo the general reluctance, promoted by disinformation. In delaying or avoiding the subject of vaccination, they involuntarily become an instrument of anti-vaccination discourse.

Conclusions It is imperative to improve the distribution of credible information about vaccination, unbiased and scientifically supported by a strong institutional position and to rethink the place of the clinician in the system of adolescent health and disease prevention in France.

We included 26 studies involving 73,428 adolescent girls and women. All trials evaluated vaccine safety over a period 0.5 to 7 years and ten trials, with follow-up 3.5 to 8 years, addressed protection against precancer. Cervical cancer outcomes are not available. Most participants enrolled were younger than 26 years of age. Three trials recruited women between 25 to 45 years. The studies compared HPV vaccine with a dummy vaccine.

We assessed protection against precancer in individuals who were free of hrHPV, free of HPV16/18 or those with or without HPV infection at the time of vaccination. We separately assessed precancer associated with HPV16/18 and any precancer.

There is high-certainty evidence that HPV vaccines protect against cervical precancer in adolescent girls and young women aged 15 to 26. The effect is higher for lesions associated with HPV16/18 than for lesions irrespective of HPV type. The effect is greater in those who are negative for hrHPV or HPV16/18 DNA at enrolment than those unselected for HPV DNA status. There is moderate-certainty evidence that HPV vaccines reduce CIN2+ in older women who are HPV16/18 negative, but not when they are unselected by HPV DNA status.

We did not find an increased risk of serious adverse effects. Although the number of deaths is low overall, there were more deaths among women older than 25 years who received the vaccine. The deaths reported in the studies have been judged not to be related to the vaccine. Increased risk of adverse pregnancy outcomes after HPV vaccination cannot be excluded, although the risk of miscarriage and termination are similar between trialarms. Long-term of follow-up is needed to monitor the impact on cervical cancer, occurrence of rare harms and pregnancy outcomes.

Resumen: la vacunación bivalente frente al VPH en población femenina de 12 y 13 años ha supuesto un clara disminución en la prevalencia de citologías positivas a VPH (efectividad del 89,1% [85,1 a 92,3%]), tanto de las tipos vacunales como de algunos otros con los que ha mostrado reactividad cruzada. Pero además, también se ha detectado un descenso claro en población no vacunada (efecto de la inmunidad de grupo)

Resumen: Es un estudio en el que se aplica un modelo teórico para determinar el coste-efectividad de dos calendarios de la vacunación del virus del papiloma, con dos o tres dosis. Concluyen que el esquema de dos dosis tendría una mayor rentabilidad si la duración de la inmunidad dura 20 o más años. Sin embargo no es posible saber la duración de la protección de ambos esquemas, por lo que será necesario un estrecho seguimiento de las cohortes que recibieron dos dosis de vacunas del papiloma humano, con la posibilidad de una dosis de refuerzo o aumentar el número de dosis para los adolescentes si se detecta disminución de la protección en el futuro.

This study provides strong evidence of the early benefits of qHPV vaccination among girls aged 14 to 17 years, offering additional justification for not delaying vaccination.

Virus respiratorio sincitial (ver también Temas A-Z)

Palivizumab prophylaxis through the novel monthly protocol for patients with hsCHD is effective in reducing respiratory syncytial virus-related hospitalizations.

Respiratory syncytial virus (RSV) causes more disease among infants and young children than most viruses, yet understanding of the pathogenesis of many aspects of RSV disease remain limited.1,2 The consequences of RSV infection differ depending on the immune and inflammatory responses of the host, pulmonary and cardiac anatomic factors of the host, and poorly understood characteristics of the virus.2 Understanding remains limited as to why most primary RSV infections are confined to the upper respiratory tract whereas in some children infection progresses to bronchiolitis and pneumonia.

Estudio prospectivo multinacional de niños menores de 1 año que tiene como objetivo evaluar la frecuencia de las infecciones por virus de la influenza y del virus sincitial respiratorio asociadas con hospitalizaciones, describir las características clínicas y la respuesta de anticuerpos a la infección y examinar los predictores de enfermedad muy grave que requieren cuidados intensivos.

En conclusión, en el periodo analizado, la vigilancia no centinela de VRS ha proporcionado una información oportuna que ha permitido una mejor caracterización de las ondas estacionales de gripe y contribuirá a una estimación más precisa del impacto de la gripe en la morbimortalidad de la población.

Down syndrome is independently associated with an increased risk for RSV hospitalization. Children with Down syndrome are older at time of RSV hospitalization and have more severe RSV illness than children without Down syndrome. This increased risk for hospitalization continues beyond 24 months

La bronquiolitis por Virus Respiratorio Sincitial (VRS) es una causa importante de morbimortalidad en niños en todo el mundo. Aunque se conoce poco sobre su patogénesis, están surgiendo excelentes oportunidades para prevenir y tratar las infecciones por VRS, particularmente tras el descubrimiento de la altamente inmunógena glicoproteína F. Es necesario desarrollar redes multidisciplinares para mejorar nuestro conocimiento sobre la patogénesis, epidemiología y manejo de esta enfermedad.

We aimed to study whether direct central nervous system invasion is responsible for the neurologic manifestations seen in hospitalized infants with respiratory syncytial virus (RSV) infection. Cerebrospinal fluid from infants with RSV infection was tested for the detection of the following respiratory RNA viruses: RSV, influenza A and B, pandemic influenza H1N1, Parainfluenza-3, human metapneumovirus, adenovirus, parechovirus and enterovirus. All children tested negative for the presence of viral material in the cerebrospinal fluid. Our results support the notion that the mechanism of RSV-induced neurologic manifestations, including apnea, is not direct central nervous system invasion.

Resumen: a nivel mundial se estiman en 2015, 33.1 millones de epidosidos de bronquiolitis por VRS, con 3.2 millones de ingresos hospitalarios y 59.600 muertes en niños menores de 5 años hospitalizados (IC 95%: 48.000 a 74.500 muertes). De ellos, 1,4 millones de ingresos hospitlarios y 27.300 fallecimientos en el hospital fueron en menores de 6 meses de edad. Se estima que la mortalidad global (hospitalizados y no) pudo ser de 118.200 niños.

Vulvovaginitis

La mayoría de las vulvovaginitis en niñas en edad prepuberal son inespecíficas y secundarias a malos hábitos higiénicos o irritantes locales y el resultado del cultivo del exudado muestra las más de las veces flora mixta bacteriana, pero en casos de vulvovaginitis crónica de evolución tórpida debemos recordar estudiar otras causas específicas, como cuerpo extraño vaginal, abuso sexual si existen indicios o buscar bacterias patógenas específicas que precisen tratamiento.

 Zika (Ver Temas A-Z)

Estudio ecológico con datos de la epidemia de infección por Zika en la Polinesia Francesa

Zika virus is a mosquito-borne virus that causes congenital Zika syndrome, characterized by microcephaly and other fetal brain anomalies. This case report presents a case of Zika virus–related fetal brain anomalies including pathologic evidence of cerebral neuronal apoptosis and macrophage infiltrates and intracerebral calcification, ventriculomegaly and corpus callosum dysgenesis detected by ultrasound at 18 weeks of pregnancy.

Resumen: estudio de casos controles en niños brasileños con microcefalia. Confirman la posible asociación entre infección congénita por virus Zika y microcefalia. También de la ausencia de relación con otros factores potencialmente implicados como la exposición a piriproxifeno o diferentes vacunas (dTpa, sarampión, rubeola, o triple vírica) recibidaas por la madre durante el embarazo

Prior to 2007, Zika virus (ZIKV) was generally considered an arbovirus of limited importance, causing a mild self-limiting febrile illness in tropical Africa and Southeast Asia. Now, a large, ongoing outbreak of ZIKV that started in Brazil in early 2015 is spreading rapidly across the Americas and has been potentially linked to congenital malformations (including microcephaly) and Guillain–Barré syndrome (GBS). In England, as of 4 February 2016, five adults have been diagnosed with ZIKV infection following travel to countries currently experiencing a ZIKV outbreak.

Resumen: excelente actualización sobre infección por virus Zika para la atención a pacientes pediátricos

Resumen

La fiebre del Zika es una enfermedad sistémica causada por un arbovirus que se ha convertido recientemente en un problema de salud pública de importancia mundial después de su propagación a través de las Américas. Esta revisión describe el conocimiento actual sobre la epidemiología del virus Zika, sus vías de transmisión, manifestaciones clínicas, las técnicas de diagnóstico y las estrategias actuales de gestión, prevención y control. También profundiza en la asociación entre la infección y las complicaciones atribuidas al virus Zika, como la microcefalia o el síndrome de Guillem-Barré.

A widespread epidemic of Zika virus (ZIKV) infection was reported in 2015 in South and Central America and the Caribbean. A major concern associated with this infection is the apparent increased incidence of microcephaly in fetuses born to mothers infected with ZIKV. In this report, we describe the case of an expectant mother who had a febrile illness with rash at the end of the first trimester of pregnancy while she was living in Brazil. Ultrasonography performed at 29 weeks of gestation revealed microcephaly with calcifications in the fetal brain and placenta. After the mother requested termination of the pregnancy, a fetal autopsy was performed. Micrencephaly (an abnormally small brain) was observed, with almost complete agyria, hydrocephalus, and multifocal dystrophic calcifications in the cortex and subcortical white matter, with associated cortical displacement and mild focal inflammation. ZIKV was found in the fetal brain tissue on reverse-transcriptase–polymerase-chain-reaction (RT-PCR) assay, with consistent findings on electron microscopy. The complete genome of ZIKV was recovered from the fetal brain.

Este estudio describe la mayor y más detallada serie de hallazgos de neuroimagen, mediante TAC y RNM, en niños con microcefalia presuntamente relacionada con la infección por el virus Zika. El patrón radiológico se caracterizó por calcificaciones cerebrales en la unión entre la sustancia blanca subcortical y cortical asociada a otras malformaciones del desarrollo cortical (paquigiria o polimicrogiria en los lóbulos frontales, anomalías de la cisterna magna, del cuerpo calloso, dilatación ventricular, retraso de la mielinización, e hipoplasia del cerebelo y del tronco cerebral).

Resumen: análisis de datos retrospectivos de un brote de enfermedad por virus Zika en la Polinesia Francesa (octubre de 20103 a abril de 2014). 66% de la población se infectó. La prevalencia basall de microcefalia fue de 2 casos por 10.000 neonatos. El riesgo de microcefalia en RN de mujeres infectadas por el virus durante el primer trimestre de embarazo fue de 95 por 10.000. Parece haber una relación importante entre microcefalia e infección por virus Zika en el primer trimestre de embarazo.

Resumen: Un informe preliminar de la OMS sobre los datos de Brasil, indica que la infección con el virus Zika en el embarazo, se asocia a una serie de anomalías fetales que incluyen la muerte fetal y la restricción del crecimiento, además de microcefalia neonatal.

Resumen: La OMS ha reforzado su consejo a las mujeres embarazadas, instándolas a no viajar a zonas en las que está circulando el virus Zika. Se hizo público a la luz de una mayor evidencia de la asociación entre el virus del Zika y las malformaciones fetales. El virus del Zika ha sido detectado en la sangre, el tejido cerebral y el LCR de los fetos después de abortos involuntarios e interrupciones voluntarias del embarazo y mortinatos.

Zoonosis

La enfermedad por campylobacter fue la zoonosis más frecuentemente comunicada y el aumento en la tendencia iniciado en 2008 de casos confirmados en humanos continuó. En la alimentación, la incidencia de Campylobacter permaneció alta en el pollo para consumo. La tendencia decreciente en la UE de casos confirmados de infección en humanos por Salmonella persistió, aunque aumentaron los casos por Salmonella Enteritidis.

El aumento significativo registrado desde 2008 de los casos de listeriosis se estabilizó en 2015. Siguió descendiendo el número de casos de infección por yersinia, siendo esta generalmente declarada en carne de cerdo y derivados. El número de casos confirmados en humanos de E.Coli productores de toxina shiga (STEC) permaneció estable respecto a 2014, principalmente provenientes de carne de rumiantes.

En total, se produjeron 4362 brotes de infecciones transmitidas por alimentos, incluidos los transmitidos por agua.