Bibliografía de 2018

Bibliografía diciembre 2018

Top ten

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

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.

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.

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

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.

 Introducción. Streptococcus pneumoniae es una causa importante de morbilidad, y la vacuna es la medida más eficaz para prevenirla. El objetivo de este estudio es analizar la evolución de la enfermedad neumocócica invasora (ENI). Material y métodos.Estudio observacional de los casos de ENI residentes en la Comunidad de Madrid notificados a la Red de Vigilancia Epidemiológica entre los años 2008 y 2015. El caso de ENI se definió como la enfermedad producida por Streptococcus pneumoniae, con aislamiento, detección de ADN o detección de antígeno, en muestras procedentes de sitios normalmente estériles. Las cepas aisladas se enviaron al Laboratorio Regional de Salud Pública para la identificación del serotipo. Los serotipos se clasificaron según su inclusión en la vacuna heptavalente (VCN7), en la vacuna trecevalente pero no en la heptavalente (VCN13 adicional) y no incluidos en la VCN13 (no VCN). Se calcularon las razones de incidencia (RI) comparando los períodos 2011-2012 y 2013-2015 con el período 2008-2010. Resultados. Se notificaron 4.307 casos. El 86,6% fueron serotipados. La RI de ENI para todos los serotipos fue de 0,67 y de 0,67; la RI para los serotipos VCN7 fue de 0,43 y de 0,45; la RI para los VCN13 adicional fue de 0,46 y de 0,25, y la RI para los no VCN fue de 1,01 y de 1,32 en los períodos 2011-2012 y 2013-2015. Los serotipos 8, 9N, 10A, 23B, 24F y el serogrupo 33 incrementaron su incidencia de manera significativa en el período 2013-2015. Los serotipos 15B y 24F supusieron el 24% de los casos no VCN13 en menores de 5 años, los serotipos 8 y 9N el 51% en población de 5 a 59 años y los serotipos 8 y 22F el 25% en mayores de 59años. Conclusiones. La incidencia de serotipos no incluidos en vacunas conjugadas ha aumentado, especialmente en menores de 5años, pero la incidencia total de ENI ha disminuido. Es imprescindible continuar con los programas de vigilancia para valorar el efecto de la vacunación sobre la incidencia de la ENI.

 Objetivos.Calcular la incidencia de enfermedad neumocócica invasiva (ENI) pediátrica en Gran Canaria (España), sus características clínicas y epidemiológicas, distribución de serotipos, resistencias antibióticas, y las variaciones en estas variables antes y después de la introducción de la vacuna PCV13.

Métodos. Estudio hospitalario prospectivo que incluye todos los pacientes con edades entre 0-14 años (190) ingresados con un diagnóstico confirmado de ENI entre enero 2001 – mayo 2010 (152 casos) y junio 2010 – diciembre 2016 (38 casos). Los pacientes se dividieron en 3 grupos de edad (<2 años; 2-5 años; y >5 años). Los síntomas clínicos se clasificaron de manera mutuamente exclusiva en meningitis; neumonía bacterémica, derrame pleural (DP), empiema, o bacteremia sin foco. Resultados. La mayoría de los casos se concentró en varones (59.47%), durante otoño-invierno (65.79%), en <2 años (55.79%) y con un aumento de la edad media entre periodos (2.5vs3.1 años). La incidencia entre periodos se redujo un 66.4% (P<0.001): de 13.1/100,000 a 4.4/100,000. Los DPs (3.9%vs18.4%, P<0.005) y empiemas (1.5%vs16.7%, P=NS) aumentaron durante el periodo post-PCV13 mientras que el resto de síntomas se redujeron pero de manera no estadísticamente significativa. Los serotipos vacunales (77%vs40.6%, P=0.000), especialmente los serotipos 19A (23.9%vs12.5%) y 14 (14.2%vs9.4%), así como la resistencia a la eritromicina (57.2%vs7.9%, P=0.000) se redujeron en el periodo post-PCV13.

Conclusión. En el periodo post-PCV13 se redujo la incidencia de ENI, los serotipos vacunales, y la resistencia a la eritromicina mientras que aumentaron los DPs.

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.

Casos clínicos

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…

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.

Para profundizar

Systemic corticosteroids and antibiotic therapy may be beneficial for treatment of septic arthritis. Even if the joint infection is eradicated by antibiotic treatment, the inflammatory process may produce residual joint damage and sequelae.

We included two RCTs involving a total of 149 children between three months and 18 years of age who were receiving antibiotics for septic arthritis. The most commonly affected joints were hips and knees. These studies were performed in Costa Rica and Israel. In both studies, dexamethasone administered intravenously (ranging from 0.15 to 0.2 mg/kg/dose every six to eight hours) during four days was the corticosteroid, and the comparator was placebo. Trials excluded patients with any degree of immunodeficiency or immunosuppression. The longest follow-up was one year. Trials did not report activities of daily living nor length of hospital stay. Both studies used adequate processes for randomisation, allocation concealment, and blinding, and review authors judged them to have low risk of selection and performance bias. Losses to follow-up were substantive in both studies, and we judged them to have high risk of attrition bias and of selective outcome reporting. We graded all outcomes as low quality due to concerns about study limitations and imprecision.

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.

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)

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.

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.

Introducción. La linfadenitis cervical es la infección más frecuente por micobacterias no tuberculosas (MNT) en niños inmunocompetentes, principalmente menores de 5 años. Durante años se ha considerado a Mycobacterium lentiflavum (M. lentiflavum) una inusual MNT causante de esta patología.

Métodos. Se realizó un estudio retrospectivo, observacional desde 2009 a 2016, que incluyó a pacientes pediátricos del Hospital Infantil Universitario Niño Jesús de Madrid, diagnosticados clínicamente y microbiológicamente de linfadenitis cervical por MNT. Resultados.En el periodo estudiado se registraron 28 casos de linfadenitis cervical. En 23 (82,14%) pacientes se aisló M. lentiflavum y en 5 (17,85%), Mycobacterium avium. De los 23 pacientes con infección por M. lentiflavum, la localización más frecuente fue la submandibular

(43,47%), 15 (65,21%) fueron niños, la media de edad global fue de 30,8 meses y todos los casos evolucionaron satisfactoriamente.

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

La vacunación con BCG (bacilo Calmette-Guérin) está incluida en el calendario de inmunización al nacimiento en países con alta incidencia de tuberculosis, con una cobertura global cercana al 90%. BCG tiene casi cien años de antigüedad y está basada en una cepa atenuada de Mycobacterium bovis, proporcionando protección contra las formas diseminadas de la enfermedad pero confiriendo una protección muy limitada contra las formas pulmonares de tuberculosis, responsables de su transmisión. Diferentes vacunas profilácticas contra la tuberculosis se encuentran hoy en desarrollo clínico para reemplazar a BCG o para mejorar la protección en individuos ya vacunados con BCG. MTBVAC es la primera y única vacuna candidata basada en una cepa de Mycobacterium tuberculosis atenuada en evaluación clínica. Los planes de desarrollo clínico del MTBVAC se dirigen en primer lugar a la prevención de la tuberculosis en recién nacidos, para reemplazar a BCG, y en segundo lugar en adolescentes y adultos.

Objective: To examine the sociodemographic characteristics of one population of young, febrile infants and identify associations between neighborhood-level social determinants of health (SDHs) with bacterial infections.

Study design: This was a retrospective cross sectional study of all infants ≤90 days old with a temperature of ≥38°C who presented in 2014 to the emergency department of an urban children's hospital in a large east coast city. The primary outcome was the presence of a bacterial infection, defined as a positive urine, blood, or cerebrospinal fluid culture that was treated clinically as a pathogen. The home address of each infant was geocoded and linked to neighborhood data based on census tract. Neighborhood-level SDHs included deprivation index, median household income, poverty, childhood poverty, social capital, and crowded housing. Associations were estimated using generalized estimating equations and negative binomial regression analysis. Models were adjusted for age, prematurity, and race/ethnicity.

Results: Of 232 febrile infants, the median age was 54 days, 58% were male, 49% were Hispanic, and 88% had public health insurance; 31 infants (13.4%) had a bacterial infection. In the adjusted analyses, the risk of bacterial infection among infants from neighborhoods with high rates of childhood poverty was >3 times higher (relative risk, 3.16; 95% CI, 1.04-9.6) compared with infants from neighborhoods with low rates of childhood poverty.

Conclusions: Our findings suggest that SDHs may be associated with bacterial infections in young, febrile infants. If confirmed in subsequent studies, the inclusion of SDHs in predictive tools may improve accuracy in detecting bacterial infections among young, 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.

Results:

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.

 Se realizó un estudio descriptivo y prospectivo de las características clínicas, epidemiológicas, pruebas complementarias y evolución de los pacientes con sospecha de IEV y clínica neurológica grave en un hospital terciario de Madrid todos ellos agrupados en Mayo 2016. Se analizaron 11 casos, 10 confirmados definidos como clínica neurológica aguda de encefalitis, rombencefalitis y/o parálisis flácida aguda, con resonancia magnética (RM) compatible y PCR positiva para enterovirus en frotis nasofaríngeo y/o rectal, sin encontrar otro agente causal. Un caso fue probable. Todos estaban previamente sanos, con mediana de edad de 26 meses y predominio femenino (6/11). No se encontró asociación epidemiológica entre los casos. Los síntomas iniciales fueron irritabilidad (11/11), fiebre (10/11) y afectación mucocutánea (8/11). La clínica neurológica apareció con una mediana de 3 días tras el inicio de síntomas sistémicos, destacando ataxia (11/11), somnolencia (10/11), temblor (9/11) y mioclonías durante el sueño (7/11). Solo 2 pacientes presentaron clínica bulbar y uno sospecha inicial de parálisis flácida (arreflexia y necesidad de ventilación mecánica), que finalmente se descartó por la rápida resolución del cuadro en 24h. Cuatro pacientes ingresaron en la UCIP por disregulación del sistema nervioso autónomo y disfunción cardíaca. En todos se realizó punción lumbar, mostrando pleocitosis en LCR de predominio linfocitario.

Se realizó RM en 10 pacientes, objetivando en 8/11 rombencefalitis, con asociación de mielitis en 7/11 y mielitis aislada en 2/11. Debido al alto porcentaje de pacientes con somnolencia e irritabilidad se realizaron 10 EEG mostrando trazado enlentecido en 9. El enterovirus fue detectado en frotis rectal (10/11) y nasofaríngeo (5/9) mediante PCR. No se aisló en LCR ni en sangre. El serotipo más frecuente fue el A71 (5/10), no se encontró ningún D68. Se administró tratamiento inmunomodulador precoz (primeras 24-48h) en los 10 casos moderados (somnolencia) o graves (clínica o neuroimagen de afectación bulbar o medular). En todos ellos se administraron inmunoglobulinas (1g/kg/día, 2 días) y, en los casos graves, además bolos de metilprednisolonaiv (30mg/kg/día, 3 días), simultáneamente. Solo los pacientes que ingresaron en la UCIP recibieron como uso compasivo fluoxetina (0,3mg/kg/día), sin objetivar clara mejoría. Dos de los casos más graves tuvieron secuelas durante 3 meses. Todos los pacientes asintomáticos tras 12 meses.

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)

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.

In this study, we used data from a large, diverse, multi-institutional national research network to examine the association of early-life antibiotic use on children’s weight.

CONCLUSIONS: Antibiotic use at <24 months of age was associated with a slightly higher body weight at 5 years of age.

·Staphylococcus aureus Bacteremia in Children Aged 5-18 Years—Risk Factors in the New Millennium. J Pediatr. 2018 Dec;203:108-115.e3. doi: 10.1016/j.jpeds.2018.07.093

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

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.

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.

Introducción: Las Guías de Práctica Clínica han demostrado ser herramientas valiosas para orientar las decisiones de los médicos Método: Investigación con un diseño antes-después: se estudió la efectividad de un método de difusión de recomendaciones diagnósticas para el manejo de lactantes hospitalizados por bronquiolitis. Pacientes con comorbilidades, exprematuros y los que fueron trasladados a otros centros sanitarios fueron excluidos. Los recursos diagnósticos estudiados fueron: radiografía de tórax, hemograma, proteína C reactiva, hemocultivo, gasometría venosa y determinación de virus respiratorio sincitial. Se analizaron un total de 11 temporadas epidémicas. Resultados: Se estudiaron 259 pacientes, 98 en el periodo preintervención (2006-10) y 131 en el posintervención (2011-17). La intervención se llevó a cabo en octubre de 2010 y 2011. Comparando los dos periodos, disminuyó el uso de radiografía de tórax, 73,5 a 16% ; hemograma 51 a 21,4% , PCR 48 a 22,1% y hemocultivo 23,5 a 7,6%. La duración de la hospitalización disminuyó 0,6 (DE = 1) días y no hubo diferencias en los reingresos. ConclusionesLa difusión organizada y sistematizada, mediante un método multimodal, de las recomendaciones diagnósticas contenidas en una guía de práctica clínica sobre bronquiolitis, es capaz de transformar la práctica médica, reduciendo el uso de recursos diagnósticos, sin incrementarse los reingresos. Ok, pero creo que top ten no, es A. hospitalaria

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.

Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. N Engl J Med. 2018 Mar 22;378(12):1121-1131.

Los lactantes con bronquiolitis grave tratados con Oxigenoterapia de alto flujo (OCH) precisan menos intensificación de tratamiento que los tratados con oxigenoterapia convencional. Los revisores del artículo concluyen que aunque existe incertidumbre sobre los resultados parece que el uso de oxigenoterapia de alto flujo puede reducir los ingresos en UCI y determinar menor nivel de cuidados intensivos respiratorios.

To determine whether antibiotic use in the first 14 postnatal days in preterm, very low birth weight (birth weight of ≤1500 g) infants is associated with risk after 14 days of age for late-onset sepsis, necrotizing enterocolitis (NEC), or death after controlling for severity of illness using the Clinical Risk Index in Babies II score, and determine whether duration of antibiotic exposure was associated with risk of adverse outcomes.

Study design: This retrospective cohort study included very low birth weight infants born at ≤326/7 weeks of gestation admitted to the neonatal intensive care unit from September 2010 to June 2014. Infants were excluded if they had major congenital anomalies or culture-proven sepsis, NEC, or death during the first 14 days of life. Antibiotic exposure was recorded as days of therapy and length of therapy in days.

Results: Of 374 infants, 70 (19%) had late-onset sepsis, NEC, or death after 14 days of age. The median number of antibiotic days of therapy and length of therapy were 5.5 and 3.0, respectively. In multivariate analysis after controlling for severity of illness, each antibiotic day of therapy was associated with a 1.24 times increased risk of sepsis, NEC, or death (OR, 1.24; 95% CI, 1.17-1.31). Risk was similar when length of therapy was used (OR, 1.47; 95% CI, 1.32-1.64).

Conclusions: After controlling for severity of illness, each day of antibiotic therapy provided to preterm, very low birth weight infants in the first 2 weeks of age is associated with an increased risk of late-onset sepsis, NEC, or death. 

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.

The Pediatric Infectious Disease Journal. 37(12):e315-e335

The intestinal microbiome plays a crucial role in the development of the immune system and regulation of immune responses. Many factors influence the composition of the infant intestinal microbiome and therefore the development and function of the immune system. This, in turn, may alter the risk of subsequent allergies, autoimmune diseases and other adverse health outcomes. Here, we review factors that influence the composition of the intestinal microbiome during the first year of life, including birth location, gestational age, delivery mode, feeding method, hospitalization, antibiotic or probiotic intake and living conditions. Understanding how the early intestinal microbiome is established and how this is perturbed provides many opportunities for interventions to improve health.

Breastfeeding vs formula feeding is the dietary factor that is most consistently independently associated with the infant intestinal microbiome. The relationship between breastfeeding status and intestinal microbiome composition varies by child race/ethnicity. Future studies will need to investigate factors, including genomic factors, which may influence the response of the microbiome to diet.

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

The recent occurrence of congenital syphilis in Columbus, OH, raised concern for an increase in syphilis among women and infants. The objectives were to examine the rates of syphilis among men, women and infants in Ohio from 2003 to 2016 and compare these rates to the rest of the United States.

Methods: This retrospective study evaluated cases of syphilis among men, women and infants from 2003 to 2016 using data from the Ohio Department of Health and the Centers for Disease Control and Prevention.

Results: In Ohio from 2003 to 2016, the number of all syphilis cases among women significantly increased from 153 (2.6/100,000) to 294 (5.2/100,000), respectively ( b = 0.26; P = 0.001; 95% confidence interval [CI]: 0.137–0.382). From 2003 to 2016, congenital syphilis in Ohio also increased significantly from 3 (2/100,000) to 13 cases (9.3/100,000), respectively ( b = 1.05; P ≤ 0.001; 95% CI: 0.687–1.408). The increase in congenital syphilis mirrored the increase in all cases of syphilis in women but not with the rates of primary and secondary syphilis. Among men, cases of primary and secondary syphilis increased significantly in Ohio and the rest of the United States, from 156 (2.8/100,000) and 5956 (4.2/100,000) in 2003 to 622 (10.5/100,000) and 24,724 (15.6/100,000) in 2016, respectively (Ohio: b = 0.55; P < 0.001; 95% CI: 0.426–0.679; United States: b = 0.77; P < 0.001; 95% CI: 0.629–0.916).

 

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.

 

Actualidad bibliográfica noviembre 2018

Este mes: dengue  en España,  ITS, medidas de higiene como  prevención de infecciones y  reducción del uso de antibióticos, adenopatías por  mycobacterias, tuberculosis, GEA,  profilaxis antimeningocócica,  Hepatitis A, azitromicina y arritmias graves, sarampión, vacunas especiales en niños con S Down, OMA, CMV, PCT, casos clínicos y más.

Top ten

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.

El objetivo de este documento es dar a conocer a los profesionales sanitarios la situación actual y el manejo de aquellas ITS, que por su relevancia necesitan una mayor atención, tanto en población general como en población infectada por el virus de la inmunodeficiencia humana.

Estas directrices para el tratamiento de las ITS, aunque orientadas desde el punto de vista clínico y centrado especialmente en el tratamiento, también recogen otros aspectos relacionados con la evaluación y valoración del paciente así como recomendaciones de diagnóstico.  

In this study, we show the effectiveness of hand hygiene programs (hand sanitizer versus hand-washing versus a control) in decreasing RIs in children at DCCs.

OBJECTIVES: Respiratory infections (RIs) are an important cause of morbidity and excessive antibiotic prescriptions in children attending day care centers (DCCs). We aimed to assess the effectiveness of an educational and hand hygiene program in DCCs and homes in reducing RI incidence and antibiotic prescriptions in children.

METHODS: A cluster, randomized, controlled, and open study of 911 children aged 0 to 3 years attending 24 DCCs in Almería (Spain) with an 8-month follow-up. Two intervention groups of DCC families performed educational and hand hygiene measures, 1 with soap and water (SWG; n = 274), another with hand sanitizer (HSG; n = 339), and the control group (CG; n = 298) followed usual hand-washing procedures. RI episode rates were compared through multilevel Poisson regression models. The percentage of days missed were compared with Poisson exact tests.

RESULTS: There were 5211 RI episodes registered. Children in the HSG had less risk of RI episodes (incidence rate ratio [IRR]: 0.77; 95% confidence interval [CI]: 0.68–0.88) and antibiotic prescriptions (IRR: 0.69; 95% CI: 0.57–0.84) compared with the those in the CG. Children in the SWG had a higher risk of RI episodes (IRR: 1.21; 95% CI: 1.06–1.39) and antibiotic prescriptions (IRR: 1.31; 95% CI: 1.08–1.56) than those in the HSG. Pupils missed 5186 DCC days because of RIs, and the percentage of days absent was significantly lower in the HSG compared with the CG (P < .001) and the SWG (P < .001).

CONCLUSIONS: Hand hygiene programs that include hand sanitizer and educational measures for DCC staff, children, and parents, reduce absent days, RIs, and antibiotic prescriptions for these infections in children at DCCs.

Resumen: buena actualización sobre gastreonteritis de etiología viral

Resumen: repaso de las diferentes pautas de profilaxis antibiotica postexposición a casos de meningitis y de su efectividad, empleada en diferentes brotes en diferentes países.

·Treatment of Multidrug-Resistant Tuberculosis Infection in Children The Pediatric Infectious Disease Journal. 37(10):1061-1064.

El CM-AEP considera acertadas las reflexiones y alertas que generó la FDA, y cree fundamental que los pediatras presten especial atención antes de prescribir azitromicina a pacientes: · Con prolongación del intervalo QT documentada o congénita. · Que actualmente estén recibiendo tratamiento con otras sustancias activas que prolonguen el intervalo QT. · Con alteración en los electrolitos, particularmente con hipopotasemia e hipomagnesemia, con bradicardia clínicamente relevante, arritmia cardiaca o insuficiencia cardiaca grave.

·Update: Recommendations of the Advisory Committee on Immunization Practices for Use of Hepatitis A Vaccine for Postexposure Prophylaxis and for Preexposure Prophylaxis for International Travel MMWR 2018 / 67(43);1216–1220

What is already known about this topic? Post exposure prophylaxis (PEP) with hepatitis A (HepA) vaccine orimmuneglobulin (IG) preventsinfectionwith hepatitis A virus whenadministeredwithin 2 weeksofexposure. Measles, mumps, and rubellavaccine (MMR) isrecommendedforinfantsaged 6–11 monthstravelingoutsidetheUnitedStates. IG cannot be administeredsimultaneouslywith MMR.

What is added by this report? HepAvaccineisrecommendedforpersonsaged≥12 monthsfor PEP. Providersmayalsoadminister IG toadultsaged>40 years, ifindicated. Thedosageof IG has beenupdated.Simultaneousadministrationof MMR and HepAvaccinesisrecommendedforinfantsaged 6–11 monthstravelinginternationally.

What are theimplicationsforpublichealthpractice? HepAvaccinefor PEP providesadvantagesover IG, includinginductionof active immunity, longerdurationofprotection, easeofadministration, and greateracceptability and availability.

Simultaneousadministrationof MMR and HepAvaccinesisrecommendedforinfantsaged 6–11 monthstravelinginternationally.

2018 / 67 (42);1186–1188

Whatisalreadyknownaboutthistopic? Measlesoccurssporadically in Israel and can be importedbytravelers. Measlesoutbreaksoccurred in 15 Europeancountriesduringthesummerof 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.

Casos clínicos

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?

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.

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.

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.

·Intestinal Involvement in Kawasaki Disease J Pediatr. 2018 Nov;202:186-193

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.

Para profundizar

La transmisión mediada por fomites puede ser una vía importante de transmisión significativa de enfermedades en varios entornos, como escuelas, guarderías y centros de atención. Se consideran dos subtipos, contagio directo por fomite o contagio mano fomite. Se examinan tres patógenos con características ambientales distintas, influenza, rinovirus y norovirus en cuatro espacios diferentes. La transmisión mediada por fomite es una vía importante para los tres patógenos examinados. La transmisión depende tanto de los factores de comportamiento que influyen en el contacto con los fomites como del entorno físico y las superficies disponibles para la contaminación en cada lugar. El estudio subraya la necesidad de valorar y estudiar críticamente como pueden organizarse los espacios desde la perspectiva de la transmisión, para diseñar intervenciones que puedan mejorar las etapas clave del proceso.

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.

·Emergence of Nontuberculous Mycobacterial Lymphadenitis in Children After the Discontinuation of Mandatory Bacillus Calmette and GuÉrin Immunization in France The Pediatric Infectious Disease Journal. 37(10):e257-e260

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.

El resfriado común es causado por virus y es en su mayoría autolimitado, pero puede tener un impacto sustancial en el trabajo, la escuela, uso de los servicios de salud, y el dinero gastado en medicamentos. Los niños tienen alrededor de 6-8 resfriados por año y los adultos tienen 2-4

En el artículo se hace una búsqueda de revisiones sistemáticas sobre el tema en la Biblioteca Cochrane y en PubMed. La evidencia de la efectividad de los tratamientos de venta libre es limitada y de baja calidad, y no se cuenta con una guía clara de manejo. En los niños es aún más limitada.  No hay evidencia de que estos tratamientos alivien los síntomas nasales y pueden causar efectos adversos, como somnolencia o malestar gastrointestinal. Los daños graves, como las convulsiones, el ritmo cardíaco rápido y la muerte se han relacionado con el uso de descongestivos en niños muy pequeños. Ninguno de los tratamientos de venta libre y de uso doméstico (aire caliente humidificado, aceite de eucalipto, equinácea) están respaldados por una evidencia adecuada.

Enferm Infecc Microbiol Clin.2018;36:586-92

Las micobacterias no tuberculosas forman un grupo heterogéneo de microorganismos que en numerosas ocasiones son causa de infección en humanos, si bien también pueden considerarse en ocasiones como contaminantes o colonizadores. El manejo de estas infecciones debe necesariamente tener en cuenta la especie aislada y su sensibilidad in vitro (aunque no en todas ellas), así como las características del propio paciente, ya que estos tratamientos suelen ser prolongados y, necesariamente, deben ser llevados a cabo por expertos en el manejo de estas infecciones. Clásicamente divididas en micobacterias de crecimiento lento y micobacterias de crecimiento rápido, los esquemas de tratamiento y los antibióticos empleados son diferentes en ambos casos. Además, en determinadas circunstancias este tratamiento deberá necesariamente ir unido a otras medidas (retirada de cuerpos extraños, cirugía) con el objetivo de tener las máximas posibilidades de conseguir la curación del paciente.

·Vaccine Impact on Long-term Trends in Invasive Bacterial Disease in New Zealand Children. The Pediatric Infectious Disease Journal. 37(10):1041-1047

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.

The introduction of the pneumococcal conjugated vaccines (PCVs) resulted in a substantial reduction of invasive pneumococcal disease (IPD) rates. However, impact on nonsevere IPD (mostly occult bacteremia) has not yet been fully elucidated. We assessed severe and nonsevere IPD (SIPD and NSIPD, respectively) rate dynamics in children < 5 years in Israel before and after PCV7/PCV13 implementation.

Methods: A prospective, population-based, nationwide surveillance. All IPD episodes recorded from 1999 through 2015 were included. NSIPD was defined as IPD episodes without meningitis, pneumonia or mastoiditis in a child with a favorable outcome (not hospitalized or hospitalized in a nonintensive care unit < 5 days, without mortality). Three subperiods were defined: pre-PCV (1999–2008), PCV7 (2010–2011) and PCV13 (2013–2015). Incidence rate ratios (IRRs) were calculated.

Results: Overall, 4,457 IPD episodes were identified; 3,398 (76.2%) SIPD, 1,022 (22.9%) NSIPD and 37 (0.8%) unknown. In 90% of NSIPD episodes, no focus was identified. In the PCV7 period, NSIPD rates significantly declined by 52%, while SIPD rates declined less prominently by 24%. Following PCV13 introduction, compared with the PCV7 period, NSIPD rates declined nonsignificantly by 17% while SIPD rates declined significantly further by an additional 53%. These trends resulted in overall reductions (comparing PCV13 and pre-PCV periods) of NSIPD and SIPD of 60% (IRR = 0.4; 0.32–0.51) and 64% (IRR = 0.36; 0.32–0.42), respectively.

Conclusions: Following PCV7/PCV13 introduction, SIPD and NSIPD rates substantially declined, with differences in rate-dynamics, alluding to differences in serotype distribution between the 2 groups. Future surveillance is warranted when considering modification in treatment protocols for suspected occult bacteremia/NSIPD cases.

·Neuroimaging Profiles and Neurodevelopmental Outcome in Infants With Congenital Cytomegalovirus Infection. The Pediatric Infectious Disease Journal. 37(10):1028-1033

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 and HIV Perinatal Transmission. The Pediatric Infectious Disease Journal. 37(10):1016-1021

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.

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.

Rotavirus commonly causes diarrhea but can also cause seizures. Analysis of insurance claims for 1773295 US children with 2950 recorded seizures found that, compared to rotavirus-unvaccinated children, seizure hospitalization risk was reduced by 24% (95% confidence interval [CI], 13%–33%) and 14% (95% CI, 0%–26%) among fully and partially rotavirus-vaccinated children, respectively.

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.

  • 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.

Resumen: repaso a la creciente incidencia de casos de escarlatina en China, y su epidemiología

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.

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.

  • Clinical prediction models for young febrile infants at the emergency department: an international validation study. Arch 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.

  • Heliox for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD006822. DOI: 10.1002/14651858.CD006822.pub5

We included three randomised controlled trials (studies in which participants are allocated by chance to receive a treatment) involving a total of 91 children with croup aged from 6 months to 4 years. Studies ran for between 7 and 16 months; two were conducted in the USA and one in Spain. In one study children with mild croup received either heliox with 30% oxygen; in another study children with moderate croup received oral dexamethasone (a type of corticosteroid) and either heliox or no treatment; and in the third study children with moderate to severe croup received injected dexamethasone and either heliox or 100% oxygen with adrenaline.

Heliox may be no more effective than 30% oxygen for children with mild croup; as effective as 100% oxygen given with one or two doses of adrenaline; and slightly more effective than no treatment for children with moderate to severe croup. None of the studies reported adverse events.

Due to very limited evidence, uncertainty remains about the effectivenessand safety of heliox. Heliox may not be more effective than 30% humidified oxygen for children with mild croup, but may be beneficial in the short term for children with moderate to severe croup treated with dexamethasone. The effect may be similar to 100% oxygen given with one or two doses of adrenaline. Adverse events were not reported, and it is unclear if these were monitored in the included studies. Adequately powered RCTs comparing heliox with standard treatments are needed to further assess the role of heliox in the treatment of children with moderate to severe croup.

·Use of acid suppressive medications and antibiotics in young infants is associated with development of allergic disease. J Pediatr. 2018 Nov;202:330-333

Conclusions H2RAs, PPIs, and antibiotics during the first 6 months of life were associated with an increase in allergic disease.

Commentary Although this study is a retrospective cohort study with a lower evidence level compared with a prospective cohort study, Mitre et al impart an important message regarding the potential risks of using acid-suppressive medications and antibiotics. It is well known that the microbiome plays an important role in a healthy immune system. The intestinal microbiome, altered by exposure to acid-suppressive medications and antibiotics can compromise the immune system, leading to the development of allergic disease. Our team in Japan, in a prospective birth cohort study,1 also found that the use of antibiotics within the first 2 years of life was associated with asthma and rhinitis. Although acid-suppressive medications and antibiotics are commonly given to infants, we should prescribe them only in appropriate situations during infancy and pay more attention to the risk of adverse effects from these medications.

In this study, we discuss the risk of developing pediatric IgAV (Henoch–Schönlein purpura) in the 3 months after vaccinations.

METHODS: We enrolled children <18 years old with IgAV seen in 5 pediatric departments from 2011 to 2016. Data on vaccinations administered during the year preceding IgAV onset were collected from immunization records. With a case-crossover method and by using conditional logistic-regression analyses, odds ratios (ORs) and 95% confidence intervals (CIs) were calculated by comparing vaccine exposure during the 3-month “index period” immediately preceding IgAV onset to that during 3 consecutive 3-month “control” periods immediately before the index period. Stratifications by season, year of onset, infection history, age, sex, type, or number of vaccines were performed. Sensitivity analyses used 1-, 1.5-, or 2-month index and control periods.

RESULTS: Among 167 children (mean age: 6.7 years) enrolled, 42 (25%) received ≥1 vaccine during the year before IgAV onset. Fifteen (9%) children were vaccinated during the 3-month index period as compared with 4% to 7% during the 3 control periods. The OR for IgAV occurring within the 3 months after vaccination was 1.6 (95% CI: 0.8–3.0). Analyses of IgAV risk within 1, 1.5, or 2 months of vaccination yielded ORs of 1.4 (95% CI: 0.5–3.5), 1.4 (95% CI: 0.6–3.2), and 1.3 (95% CI: 0.6–2.6), respectively. Stratifications revealed no significant association.

CONCLUSIONS: Vaccination may not be a major etiological factor of childhood IgAV.

2018 / 67(42);1178–1185

Whatisalreadyknownaboutthistopic? CDC compiles, collects, and analyzes data on influenza activityto monitor the timing and severityofeach influenza season.

Whatisaddedbythisreport? ReportedSouthernHemisphere influenza activitywasrelativelylow and fairlymild, with influenza A(H1N1)pdm09 virusespredominating in mostregions. In theUnitedStates, influenza activitywaslow in allregions, typicalforthis time ofyear. Fourteen influenza variant virus infectionswerereported in theUnitedStates, and mostwereassociatedwithexposuretoswine.

What are theimplicationsforpublichealthpractice? Annual influenza vaccinationisrecommendedforallpersonsaged≥6 monthswho do nothave a contraindication. Providersshouldencourage influenza vaccinationnow prior totheincreaseof influenza activity.

 

Actualidad bibliográfica octubre 2018

Top Ten

 

Objetivo:Valorar si existe relación entre la prescripción de antibióticos y realización de pruebas complementarias con la hiperfrecuentación y la fidelización.

Métodos:Estudio descriptivo por una red de pediatras centinela de Atención Primaria (PAPenRed). Cada pediatra revisó las visitas espontáneas (en Atención Primaria y urgencias) durante 12 meses de 15 pacientes escogidos aleatoriamente de su cupo. También se recogió la prescripción de antibióticos y las pruebas complementarias realizadas a éstos.

Resultados: 212 pediatras que revisaron a 2.726 pacientes. Un 8,3% fueron hiperfrecuentadores moderados ( consultas entre +1 y +2 desviaciones estándar) y 5,2% hiperfrecuentadores extremos (número de consultas > 2 desviaciones estándar). Un 49,6% fueron pacientes de alta fidelización (>75% de visitas con su pediatra).

La razón de tasas de prescripción de antibióticos para hiperfrecuentadores moderados fue 2,13 y la de hiperfrecuentadores extremos 3,25 respecto a no hiperfrecuentadores. Las razones de tasas de realización de pruebas complementarias fueron 2,25 y 3,48 respectivamente.

Las razones de tasas de prescripción de antibióticos fueron 1,34 en pacientes de fidelización media-alta, 1,45 para fidelización media-baja y 1,08 para los de baja fidelización respecto a los de alta fidelización. Para la realización de pruebas complementarias las razones de tasas fueron 1,46 ; 1,60 y 0,84 respectivamente.

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.

Prescripción de antibióticos asociados a faringoamigdalitis en menores de 14 años. Ojo de Markov número setenta y seis - septiembre 2018

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.

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.

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.

  • Ambulatory Visits for Otitis Media before and after the Introduction of Pneumococcal Conjugate Vaccination. J Pediatr. 2018 Oct;201:122-127

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.

La infección por citomegalovirus (CMV) es la causa más común de infección viral congénita en los paíse. 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.


 

En este artículo se destacan los conceptos actuales sobre la epidemiología de la TB. Los estudios longitudinales que han examinado respaldan un período de incubación promedio de unos pocos meses a dos años, y solo una pequeña proporción de personas contraen la enfermedad más adelante. No hay evidencia o base epidemiológica para una curva bimodal que diferencie la TB progresiva primaria de la TB de reactivación. La mayoría de la enfermedad tuberculosa se manifiesta poco después de la infección, y la enfermedad rara vez ocurre más de dos años después de la infección. La gran carga global de la TB es debida a una infección transmitida recientemente. Solo en los países con una baja carga de TB, donde la transmisión en curso es mínima, la TB de infección remota contribuye de manera sustancial a la carga de TB activa. la historia natural de la TB no respalda los muchos términos utilizados para describir las diversas fases de la infección de TB. Estos términos no solo son confusos, sino incluso engañosos. Sugerimos usar solo tres términos simples: reactividad tuberculosa, infección primaria y TB activa. Reconocer que el período de incubación de la TB es generalmente más corto de lo que se pensaba anteriormente tiene implicaciones importantes para los ensayos de vacunas, permitiendo ensayos breves de eficacia.

La inmunorreactividad a la TB no indica necesariamente la presencia de bacterias vivas, ya que la reactividad puede persistir después de que se haya eliminado la infección

La clasificación de dos mil millones de personas con evidencia de inmunorreactividad como una infección latente de TB puede desviar la investigación fundamental y las intervenciones de salud pública de la TB activa transmisible y de las personas recién infectadas con mayor riesgo de progresión a la enfermedad.

Objetivo: estudiar las características clínicas y demográficas, así como el uso de oseltamivir, de los niños hospitalizados por gripe en un hospital pediátrico terciario. Pacientes y métodos: estudio descriptivo observacional de niños entre 0 y 18 años ingresados en las temporadas de diciembre a mayo de 2012 a 2017 con diagnóstico confirmado microbiológicamente de gripe. Resultados: se han estudiado 166 pacientes. El porcentaje de ingresos sobre el total de ingresados en las mismas fechas osciló entre el 2,03 y el 9,69%. El mayor número de ingresos fueron en la penúltima temporada de estudio (p <0,0001). Los niños diagnosticados de gripe A presentaron una edad menor que los que lo fueron de gripe B (2,45 frente a 3,88 años, p <0,0001), no encontrándose diferencias significativas en cuanto al sexo, los días de estancia media, la necesidad de antibioterapia o de broncodilatadores. Recibieron tratamiento con oseltamivir un total de 96 niños (57,83%), 75 de ellos en la temporada 2015-2016. No se encontraron diferencias en las características de los niños que lo recibieron frente a los que no. La estancia media global fue 0,89 días mayor en aquellos niños que recibieron el antiviral, diferencia casi significativa en el total de la muestra (p = 0,052), durante la temporada 2015-2016 la duración fue 1,8 días mayor (p = 0,039). No se encontraron diferencias significativas en cuanto al porcentaje de pacientes con neumonía ni de los que precisaron ingreso en la Unidad de Cuidados Intensivos Pediátricos entre los tratados respecto a los no tratados. Conclusiones: el porcentaje de niños ingresados por gripe es importante, habiéndose incrementado en la última temporada. Los niños diagnosticados con gripe A tienen una edad significativamente menor que los que presentaron gripe B. En nuestro caso no se encontraron ventajas en el tratamiento con oseltamivir.

El Instituto Nacional para la Excelencia en la Salud y el cuidado (NICE, por sus siglas en inglés) ofrece una guía para la fiebre escarlata. La escarlatina suele ser una enfermedad leve y autolimitada, y se ha vuelto más común. La erupción típica es roja, puntiaguda, con una textura de papel de lija, se extiende desde el tronco y se asienta en las flexiones. Las personas pueden ser infecciosas durante dos o tres semanas después de que aparecen los síntomas, a menos que sean tratados.Los antibióticos minimizan el riesgo de complicaciones y la transmisión hacia adelante (por lo general, no infecciosas en 24 horas).En raras ocasiones, se desarrollan infecciones estreptocócicas invasivas del grupo A, como meningitis, neumonía y artritis séptica

Casos clínicos

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.

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.

El microorganismo Actinotignum schaalii (A. schaalii) es un bacilo grampositivo, anaerobio facultativo relacionado , sobre todo con infecciones del tracto urinario (ITU). La mayoría de los casos publicados son en pacientes adultos.

Varón de 7 años de edad con inflamación peneana apreciable desde el mismo día. No sintomatología miccional ni otras manifestaciones. Antecedentes personales : había pasado el fin de semana en la playa; fimosis y adherencias balanoprepuciales tratadas con corticoide tópico a los 5 años de edad. En la exploración física se apreció una inflamación y eritema a nivel de glande, prepucio y cuerpo del pene, con dolor a la retracción prepucial y abundante exudado purulento amarillento-verdoso, siendo el resto de normal. Se recogió una muestra de exudado , se lavó con SSF y aplicó crema de bacitracina, neomicina y polimixina B. El paciente fue dado de alta con tratamiento de lavados con SSF y mupirocina en crema. A los 3 días se apreció una franca mejoría clínica, continúandose el tto 7 días. El estudio microbiológico del exudado balanoprepucial mostró A. schaalii .El antibiograma mostró las siguientes concentraciones mínimas inhibitorias (mg/l): sensible a vancomicina (0,25), ampicilina (0,016), amoxicilina/ácido clavulánico (0,016) y cefotaxima (0,016), y resistente a clindamicina (> 256)

A.schaalii puede formar parte de la microbiota del tracto genitourinario1. Se sospecha que es causa infradiagnosticada de infecciones genitourinarias. Generalmente, se asocia esta bacteria a ITU, en adultos de edad avanzada, con enfermedad nefrourinaria de base, habiéndose descrito también endocarditis, osteomielitis e infecciones de tejidos blandos1. Se ha relacionado la humedad producida en la zona genital por el uso de pañales en niños y por problemas de incontinencia en personas mayores como factores favorecedores de la colonización.

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.

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.

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.

Para profundizar

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.

Las infecciones por enterovirus (EV) son comunes en la infancia, produciendo cuadros benignos como herpangina o enfermedad boca-mano-pie, y son la causa más frecuente de meningitis linfocitaria. Ocasionalmente, con naturaleza epidémica, se presentan casos con afectación neurológica en forma de parálisis flácida aguda espinal y/o afectación romboencefálica, como en el brote epidémico de 2016 en Cataluña.

Background: Immunization of pregnant women with tetanus-diphtheria-acellular pertussis vaccine (Tdap) provides protection against pertussis to the newborn infant.

Methods

In a randomized, controlled, observer-blind, multicenter clinical trial, we measured the safety and immunogenicity of Tdap during pregnancy and the effect on the infant’s immune response to primary vaccination at 2, 4, and 6 months and booster vaccination at 12 months of age. A total of 273 women received either Tdap or tetanus-diphtheria (Td) vaccine in the third trimester and provided information for the safety analysis and samples for the immunogenicity analyses; 261 infants provided serum for the immunogenicity analyses.

Results: Rates of adverse events were similar in both groups. Infants of Tdap recipients had cord blood levels that were 21% higher than maternal levels for pertussis toxoid (PT), 13% higher for filamentous hemagglutinin (FHA), 4% higher for pertactin (PRN), and 7% higher for fimbriae (FIM). These infants had significantly higher PT antibody levels at birth and at 2 months and significantly higher FHA, PRN, and FIM antibodies at birth and 2 and 4 months, but significantly lower PT and FHA antibody levels at 6 and 7 months and significantly lower PRN and FIM antibody levels at 7 months than infants whose mothers received Td. Differences persisted prebooster at 12 months for all antigens and postbooster 1 month later for PT, FHA, and FIM.

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.

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.

Introducción: los flujos migratorios, junto a las medidas de prevención de la transmisión vertical, han cambiado la epidemiología de los nuevos diagnósticos de infección por el virus de la inmunodeficiencia humana. Objetivo: conocer las características clínicas y epidemiológicas de los nuevos diagnósticos de infección por el VIH en Navarra. Material y métodos: revisión retrospectiva de las historias clínicas de los pacientes controlados durante 15 años (2000-2014) analizando variables epidemiológicas y clínicas, con tres puntos de corte quinquenales. Datos poblacionales del Instituto Nacional de Estadística. Resultados: 15 pacientes estudiados, todos por transmisión vertical. Madres de origen extranjero: globalmente el 47%. El 0% en 2004, 36% en 2009 (100% de nuevos diagnósticos) y 36% en 2014 (75% de los nuevos). No se encontraron diferencias en el estadio clínico, inmunológico, ni en la carga viral según su origen. El contagio materno fue al inicio por uso compartido de jeringuillas; posteriormente por vía heterosexual. Conclusiones: las características de los niños infectados por virus de la inmunodeficiencia humana han cambiado, siendo en la actualidad mayoritariamente hijos de inmigrantes y el contagio materno vía heterosexual.

Increasing numbers of hepatitis E cases are being reported in several European countries, including Italy, but the burden of hepatitis E virus (HEV) infection is largely unknown in the latter. To gain a better understanding of HEV epidemiology at national level in Italy, we piloted a strengthened and integrated human (epidemiological and virological) and environmental HEV surveillance system between 2012 and 2016. Over the 5-year period, 169 confirmed hepatitis E cases were identified, with a national annual incidence of 0.72 cases per 1,000,000. Of 65 HEV-RNA positive samples of sufficient quality for molecular analysis, 66% were genotype HEV3, 32% HEV1 and 1% HEV4. The most frequent risk factor reported by all HEV3 infected cases, was the consumption of undercooked pork and sausage. For the environmental surveillance, 679 urban sewage samples were collected from 53 wastewater treatment plants and HEV-RNA was detected in 38/679 of the samples. Among these, 25 (66%) were genotype HEV3 and the remaining were HEV1. We demonstrate that autochthonous transmission and environmental circulation of genotype HEV3 is adding to travel-related HEV transmission in Italy. We recommend the ‘One Health’ approach to integrated surveillance, and to include HEV-related messages within health information campaigns focussing on food security.

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.

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.

  • 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.

Conclusions Serotype 19A is most commonly associated with pneumococcal HUS, despite the introduction of the 13-valent vaccine. Chronic kidney disease is a significant complication of pneumococcal HUS.

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.

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.

 

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.

Actualidad bibliográfica agosto-septiembre 2018

Este mes artículos sobre Neumonías, petequias, CMV, TBC, test rápido estreptocócico, infecciones de orina, tosferina, Kawasaki, información sobre antibióticos, infecciones respiratorias, vacunas frente a meningococo y tosferina, casos clínicos y más.

  • Consenso nacional sobre diagnóstico, tratamiento y seguimiento cardiológico de la enfermedad de Kawasaki An Pediatr (Barc) 2018;89:188.e1-188.e22
    La enfermedad de Kawasaki es una vasculitis aguda autolimitada que afecta a vasos de pequeño y mediano calibre y es la causa más común de enfermedad cardiaca adquirida en niños en nuestro medio. Hasta un 25% de pacientes no tratados desarrollan aneurismas coronarios. Se sospecha que un agente infeccioso puede ser el desencadenante de la enfermedad. En base a la evidencia previa, se proponen recomendaciones para el diagnóstico, tratamiento de la enfermedad aguda y manejo a largo plazo de estos pacientes, con el fin de unificar criterios. El diagnóstico debe ser rápido, basado en algoritmos de fácil manejo y con el apoyo de pruebas complementarias. Este documento recoge la indicación de las técnicas de imagen disponibles, así como la planificación de las revisiones cardiológicas en función de la afectación inicial. La inmunoglobulina intravenosa es la base del tratamiento inicial. El papel de los corticoides aún es controvertido. Un equipo multidisciplinar ha elaborado un esquema con diferentes pautas de tratamiento en función de los factores de riesgo al diagnóstico, situación clínica del paciente y respuesta al tratamiento previo, incluyendo indicaciones sobre tromboprofilaxis en pacientes con afectación coronaria. La estratificación del riesgo para el tratamiento a largo plazo es esencial, así como las recomendaciones acerca del proceder en función de la afectación cardiológica inicial y su evolución. Los pacientes con aneurismas coronarios requieren un seguimiento cardiológico continuo e ininterrumpido de por vida.

  • 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…

  • 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.

Las infecciones respiratorias agudas representan aproximadamente un tercio de todas las consultas pediátricas en atención primaria y el 8-18% de las hospitalizaciones agudas en el Reino Unido. Los niños, especialmente los preescolares, pueden tener hasta 6-10 resfriados virales al año. Los padres a menudo buscan la tranquilidad de que todo está bien o pueden tener inquietudes sobre una enfermedad grave, a veces provocada por los antecedentes familiares o por un diagnóstico inquietante en el hijo de un amigo. La alteración del sueño y el tiempo que los cuidadores deben estar lejos del trabajo pueden generar estrés y una calidad de vida deteriorada. El médico debe distinguir a los niños con una infección autolimitada recurrente o problemas menores, la mayoría de los casos, de aquellos con una afección subyacente más grave que pueden necesitar investigación y tratamiento. Diferenciar infecciones del tracto respiratorio superior e inferior, puede ser difíci porque los síntomas y signos se superponen y ambos pueden estar presentes al mismo tiempo. Este artículo presenta un enfoque práctico para el diagnóstico y el tratamiento del niño aparentemente sano con infecciones recurrentes del tracto respiratorio inferior.

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

  • Knowledge, attitudes and misconceptions of Italian health care professionals regarding fever management in children. BMC 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.

  • 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.

  • HPV vaccines are effective and safe and work best in young women, reviewfinds. BMJ 2018;361:k2059

Las vacunas contra el virus del papiloma humano (VPH) son efectivas contra los cambios precancerosos que podrían causar cáncer de cuello uterino y no provocan efectos secundarios graves, según una revisión Cochrane.Las conclusiones tranquilizadoras, basadas en 26 estudios que involucraron a 73 428 mujeres, confirmaron lo que los ensayos de vacunas habían demostrado, que son una herramienta poderosa para reducir las muertes por cáncer de cuello uterino. Funcionan mejor si se administran a mujeres jóvenes que están libres de VPH en el momento de la vacunación, casi eliminando las lesiones cervicales, pero también reducen aproximadamente a la mitad este riesgo en mujeres de 15 a 26 años que ya están infectadas con el VPH.

We included 43 studies with 4565 children aged up to 18 years published from 1964 to 2013. The glucocorticoids investigated included beclomethasone, betamethasone, budesonide, dexamethasone, fluticasone, and prednisolone. Most studies (26, 60%) compared any glucocorticoid to placebo. Of these, 15 (58%) tested dexamethasone compared to placebo. Three studies compared 0.6 mg/kg to 0.15 mg/kg dosages of dexamethasone, a common clinical question. Half of the studies (22, 51%) described outpatients who presented to emergencydepartments or outpatient clinics, and 18 (42%) took place in North America, eight (19%) in Europe, seven (16%) in Asia, and 10 (23%) in Australia. Twenty-six (60%) studies compared glucocorticoids to fake treatment (placebo); four (10%) compared glucocorticoids to epinephrine; 11 (26%) compared one glucocorticoid to another; three (7%) compared one glucocorticoid to a combination of glucocorticoids; five (12%) compared glucocorticoids given in different ways; and four (9%) compared glucocorticoids given in different amounts.

Glucocorticoids improved croup symptoms at two hours (moderate-certainty evidence), and the effect lasted at least 24 hours (low-certainty evidence). Glucocorticoids reduced rates of return visits, admissions, and readmissions (moderate-certainty evidence). When treated with placebo, 204 of every 1000 children will return for medical care. When treated with glucocorticoids, 74 to 153 of every 1000 children will return for medical care. Glucocorticoids reduced length of stay by 15 hours (range 6 to 24 hours), but made no difference in need for additional treatments. Of studies that compared glucocorticoids to placebo, 50% collected data on side effects. Four studies reported rare occurrences of secondary infections (e.g. pneumonia, ear infection). Most other side effects were not severe (e.g. emotional distress, hyperactivity, vomiting). We are not certain which type, amount, and administration mode (oral, inhaled, injected) of glucocorticoids is best for reducing symptoms of croup in children.

The three studies that allowed us to reach conclusions involved 1135 healthy infants aged mostly between two and six months. The infants were vaccinated in the thigh with either 25 G 25 mm (narrow, long needles), 23 G 25 mm (wide, long needles), or 25 G 16 mm needles (narrow, short needles). The needles were inserted at right angles (90° angle) into the skin and pushed down into the muscle of the thigh. The vaccines injected were combination vaccines designed to protect against several diseases including diphtheria (D), tetanus (T), whooping cough (pertussis), and Haemophilus influenzae type b disease (Hib). The vaccines all contained whole-cell pertussis (wP) vaccine antigens. These vaccines are commonly used in low- and middle-income countries but not in high-income countries. Our review findings are therefore most relevant to low- and middle-income countries.

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 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 antigencomponent. These vaccines are predominantly used in low- and middle-income countries. The applicability of the findings to vaccines with acellular pertussis components and other vaccines with different reactogenicity profiles is uncertain.

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.

Casos clínicos

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

A 14-month-old child presented with a 4-day history of diaper rash consisting of round erosions with a thin crust on an erythematous background symmetrically distributed around the anal orifice and crops of perilesional vesicles (figure 1). During the examination, further lesions were identified on the extremities and hand-foot-mouth disease (HFMD) caused by coxsackie virus A6 (CVA6) was confirmed on serology.

  • 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

  • Brain Hydatid in a Child The Journal of Pediatrics 2018; 199: 280.

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.

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.

Para profundizar

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.

El gobierno ha dado luz verde a los niños de entre 12 y 13 años en Inglaterra para que reciban la vacuna contra el virus del papiloma humano (VPH) y aspira a lanzar la vacunación el próximo otoño. La decisión sigue una recomendación del Comité Conjunto sobre Vacunación e Inmunización para extender el programa actual para niñas a los niños. Después de considerar las cuestiones más amplias de la economía de la salud, incluidos los beneficios de prevenir el cáncer en muchos años en el futuro, que descubrió que incluir a los niños en el programa de vacunación sería financieramente viable. Este modelo también tuvo en cuenta los años perdidos de cáncer si los niños fueran excluidos de la vacunación.

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.

Background: Pneumonia is the leading infectious cause of death among children less than 5 years of age. Predictive tools, commonly referred to as risk scores, can be employed to identify high-risk children early for targeted management to prevent adverse outcomes. This systematic review was conducted to identify pediatric pneumonia risk scores developed, validated and implemented in low-resource settings.

Methods: We searched CAB Direct, Cochrane Reviews, Embase, PubMed, Scopus and Web of Science for studies that developed formal risk scores to predict treatment failure or mortality among children less than 5 years of age diagnosed with a respiratory infection or pneumonia in low-resource settings. Data abstracted from articles included location and study design, sample size, age, diagnosis, score features and model discrimination.

Results: Three pediatric pneumonia risk scores predicted mortality specifically, and 2 treatment failure. Scores developed using World Health Organization–recommended variables for pneumonia assessment demonstrated better predictive fit than scores developed using alternative features. Scores developed using routinely collected healthcare data performed similarly well as those developed using clinical trial data. No score has been implemented in low-resource settings.

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

BACKGROUND AND OBJECTIVES: The ability of the chestradiograph (CXR) to exclude the diagnosis of pneumonia in children is unclear. We sought to determine the negative predictive value of CXR in children with suspected pneumonia.

METHODS:

Children 3 months to 18 years of age undergoing CXRs for suspected pneumonia in a tertiary-care pediatric emergency department (ED) were prospectively enrolled. Children currently receiving antibiotics and those with underlying chronic medical conditions were excluded. The primary outcome was defined as a physician-ascribed diagnosis of pneumonia independent of radiographic findings. CXR results were classified as positive, equivocal, or negative according to radiologist interpretation. Children with negative CXRs and without a clinical diagnosis of pneumonia were managed for 2 weeks after the ED visit. Children subsequently diagnosed with pneumonia during the follow-up period were considered to have had false-negative CXRs at the ED visit.

RESULTS:

There were 683 children enrolled during the 2-year study period, with a median age of 3.1 years (interquartile range 1.4-5.9 years). There were 457 children (72.8%) with negative CXRs; 44 of these children (8.9%) were clinically diagnosed with pneumonia, and 42 (9.3%) were given antibiotics for other bacterial syndromes. Of the 411 children with negative CXRs who were managed without antibiotics, 5 were subsequently diagnosed with pneumonia within 2 weeks (negative predictive value of CXR 98.8%; 95% confidence interval 97.0%-99.6%).

CONCLUSIONS:

A negative CXR excludes pneumonia in the majority of children. Children with negative CXRs and low clinical suspicion for pneumonia can be safely observed without antibiotic therapy.

Pediatrics Sep 2018, 142 (3) e20182025; DOI: 10.1542/peds.2018-2025

Pneumonia is the greatest killer of children worldwide,1 with 920 136 deaths in children in 2015.2 Although less lethal in developing countries like the United States, the burden is still consi-derable, with annual ambulatory visit rates for community-acquired pneumonia (CAP) in US chil-dren of 16.9 to 22.4 per 1000 in the population.3

Although CAP is a clinical diagnosis, individual signs and symptoms have poor prognostic va-lue,4 and children may undergo radiography to confirm or disprove the diagnosis. Although both viruses and bacteria can cause CAP, physicians are generally trying to rule out a bacterial infection with a chest radiograph (CXR) because the main clinical decision is whether to prescribe antibiotics.

Some physicians may be concerned that CXRs can have false-negative results in the early stages of CAP or in the setting of dehydration.5 To address these concerns, Lipsett et al6report the results of a prospective observational cohort study in children 3 months to 18 years of age undergoing CXR for suspected CAP. The primary outcome was a clinical diagnosis of pneumonia during the …

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.

  • Estudio clínico-epidemiológico de la infección por Bordetella pertussis en la isla de Gran Canaria en el período 2008-2016 An Pediatr (Barc) 2018;89:170-5
    Objetivo: Describir el patrón epidemiológico y clínico de la infección por Bordetella pertussis (tosferina) en niños menores de un año hospitalizados en un hospital pediátrico de Gran Canaria.
    Pacientes y métodos: Se revisaron retrospectivamente las historias clínicas de los pacientes con diagnóstico de infección por B. pertussis mediante PCR , de enero de 2008 a diciembre de 2016.
    Resultados: Se identificaron 110 pacientes, de los cuales 105 (95,4%) fueron menores de 6 meses y el 59,1% eran varones. La incidencia anual de hospitalización se estimó entre 13,7 y 425,0 casos por cada 100.000 lactantes menores de 12 meses, con 2picos en 2011 y 2015. Los familiares cercanos fueron las principales fuentes de contagio. Las principales manifestaciones fueron la tos pertusoide asociada con signos catarrales, cianosis y linfocitosis. El 15,4% de los pacientes presentaron complicaciones (principalmente neumonía), pero la evolución fue favorable en todos los casos. La menor edad y la no vacunación se asociaron con un mayor riesgo de desarrollar complicaciones (p < 0,05). La coinfección viral ocurrió en el 31,6% de los pacientes diagnosticados de infección por B. pertussis.
    Conclusiones: La incidencia de infección por B. pertussis ha aumentado en los últimos años en nuestra área, con un menor desarrollo de complicaciones y con tasas de mortalidad inferiores r. La menor edad y la no vacunación previa se consideran factores de riesgo para el desarrollo de complicaciones. La vacunación en mujeres embarazadas probablemente disminuirá la incidencia en el futuro, sobre todo en niños menores de 6 meses.

  • Safer Pertussis Vaccines for Children: Trading Efficacy for Safety. Pediatrics Jul 2018, 142 (1) e20181036; DOI: 10.1542/peds.2018-1036

The decision to replace effective whole-cell vaccines for pertussis with less reactogenic but potentially less efficacious acellular vaccines for the primary immunization of children in the United States in the 1990s was carefully considered.1 The performance of the heat- or formalin-inactivated Bordetella pertussis whole-cell vaccine combined with diphtheria and tetanus toxoids (diphtheria, tetanus, whole-cell pertussis [DTwP]) licensed in the 1940s had resulted in a dramatic decrease in the number of cases of pertussis to a nadir in the mid-1970s.2 However, parallel to this success, the occurrence of rare but potentially serious adverse events associated with DTwP administration became unacceptable. Particularly concerning was the occurrence of high fever, febrile seizures, prolonged crying, and acute encephalopathy that sometimes followed whole-cell pertussis vaccination in some young infants.

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.

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.

Pediatrics Jul 2018, 142 (1) e20180119; DOI: 10.1542/peds.2018-0119

The benefit of prophylaxis must be weighed against its risks. In this meta-analysis, we quantify the risk of developing a multidrug-resistant recurrent UTI.

Pediatrics Jul 2018, 142 (1) e20173703; DOI: 10.1542/peds.2017-3703

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.

The implementation of a QI initiative improved guideline-based testing for GAS pharyngitis in a large community pediatrics practice.

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.

Inagaki et al from the University of Mississippi Medical Center at Jackson performed a retrospective analysis of serial cross-sectional data during 4 years between 2000-2012 using the Kids' Inpatient Database (KID). They aimed to assess risk factors, geographical distribution, length of stay, and birth hospital charges for cases of symptomatic congenital cytomegalovirus infection (cCMV). Among 1349 cases of cCMV identified, investigators identified non-Hispanic black race, government-sponsored insurance, and birth in the American South and West as having significantly increased odds ratios (95% CIs ranging from 1.37 to 2.83) for cCMV. In-hospital mortality ranged from 3.2%–6.8% and preterm birth was remarkably common (50.4% to 59.2%). Costs of inpatient birth hospitalization alone were substantial.

This same volume of The Journal includes a trifecta concerning cCMV. Lu et al (J Pediatr 2018;199:144-50) and Pasternak et al (J Pediatr 2018;199:166-70) reported on screening and therapeutic data for infants at the other end of the cCMV clinical spectrum—asymptomatic at birth. In an accompanying editorial, Ross et al (J Pediatr 2018;199:7-9) provide context and evidence-based opinion for an approach to asymptomatic cCMV.

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.34 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.356 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.

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.

Results.

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.

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.

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.

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.

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.

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.

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.

It is estimated that 2 million children (younger than 15 years of age) are infected with multidrug-resistant (MDR) strains of Mycobacterium tuberculosis (TB), known as MDR-TB infection.1 Data on the natural history of TB infection—which are often extrapolated to MDR-TB infection—show that young children (younger than 5 years of age) with TB infection are at high risk (up to 25%) of progressing to TB disease within 2–3 years of exposure, with infants’ risk of progression approaching 50%.2 It is noteworthy that older children and adolescents (10–20 years of age) also have an increased risk of developing TB disease after infection. Most children who develop MDR-TB disease are not diagnosed and started on appropriate therapy; mortality is high. However, even if diagnosed and treated, individuals must tolerate long (up to 18–24 months) courses of therapy with multiple (4–6) second-line drugs associated with far more adverse effects (AEs) than the 6–9 months of treatment with first-line drugs for drug-susceptible (DS)-TB disease. Thus, treatment of MDR-TB infection (often referred to as “preventive therapy”) to prevent progression to disease is critical.

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.

  • 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.

I thought polio had already gone.” Yet, a battle against wild polio virusis ongoing in three remain in gendemi ccountries (Afghanistan, Nigeria, and Pakistan). A formmutated from the oral vaccine, which also paralyses, cause dout breaks in Syria and the Democratic Republic of the Congo in 2017. Reducing the number children with polio paralysis from 1000 per day in 1988 to 22 in total in 2017 is a remarkable achievement. In the past few decades, however, dead lines for interrupting transmission of the polio virus have been repeatedly missed and modified. Children and families continue to be harmed, front line vaccinator shave been murdered, staff morale has suffered in relen tlessly stress ful circumstances, countries free of polio have to keep vaccinating, and donors must continue to find the nearly $1bn (£736m; €842m) for eachy earthatthe goal is missed. Why is finishing the job proving so difficult?

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.

CONCLUSIÓN.

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 .

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.

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.

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.

Hospitalizations for infections have been associated with subsequent decreased cognitive ability, but it is uncertain if childhood infections influence subsequent scholastic achievement (SA). We aimed to estimate the association between infections during childhood and SA.

Methods: Nationwide prospective cohort study including 598,553 children born in Denmark between 1987 and 1997 and their parents. Exposures were hospitalization for infections and treatment with anti-infective agents. Outcomes were completion of ninth grade and ninth grade test scores. Data were analyzed with logistic and linear regression analysis techniques and adjusted for any mental disorder, birthweight, Apgar score, malformations at birth, chronic somatic diseases, first-born child, parental educational level and parental mental disorders.

Results: Hospitalization with infections was linked to lower completion of ninth grade with an odds ratio of 0.82 (95% confidence interval: 0.79–0.85) compared with children without prior hospitalizations for infections. Dose–response relationships were observed with respect to number of hospital contacts for infections and a shorter time since last hospitalization (all P < 0.001). Among those who completed the ninth grade test score, we found a dose–response and time–since relationship between number of prior severe infections and subsequent lower grade scores (P < 0.001). Treatment of nonsevere infections with anti-infective agents did not predict lower completion of ninth grade but was associated with lower grade scores (P < 0.001).

Conclusions: Infections, particularly those requiring hospitalizations, were associated with subsequent affected cognitive ability as indicated by lower SA. These findings might also be explained by missed school days or socioeconomic factors associated with the susceptibility of acquiring infections.

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.

  • A case report of hemolyticstreptococcal gangrene in thedangertriangle of thefacewiththrombocytopenia and hepatitis. BMC 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

  • Occurrence of erythema migrans in children with Lyme neuroborreliosis and the association with clinical characteristics and outcome – a prospectivecohortstudy. BMC 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.

Background: To discuss the clinical significance of interleukin (IL)-6 in the differential diagnosis of sepsis and its capability of differentiating the sepsis induced by Gram-negative bacteria from that induced by Gram-positive bacteria.

Methods: A total of 379 children with sepsis were involved in this study to form the case group, and their C-reactive protein (CRP), procalcitonin (PCT) and IL-6 levels before antibiotics and after recovery were checked. Receiver operating characteristic curve was applied to evaluate the significance of CRP, PCT and IL-6 in the differential diagnosis of sepsis and their capability of differentiating the sepsis induced by Gram-negative bacteria from that induced by Gram-positive bacteria.

Results: When these 3 indicators were applied to the differential diagnosis of sepsis, the area under the curve (AUC) of IL-6, PCT and CRP was 0.881, 0.877 and 0.754, respectively. The combination of IL-6 and PCT presented highest diagnostic efficiency. CRP, PCT and IL-6 levels in children with sepsis induced by Gram-negative bacteria were significantly higher than those in children with sepsis induced by Gram-positive bacteria.

Conclusions: CRP, IL-6 and PCT are applicable to the differential diagnosis of sepsis and differentiating the sepsis induced by Gram-negative bacteria from Gram-positive bacteria. Appropriate combinations of these indicators are capable of increasing differential diagnosis efficiency. These indicators can be used as markers of antibiotics usage, but whether they can be used as markers to withdraw antibiotics is still needed to be observed.

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.

La monitorización del gradiente térmico es un procedimiento no invasivo, de fácil implementación, mediante sondas de temperatura en la axila (temperatura central) y en la planta del pie (temperatura periférica). Se definió gradiente térmico como una DTcp >2 °C durante al menos 4 horas.

El incremento de la diferencia entre la temperatura central y periférica es un signo precoz de sepsis tardía en recién nacidos prematuros de <32 semanas o de <1500 g al nacimiento.

Dado su valor diagnóstico y las evidencias de reducción de la mortalidad por sepsis obtenidas con su aplicación, recomendamos la implementación de este método dentro del protocolo de detección precoz de la sepsis neonatal.

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.

Se ha indicado que el uso de antibióticos prenatales modifica la microbiota vaginal y favorece las infecciones neonatales causadas por bacilos gramnegativos.
Estudio de cohorte prospectivo (enero 2016-agosto 2017). Objetivo : determinar causantes de Sepsis neontal temprana (SNT)en función del uso de antibióticos prenatales y su asociación con la resistencias. Se incluyeron todos los recién nacidos en el Hospital Civil de Guadalajara (Jalisco). NO hay programe de detección materna prenatal de SGB . La prescripción de antibióticos prenatales se realiza en infecciones urinarias, rotura prematura de membranas, corioamnionitis, fiebre materna y profilaxis en nacimientos por cesárea. Se diagnosticó SNT en los RN con clínica de sepsis y hemocultivo o /o cultivo de LCR positivos en las 72 hdv. Se investigó la administración de antibióticos prenatales y se clasificó como administración preparto o transparto.
Se registraron 13.899 nacimientos. Presentaron edad gestacional < 37 semanas el 13,6%, y factores de riesgo maternos para infección el 3,3%: fiebre sin foco (n = 6), corioamnionitis (n = 11), infección de vías urinarias (n = 109) y rotura prematura de membranas (n = 333). Recibieron antibióticos prenatales el 24,2%. los antimicrobianos más prescritos fueron cefalotina (70,4%), ampicilina (20,3%) y clindamicina (4%). La administración fue más frecuente en nacidos por cesárea , en partos múltiples, en prematuros , RN con peso ≤ 2.500 g e hijos de madres con factores de riesgo. Se diagnosticaron 72 eventos de SNT y 11 fueron polimicrobianos . La causa más frecuente de SNT fueron las enterobacterias (53%). Globalmente, las resistencias fueron: 88,2%, ampicilina, 20,5% trimetoprim-sulfametoxazol, 15,9% ceftriaxona, 15,8% piperacilina-tazobactam, 13,6% a gentamicina, 9,1%a¡ meropenem y¡ 2,3% amikacina. El microorganismo más frecuente fue Klebsiella pneumoniae. Los pacientes infectados por bacilos gramnegativos mostraron menor edad gestacional y menos peso al nacimiento); el uso de antibióticos transparto) también fue más frecuente en estos pacientes. Al analizar la asociación de SNT con el uso antibióticos prenatales ajustados a la edad gestacional y el peso no se observó asociación significativa , sin embargo, al estudiar la relación de los antibióticos transparto y SNT por bacilos gramnegativos se estimó asociación significativa (OR 4; IC 95%: 1,1-14,2) independiente de la edad y el peso. Al comparar las resistencias antimicrobianas en función de la exposición a antibióticos prenatales se observó que en las enterobacterias la proporción de resistencia no fue diferente. Se observó que en RN con antibióticosdurante el parto hubo mayor probabilidadde infecciones por bacilos gramnegativos. En regiones donde la principal etiología de SNT es el SGB se ha demostrado el efecto protector de los antibióticos prenatales; sin embargo, en lugares donde la principal causa son las enterobacterias este efecto es incierto


 

Actualidad bibliográfica Julio 2018

Este mes: vacunas antimeningocócicas, fiebre reumática, infecciones por herpes simple neonatal, transmisión vertical  de Chlamydia trachomatis,  uso  de antibióticos,  profilaxis antibiótica e infecciones por patógenos multiresitentes, antibióticos y asma, etiología de OMA supurada, tuberculosis, bacteriemia en menores de 3 meses, enfermedad invasiva  por neumococo, infecciones por parvovirus (Erythrovirus) B19, rubeola, sarampión y paperas,  casos clínicos y más.

Top ten

  • Novedades en vacunas frente a meningococo B

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.

  • Guía de la Sociedad Española de Infectología Pediátrica sobre prevención, diagnóstico y tratamiento de la infección neonatal por virus herpes simplex An Pediatr (Barc).2018;89: 64.e1-64.e10
    La infección herpética neonatal es una entidad muy poco frecuente pero que se asocia a una alta morbimortalidad. La mayor parte de los neonatos adquieren la infección  en el p periparto. Para que ocurra esta transmisión es necesaria la excreción viral genital, con o sin síntomas, alrededor del momento del parto. Existen intervenciones para prevenir la transmisión del virus herpes simplex : La realización de una cesárea en presencia de lesiones herpéticas, y la disminución de la excreción viral administrando en las últimas semanas del embarazo tratamiento antiviral a gestantes con herpes genital activo.
    El diagnóstico y tratamiento precoz del herpes neonatal requiere de un alto índice de sospecha, sobre todo en ausencia de lesiones cutáneas. Se recomienda descartar la infección por herpes neonatal en aquellos recién nacidos con lesiones cutaneomucosas, afectación del sistema nervioso central o cuadro séptico de origen no aclarado.
    El pronóstico de los neonatos con enfermedad cutánea  en la era del aciclovir a dosis altas es excelente. El tratamiento antiviral disminuye la mortalidad de las formas diseminadas y con afectación exclusiva del sistema nervioso central, pero también mejora el pronóstico neurológico en los casos de enfermedad diseminada. De forma notable, la introducción del tratamiento supresor con aciclovir oral durante los meses siguientes a la infección aguda ha mejorado el pronóstico neurológico en los pacientes con afectación del sistema nervioso central.
  • Outpatient Antibiotic Use and the Need for Increased Antibiotic Stewardship Efforts. Pediatrics. 2018;141. pii:e20174124

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

Resumen: muy buena actualización sobre tratamiento de la tuberculosis. Tanto adultos como pediátrica.

Resumen: muy buena revisión y actualización sobre el diagnóstico de la tuberculosis incluyendo nuevos biomarcadores.

We included studies comparing antibiotic therapy for asthma exacerbations in adults or children versus placebo or usual care not involving an antibiotic. We allowed studies including any type of antibiotic, any dose, and any duration, providing the aim was to treat the exacerbation. We included parallel studies of any duration conducted in any setting and planned to include cluster trials. We excluded cross-over trials. We included studies reported as full-text articles, those published as abstracts only, and unpublished data.

Six studies met our inclusion criteria and included a total of 681 adults and children with exacerbations of asthma. Mean age in the three studies in adults ranged from 36.2 to 41.2 years. The three studies in children applied varied inclusion criteria, ranging from one to 18 years of age. Five studies explicitly excluded participants with obvious signs and symptoms of bacterial infection (i.e. those clearly meeting current guidance to receive antibiotics). Four studies investigated macrolide antibiotics, and two studies investigated penicillin (amoxicillin and ampicillin) antibiotics; both studies using penicillin were conducted over 35 years ago. Five studies compared antibiotics versus placebo, and one was open-label. Study follow-up ranged from one to twelve weeks. Trials were of varied methodological quality, and we were able to perform only limited meta-analysis.

Authors' conclusions: 

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.

  • ¿Es la transmisión vertical de Chlamydia trachomatis un problema poco reconocido en España? An Pediatr (Barc).2018; 89: S1695-4033(18)30225-X

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.

Casos clínicos

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.

Para profundizar

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.

  • Infecciones por Erythrovirus B19. Seis años de seguimiento en población adulta y pediátrica An Pediatr (Barc).2018; 89: DOI: 10.1016/j.anpedi.2018.05. 016

Introducción. El Erythrovirus B19 (anteriormente parvovirus B19) causa eritema infeccioso que afecta mayoritariamente durante la infancia y la adolescencia, pero también está relacionado con artropatías, crisis aplásicas y abortos en adultos. El propósito de esta revisión es estudiar las características de las infecciones  por Erythrovirus B19 diagnosticadas en nuestro hospital en los últimos 6 años y las diferencias entre la  infección en adultos y niños.

Material y métodos: Estudio retrospectivo de los casos diagnosticados de Erythrovirus B19 mediante serología, entre enero de 2010 y diciembre de 2015.

Resultados: Fueron diagnosticados 56 casos, 34 adultos (32 mujeres y 2 varones) y 22 menores de 18 años (12 niñas y 10 niños). El 75% de los casos se dieron entre primavera y verano. Seis fueron en gestantes y en 2 hubo complicaciones graves que conllevaron la muerte fetal. En la población pediátrica los síntomas más frecuentes fueron fiebre (64%), exantema (50%) y anemia (55%). En adultos las artralgias (59%) y menos frecuentemente la anemia (41%), la fiebre (32%) y el exantema (29%).

Conclusiones: En pediatría la clínica más frecuente es el exantema y la fiebre, y en adultos las artralgias. También es frecuente la anemia, los casos más graves en presencia de enfermedad hematológica previa.

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

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.

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.

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.

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.

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%).ç

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.

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.

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

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.

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.

Estudio realizado para conocer el riesgo de resurgencia del sarampión, rubeola y paperes en Francia. Las conclusiones son: puede afectar gravemente  a menores de 1 año, aunque la población con riesgo más alto son los adolescentes.

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 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

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.

For the main effects analysis, five studies met our inclusion criteria: one RCTwith 136 participants and four non-randomized studies with 612 participants. We excluded 18 non-randomized studies with critical risk of bias, where none had attempted to control for confounding.

We do not know if ribavirin reduces mortality (1 RCT; RR 1.13, 95% confidence interval (CI) 0.29 to 4.32; 136 participants; very low-certainty evidence3 non-randomized studies; RR 0.72, 95% CI 0.41 to 1.28; 549 participants; very low-certainty evidence). We do not know if ribavirin reduces the length of stay in hospital (1 RCT: mean difference (MD) 0.70 days, 95% CI -0.39 to 1.79; 136 participants; and 1 non-randomized study: MD -0.80, 95% CI -2.70 to 1.10; 50 participants; very low-certainty evidence). We do not know if it reduces the risk of patients needing platelet transfusions (1 RCT: RR 1.23, 95% CI 0.77 to 1.96; 136 participants; very low-certainty evidence). For adverse effects (including haemolytic anaemia and a need to discontinue treatment), we do not know whether there is an increased risk with ribavirin in people with CCHF as data are insufficient.

We do not know if adding ribavirin to early supportive care improves outcomes. One non-randomized study assessed mortality in people receiving ribavirin and supportive care within four days or less from symptom onset compared to after four days since symptom onset: mortalitywas lower in the group receiving early supportive care and ribavirin, but it is not possible to distinguish between the effects of ribavirin and early supportive medical care alone.

In the subsidiary analysis, 18 studies compared people receiving ribavirin with those not receiving ribavirin. All had a critical risk of bias due to confounding, reflected in the mortality point estimates favouring ribavirin.

Resumen: análisis del amplio uso de IGRAs y su comportamiento en niños con enfermedad tuberculosa. En niños menores de 5 años la sensibilidad de los IGRA es similar a la de la tuberculina, pero la sensibilidad de ambos es menor en niños de menos de 2 años. Los resultados indeterminados son más frecuentes en niños menores de 1 año y en los que tienen enfermedad del sistema nervioso central. En niños de 5 o más años su sensibilidad es mayor que la de la tuberculina y deberían de considerarse el test de elección.

 

Resumen: estudio a gran escala de los efectos secundarios severos de la vacuna DTPa según los datos recogidos en el accine Adverse EventReportingSystem (VAERS) en USA. Concluyen que no se han detectado ni nuevos ni inesperados efectos adversos con esta vacuna.

 

Actualidad bibliográfica junio 2018

Este mes: Duración del tratamiento en faringoamigdalitis aguda, enfermedad invasiva por estreptococo, vacunas para fiebre tifoidea, vacuna frente a VPH, tubos de drenaje , OMA: etiología, educación a padres sobre vacunas, Clostridium difficile, hepatitis C, VRS, vacunas frente a meningococo ACWY, tosferina, TBC, brucelosis, cuidados sanitarios para refugiados, casos clínicos y más…

TOP-TEN

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.

En los últimos años se ha detectado un incremento de los casos graves de enfermedad invasiva (EI) por Streptococcus pyogenes o estreptococo beta-hemolítico del grupo A (SGA). El objetivo del estudio fue determinar la epidemiología y las características clínicas de las EI por SGA en un hospital pediátrico de tercer nivel.

Estudio retrospectivo realizado en un hospital urbano materno-infantil de tercer nivel. Se incluyeron los pacientes ingresados con diagnóstico final de EI por SGA durante 6 años (2009-2014).

Se consideró EI cuando SGA se aisló en muestras estériles, en pacientes con fascitis necrosante cuando se aisló en muestras de la zona de la lesión y en pacientes con síndrome shock tóxico estreptocócico (SSTS) cuando se aisló en cualquier muestra.

Se recogieron datos demográficos, tipo de infección, factores de riesgo, presentación clínica, datos analíticos al ingreso, tratamiento, necesidad de ingreso en unidad de cuidados intensivos pediátricos (UCIP), datos microbiológicos, estancia hospitalaria y evolución.

Se incluyeron 52 casos (12/10.000 ingresos); edad mediana de 3 años (p25-75: 1,4-6,9 años); 28 (53,8%) eran varones. Presentaban factores de riesgo 14 (26,9%) casos. El motivo de consulta incluía fiebre en 51 (98,1%); la clínica acompañante más frecuente fue la cutánea (21; 40,4%). En 50 (96%) casos se aisló SGA en al menos un medio estéril. Se diagnosticaron 14 (26,9%) infecciones de piel y partes blandas, 14 (26,9%) neumonías, 12 (23,1%) infecciones osteoarticulares, 10 (19,2%) SSTS, 6 (11,5%) bacteriemias ocultas, 4 (7,7%) meningitis y 2 (3,8%) sepsis.

Requirieron cirugía 18 (34,6%) casos y 17 (32,7%) ingreso en unidad de cuidados intensivos. La mediana de estancia hospitalaria fue de 9,5 días (p25-75: 8-15 días). Presentaron secuelas 3 pacientes y hubo un fallecimiento.

La EI por SGA fue un motivo poco frecuente aunque grave de hospitalización. Las infecciones de piel y partes blandas, y las pleuroneumonías fueron las formas de EI más habituales. A pesar de la gravedad, la mortalidad en la serie fue baja

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

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.

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.

Casos clínicos

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.

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.

Para profundizar

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.

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 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

Comentario sobre la incidencia, forma de presentación de la infección por VRS en embarazadas y posibles beneficios de las nuevas vacunas en la madre y en el niño. El editorial se realiza a propósito de un estudio realizado en Nepal y Mongolia por Nunes et al. El artículo es interesante, perome parece más interesante, para los pediatras, el comentario editorial.

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.

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.

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.

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.
 

Los índices de mortalidad por TB en la Unión Europea descendieron en general durante el periodo 2000-2010 para ambos sexos. Los varones reflejan unos índices superiores de mortalidad que las mujeres en todos los países. Nuestros hallazgos fueron consistentes con la tendencia a la baja de la mortalidad por TB en muchos otros países a nivel mundial.

This study described a pertussis outbreak caused by macrolide-resistant B. pertussis in a primary school and indicated that close contact of index case causes the bacterial transmission.

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.

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.

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.

La bronquiolitis aguda (BA) del lactante tiene una evolución grave entre el 6 y el 16% de los casos ingresados. Su patogenia y evolución está relacionada con la respuesta de los linfocitos T. El objetivo del presente estudio es comprobar si la menor respuesta linfocitaria sistémica está relacionada con una peor evolución de la BA en lactantes ingresados.

Pacientes y método

Estudio retrospectivo de casos-controles anidados en una cohorte de ingresados por BA-VRS en el periodo de octubre del 2010 a marzo del 2015. Se incluyó a aquellos con hemograma en las primeras 48 h de dificultad respiratoria. Se excluyó a los lactantes con patología de base, sobreinfección bacteriana y prematuros ≤ 32 semanas de gestación. La variable principal dicotómica fue ingreso UCIP. Otras variables fueron: sexo, edad, edad posmenstrual, exposición gestacional y posnatal al tabaco, mes de ingreso, tipo de lactancia y días de evolución del distrés respiratorio.

Conclusiones Existe relación entre la linfocitosis<3.700/ml en los primeros días de la dificultad respiratoria y una peor evolución en lactantes < 12 meses previamente sanos y edad gestacional mayor de 32 semanas con BA-VRS

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.

Prenatal antibiotic exposure was associated with lower rates of NEC or death of infants born preterm, and its impact on infant outcomes warrants further study.

Introducción: Las infecciones respiratorias agudas de causa viral son unas entidades muy frecuentes. La dificultad para valorar la detección de un determinado virus en estas entidades podría solucionarse con la determinación de la carga viral.

Métodos: Se ha realizado un estudio prospectivo sobre el valor medio de los Ct (cycle threshold value) detectados frente al VRS-A, VRS-B y los virus gripales A (H1N1)pdm09, A(H3N2) y B en pacientes de diferente procedencia y edad. La detección se ha realizado mediante una técnica de amplificación molecular (RT-PCR) comercial.

Resultados: Se han detectado valores medios de Ct distintos para cada virus. En las infecciones por VRS, no se han observado diferencias entre las causadas por el VRS-A o VRS-B en pediatría. De acuerdo con la edad de los pacientes solo se ha observado significación estadística en los incluidos en los grupos de 0-4 meses para el VRS-A y este grupo y el de 5-12 meses para el VRS-B (valores más elevados). En los pacientes adultos se ha detectado una carga viral menor que en los pediátricos.

En las infecciones gripales no se ha observado significación estadística en los valores medios detectados en los pacientes procedentes de la Red Centinela, en los diagnosticados en las urgencias de adultos ni en los ingresados hospitalarios. En los pacientes adultos ingresados en la UCI solo se ha observado un valor medio algo más bajo en los infectados por el virus gripal A (H1N1)pdm09 pero sin significación estadística. No hubo ningún paciente ingresado en la UCI con infección por gripe B.

Conclusión: La detección de la carga viral podría ser una buena herramienta para la evaluación, seguimiento y pronóstico de las infecciones respiratorias agudas víricas. A excepción de las causadas por el VRS, no se han observado diferencias significativas en las infecciones gripales, salvo en los pacientes pediátricos de menor edad.

Actualidad bibliográfica mayo 2018

Este mes: alergia a antibióticos, sarampión en Europa, escarlatina, uso de antibióticos, herpes neonatal, malaria, infección TBC, PCR, Leishmania visceral, enfermedad de Lyme, resistencia en neumococos, apendicitis, fiebre sin foco, vacuna antigripal y más…

Resumen: excelente revisión bibliográfica sobre alergias a antimicrobianos en edad pediátrica. Incide en la buena clasificación del tipo de reacción alérgica producida.

  • European countries are urged to carryout catch-up campaigns as measles outbreakscontinue. BMJ 2018;361:k1771

El Centro Europeo para la Prevención y Control de Enfermedades, ha aconsejado a los países europeos quedeberían llevar a cabo campañas de actualización de vacunación dirigidas a adolescentes y jóvenes para frenar los brotes de sarampión en todo el continente.

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 rápida del riesgo realizada por el centro encontró que los trabajadores de la salud no vacunados se vieron afectados en los últimos brotes.

Después de décadas de caída de la incidencia, la escarlatina está en aumento. Las tasas actuales en Inglaterra son las más altas durante 50 años y todas las partes del país se ven afectadas. Los brotes son comunes en las guarderías y las escuelas y la edad media de los casos es de cuatro años ( LancetInfectDisdoi: 10.1016 / S1473-3099 (17) 30693-X). El análisis de los aislados de Streptococcuspyogenes muestra una diversidad de tipos de genes de la proteínaM, de forma que el aumento en la incidencia no puede explicarse por la aparición de una nueva cepa virulenta con capacidad mejorada para causar escarlatina.

Objetivos Evaluar la adecuación de la prescripción de antimicrobianos en población pediátrica en un servicio de urgencias.

Métodos Estudio observacional, descriptivo y transversal en población menor de 14 años atendida en las urgencias hospitalarias de un hospital comarcal durante el año 2013. Se seleccionó una muestra aleatoria de 630 pacientes (intervalo de confianza: 99%; error alfa: 5%). Se analizó el grado de adecuación del tratamiento antimicrobiano comparando nuestra práctica clínica con las recomendaciones de una guía de tratamiento antimicrobiano basada en la mejor evidencia disponible diseñada especialmente para este estudio.

Resultados Se prescribió antimicrobiano al 16,5% de los pacientes (n=104). El tratamiento fue considerado inadecuuado en el 51,9% de los pacientes (n=54). Se prescribió tratamiento innecesario en el 40,7%, la elección del antimicrobiano fue incorrecta en el 35,2% y la posología en el 24,1%. Las principales enfermedades en las que se produjo la prescripción inadecuada fueron: otitis media aguda, episodio de sibilancias, fiebre sin foco, faringoamigdalitis aguda y neumonía adquirida en la comunidad.

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.

Broad-spectrum antibiotics were not associated with less treatment failure, risk difference 0.3% (95% CI, −0.4% to 0.9%), and were associated with more clinician-reported and patient-reported adverse events, risk difference 1.1% (95% CI, 0.4% to 1.8%) and 12.2% (95% CI, 7.3% to 17.2%), respectively.

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

La infección herpética neonatal es una entidad muy poco frecuente pero que se asocia a una alta morbimortalidad. La mayor parte de los neonatos afectos adquieren la infección por virus herpes simplex en el periodo periparto. Para que ocurra esta transmisión es necesaria la excreción viral genital, con o sin síntomas, alrededor del momento del parto. Existen intervenciones basadas en la evidencia para prevenir la transmisión del virus herpes simplex al recién nacido. La realización de una cesárea en presencia de lesiones herpéticas, y la disminución de la excreción viral administrando en las últimas semanas del embarazo tratamiento antiviral a gestantes con herpes genital activo, son las mejores medidas preventivas de las que se dispone. El diagnóstico y tratamiento precoz del herpes neonatal requiere de un alto índice de sospecha, sobre todo en ausencia de lesiones cutáneas. Se recomienda descartar la infección por herpes neonatal en aquellos recién nacidos con lesiones cutaneomucosas, afectación del sistema nervioso central o cuadro séptico de origen no aclarado. El pronóstico de los neonatos con enfermedad cutánea en la era del aciclovir a dosis altas es excelente. El tratamiento antiviral disminuye la mortalidad de las formas diseminadas y con afectación exclusiva del sistema nervioso central, pero también mejora el pronóstico neurológico en los casos de enfermedad diseminada. De forma notable, la introducción del tratamiento supresor con aciclovir oral durante los meses siguientes a la infección aguda ha mejorado el pronóstico neurológico en los pacientes con afectación del sistema nervioso central

Selling antibiotics without prescription is common in many countries; beyond the administrative restrictions, this practice is a risk for patients and society. The aim of the study was to evaluate the information provided by the staff of the pharmacy to a simulated patient requesting an antibiotic.

MATERIAL AND METHODS:

A prospective study was carried out in January 2013 - February 2014 in the Health Region of Tarragona, in which a mystery shopper visited 220 pharmacies requesting an antibiotic to be sold.

RESULTS:

The actress was not asked about allergies in 73.9% of cases and never was asked about possible pregnancy. Recommendation to see a doctor was observed in 36.1% of cases. When antibiotics were not sold, the explanation provided by the staff was reasoned only in 9.9% of the cases.

CONCLUSION:

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

Detection and treatment of latent tuberculosis infection (LTBI) is an essential measure for tuberculosis (TB) control in low-incidence countries. However, such strategy is limited by the low predictive ability of the diagnostic tests for the development of active TB among infected people and the long-term and toxic treatment regimens. The in vitro interferon-gamma release assays are more specific and sensitive than the tuberculin skin test (TST), and enable a better selection of cases requiring treatment. Nonetheless, their capacity to predict development of TB is still poor. In addition, treatment regimens for LTBI are long, and compliance rates are low. This review discusses the use of the available diagnostic tests and the new approaches to the diagnosis of LTBI, as well as its management in different clinical scenarios.

Resumen: excelente revisión-actualización de la malaria. No es pediátrica, va referida a cualquier edad.

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

Casos clínicos

  • Neonatal Parotitis J Pediatr. 2018 May;196:319

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
 

Para profundizar

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.

La guía se centra en el diagnóstico y el tratamiento de la enfermedad de Lyme de acuerdo con la presentación clínica y los síntomas en lugar de utilizar las diferentes clasificaciones de la enfermedad de Lyme, que están mal definidas y controvertidas. Faltan pruebas de buena calidad sobre la epidemiología, la prevalencia, el diagnóstico y el tratamiento de la enfermedad de Lyme.

Este artículo resume las recomendaciones más recientes del Instituto Nacional de Excelencia en Salud y Atención (NICE): https://www.bmj.com/content/bmj/suppl/2018/04/12/bmj.k1261.DC1/crum090318.wi.pdf

Background:

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.

Methods:

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.

Results:

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).

Conclusion:

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.

El virus del papiloma humano (VPH) se identifica en primer lugar en dermatología y posteriormente se demuestra que es una causa necesaria para el desarrollo de cáncer de cuello uterino y de otros tumores, tras una infección persistente por alguno de sus genotipos oncogénicos. Desde hace 10 años, las infecciones y neoplasias más frecuentes relacionadas con el VPH pueden prevenirse mediante la inmunización con 2vacunas, una bivalente y otra tetravalente, y acaba de comercializarse una nonavalente. Durante el periodo 2007-2008 se incluyó la vacuna frente al VPH en el calendario de las comunidades autónomas y es la segunda vacuna, después de la de la hepatitis B, que previene el cáncer. En estos 10 años de disponibilidad de estas vacunas se ha progresado en su conocimiento y se han producido avances importantes en las estrategias de vacunación y en las indicaciones y las recomendaciones: adelanto de la edad de vacunación en el calendario, pautas de 2dosis desde los 9 hasta los 13-14 años, vacunación sistemática del varón en algunos países, inmunización de la mujer más allá de la adolescencia, implementación de programas de vacunación en países en desarrollo, prevención de otras neoplasias, recomendaciones de vacunación para poblaciones de riesgo elevado de infección por el VPH, evidencia científica del impacto y la efectividad de la vacunación, y confirmación de la seguridad de estas vacunas, con más de 270 millones de dosis administradas, como ya se había observado en los ensayos clínicos. El papel de los profesionales de la salud es fundamental para alcanzar y mantener coberturas vacunales elevadas.

Background:

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.

Methods:

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.

Results:

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.

Conclusions:

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.

The Pediatric Infectious Disease Journal. 37(5):492-494, May 2018.

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.

Background:

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.

Methods:

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.

Results:

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.

Conclusions:

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.

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.

  • Predicting the severity of dengue fever in children on admission based on clinical features and laboratory indicators: application of classification tree analysis. BMC Pediatrics (2018) 18:109

La fiebre del dengue es una enfermedad viral reemergente que ocurre comúnmente en áreas tropicales y subtropicales. El retraso en el diagnóstico puede estar asociado con un tratamiento inadecuado y un mayor riesgo de muerte. El diagnóstico precoz y correcto puede ayudar a mejorar el manejo de casos y optimizar el uso de recursos. El objetivo de este estudio fue desarrollar un modelo predictivo para caracterizar la gravedad del dengue. El árbol de decisiones que describimos, utilizando cinco indicadores clínicos y de laboratorio simples, puede usarse para predecir casos graves de dengue en pacientes pediátricos al ingreso. Este algoritmo es potencialmente útil para guiar un plan de monitoreo del paciente y el manejo ambulatorio de la fiebre en entornos de escasos recursos.

Pediatrics Apr 2018, 141 (4) e20172918; DOI: 10.1542/peds.2017-2918

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.

Resumen: en todo el periodo se ha dado un incremento rápido y relativamente importante de enfermedad neumocócica invasiva producida por serotipos no incluidos en la vacuna tetravalente. Por el contrario, han disminuido en conjunto en un 37% las enfermedades invasivas por neumococo. Los serotipos que más recientemente han emergido en poblaciones no vacunadas han sido el 8, 12F y 9N, responsables de un 40% de enfermedades neumocócicas invasivas en Reino Unido en 2016/17. Detallan que en menores de 5 años de edad la incidencia de enfermedad invasiva en menores de 5 años permanece, sin embargo, baja y estable desde 2013/14, con la mayoría de fenómenos de reemplazo ocurriendo en adultos. No obstante el incremento

Main Results Infants receiving LR demonstrated significantly lees crying after one month of treatment, number needed to treat to reduce crying by 50%, 3 (95% CI, 2-5). Inflammatory markers were significantly reduced in patients treated with LR.

Conclusions LR was effective in ameliorating crying in infants with infantile colic.

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.

Early-life transient dysbiosis has long-lasting effects on human health, suggesting a role of the microbiome in the DOHaD.

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.

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.

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

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.

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.

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.

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.

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

Actualidad bibliográfica abril 2018

Este mes: Tuberculosis,  enfermedades infecciosas  importadas, microbiota, antivacunas, infecciones por Clostridium difficile, enfermedad de Kawasaki,  eficacia de vacunas antigripales,  lecturas de antibiograma, corticoides sistémicos  en OMA, malaria, test no invasivos para  Helicobacter pylori, casos clínicos y más.

Top ten

Se presentan los resultados de la vigilancia epidemiológica de la tuberculosis en España en 2015 a partir de los casos notificados a la Red Nacional de Vigilancia Epidemiológica, así como la actualización del tratamiento de los casos declarados en 2014. La tasa de incidencia de tuberculosis en 2015 fue de 10,59 casos por 100.000 habitantes, un 10% inferior a la del año 2014. Este descenso se debió, fundamentalmente, a la tendencia descendente y sostenida de las tasas de tuberculosis pulmonar, de otras localizaciones y en los adultos, mientras que en los casos de meningitis tuberculosa y en niños el descenso es menos acusado, con tendencia a la estabilización. El porcentaje de casos nacidos en otros países se mantiene estable (aproximadamente 30% del total). Se dispone de información sobre el estatus VIH del 63% de los casos, de los que el 7% fueron VIH positivos. Respecto a los resultados de tratamiento, el 77% de los casos nuevos pulmonares confirmados por cultivo declarados en 2014 tuvieron un resultado satisfactorio, 6% fallecieron, y del 11% no se disponía de información.

En el mundo global, el conocimiento de las enfermedades infecciosas importadas es esencial en la práctica diaria, tanto para el microbiólogo-parasitólogo como para el clínico en enfermedades infecciosas que atiende a viajeros internacionales. Entre los destinos turísticos más visitados se encuentran muchos países tropicales o subtropicales, donde el riesgo de contraer una enfermedad infecciosa es más elevado. La SEIMC ha considerado pertinente la elaboración de un documento de consenso que sirva de ayuda tanto a médicos de Atención Primaria como a especialistas en Medicina Interna, Enfermedades Infecciosas y Medicina Tropical que atienden a viajeros que regresan con infecciones tras un viaje a zonas tropicales y subtropicales. Se han excluido de forma explícita los aspectos de prevención de estas y las infecciones importadas por inmigrantes, objeto de otros documentos de la SEIMC.

Varios tipos de profesionales (clínicos, microbiólogos y parasitólogos) han desarrollado este documento de consenso tras evaluar los datos disponibles basados en la evidencia para proponer una serie de datos clave acerca de este aspecto. Inicialmente se revisan los aspectos generales acerca de la evaluación general del viajero que regresa con una potencial infección. En un segundo bloque se señalan los datos clave (agentes causales, procedimientos diagnósticos y medidas terapéuticas) de los síndromes infecciosos principales en el viajero que regresa (síndrome gastrointestinal (diarrea aguda o persistente), síndrome febril sin foco aparente, lesiones cutáneas localizadas e infecciones respiratorias). Finalmente se describen las características en viajeros especiales como la viajera embarazada y el viajero inmunodeprimido.

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.

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.

Casos clínicos

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.

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.

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.

The Pediatric Infectious Disease Journal. 37(4):370-372, April 2018

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.

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.

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

Para profundizar

Halden F. Scott, Emily E. Greenwald, Lalit Bajaj, Sara J. Deakyne Davies, Lina Brou, Allison Kempe

Resumen

Introducción: la enfermedad de Kawasaki es una vasculitis aguda, febril y autolimitada, que puede complicarse con alteraciones cardiovasculares. Su diagnóstico se basa en criterios clínicos. A pesar de un tratamiento eficaz, es la principal causa de cardiopatía adquirida en niños de países desarrollados. Objetivos: analizar la prevalencia de alteraciones coronarias en pacientes pediátricos diagnosticados en nuestro medio; evaluar las características demográficas, clínicas y analíticas de la población de estudio y describir los factores de riesgo de alteración coronaria en niños con enfermedad de Kawasaki.

Métodos: se revisaron de forma retrospectiva las historias clínicas de los niños diagnosticados de enfermedad de Kawasaki desde enero de 1997 hasta diciembre de 2016 en el Hospital Clínico San Carlos (Madrid, España). Se consideró diagnóstico de enfermedad de Kawasaki la presencia de los criterios clínicos propuestos por la Academia Americana de Pediatría en 2017.

Resultados: la enfermedad de Kawasaki se presentó fundamentalmente durante el invierno (n = 13; 56,5%) en mujeres (n = 12; 52,2%) de cinco años o menos (n = 18; 78,3%), que desarrollaron fiebre (n = 23; 100%) junto con cambios en la mucosa orofaríngea (n = 21; 91,3%) y presentaron proteína C reactiva y velocidad de sedimentación globular elevadas (n = 20; 86,95% y n = 13; 86,6%). Fueron tratados con inmunoglobulina intravenosa (n = 22; 95,7%) y ácido acetilsalicílico a dosis antiinflamatoria (n = 22; 95,7%) o antiagregante (n = 20; 87%). Tres pacientes (13%) desarrollaron alteraciones coronarias, que terminaron remitiendo.

Conclusiones: en nuestra cohorte, la prevalencia de alteraciones coronarias fue similar a la reportada en nuestro medio y superior a la descrita en estudios internacionales. Los factores de riesgo de alteración coronaria son predominantemente niños con retraso en el diagnóstico y tratamiento, leucocitosis >12 000/ul, proteína C reactiva >3 mg/dl y trombocitosis.

The update, which has incorporated recommendations for children (following the adult recommendations for epidemiology, diagnosis, and treatment), includes significant changes in the management of this infection and reflects the evolving controversy over best methods for diagnosis.

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.

La aplicación de los puntos de corte establecidos por el European Committee on Antimicrobial Susceptibility Testing (EUCAST) en comparación con los del Clinical and Laboratory Standards Institute (CLSI) modifica los criterios de interpretación de la sensibilidad de algunos antimicrobianos y esto conduce a cambios en los informes de sensibilidad antibiótica acumulada.

Análisis de la influencia de la aplicación del EUCAST en 10.359 aislados clínicos de Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus y Enterococcus spp.

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%).

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.

Malaria continues to be a major cause of childhood mortality and was responsible for an estimated 303,000 (165,000–450,000) deaths in children under 5 years old in 2015. However, this represents a 60% reduction in mortality since 2000,1 one of biggest successes in terms of the Millennium Development Goals. Central to this achievement was the widespread deployment of effective tools for prevention and treatment, including insecticide treated nets and Artemisinin-based Combination Therapies (ACTs). The recent emergence and spread of Plasmodium falciparum parasites resistant to ACTs, and mosquitoes resistant to the pyrethroids, the most commonly used insecticide, threaten to reverse these gains, and the hopes of eliminating malaria. This review provides an update on antimalarial resistance and approaches to treatment.

Enferm Infecc Microbiol Clin 2018;36:241-5

La microbiota es el conjunto de microorganismos que reside en nuestro cuerpo, que a su vez pueden diferenciarse según su comportamiento en comensales, mutualistas y patógenos. El conocimiento de este ecosistema se ha visto considerablemente incrementado tras la introducción de las técnicas de secuenciación masiva del gen 16S ARNr (gen ADNr 16S).

Consideraciones clínicas

Desde el nacimiento existe una relación simbiótica entre la microbiota y nuestras células que evoluciona en el tiempo, adaptándose a los cambios. Su composición presenta particularidades y características propias de cada individuo, pudiendo variar en función de genética, la dieta y la interacción con el medio ambiente. El estudio de este ecosistema es un campo de rápido avance científico, aceptando universalmente que para alcanzar un estado de salud adecuado es necesario tener también una microbiota «sana». La disbiosis puede producirse en cuestión de días, particularmente tras la ingesta de antibióticos, pero también puede ser consecuencia de otras acciones a más largo plazo, fundamentalmente relacionadas con la dieta. En una persona adulta, el tracto gastrointestinal puede albergar entre 500 y 1.000 especies de microorganismos, siendo las bacterias de los filos Bacteroidetes y Firmicutes los mayoritarios. En menor proporción se detectan Proteobacteria, Verrucomicrobia, Fusobacteria, Cyanobacteria, Actinobacteria y Spirochaetes, las arqueas, los hongos, los protozoos, los virus y otros microorganismos.

En los obesos la ratio Firmicutes/bacteroides está muy alterada por el aumento de los Firmicutes. El aumento de Firmicutes también se ha descrito en anc Firmicutes/Bacteroides ianos de forma fisiológica como consecuencia de la edad.

Las principales funciones de la microbiota intestinal son prevenir la colonización por otros microorganismos patógenos, ayudar a digerir los alimentos, producir vitaminas B y K que el organismo humano no es capaz de sintetizar y estimular al sistema inmune. Tras el nacimiento, las células del sistema inmune carecen de estímulos, reconociendo a todos los antígenos de su alrededor como parte del organismo y bloqueando la respuesta inflamatoria contra ellos. Los primeros contactos de la microbiota con las líneas celulares inmunológicas sin diferenciar van a ayudar a definir lo que es lo «propio» de lo «extrano˜ ». Sería la base de ciertas enfermedades autoinmunes donde los antígenos de la microbiota intestinal representan un estímulo suficientemente grande como para desencadenar una respuesta inflamatoria. En otras enfermedades, como el síndrome metabólico y la obesidad,también se atribuye a la microbiota intestinal el origen del estímulo que origina una respuesta inflamatoria basal continuada.

Recientemente se ha descrito la existencia del eje cerebrointestino, que conecta el sistema nervioso central con la microbiota intestinal a través del nervio vago, el sistema parasimpático, los metabolitos bacterianos, que pueden tener acciones como neurotransmisores, y el sistema endocrino asociado al tracto digestivo. Así pues, además de las enfermedades que clásicamente se han relacionado con

alteraciones en la microbiota, como la obesidad, la diabetes tipo 2, las enfermedades inflamatorias del intestino y las alergias, últimamente también se han relacionado otras enfermedades del sistema nervioso central, como el autismo, la ansiedad, la depresión y la dependencia alcohólica.

También se describe el procedimiento de transferencia de materia fecal, particularmente utilizado para el tratamiento de las recidivas de la diarrea por Clostridium difficile, y las bases metodológicas de las nuevas técnicas moleculares utilizadas en la caracterización de la microbiota.

. Cochrane Database of Systematic Reviews 2018, Issue 3. Art. No.: CD012080. DOI: 10.1002/14651858.CD012080.pub2

(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.

Resumen

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.

Palivizumab prophylaxis through the novel monthly protocol for patients with hsCHD is effective in reducing respiratory syncytial virus-related hospitalizations.

 

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.

Actualidad bibliográfica marzo 2018

Este mes: aumento de casos de escarlatina, tratamiento de abscesos cutáneos, iniciativa europea contra las resistencias bacterinas, hepatitis B, hepatitis C, trasmisión vertical de enfermedad de Chagas, Zyka, profilaxis antibiótica ante CUMS, adecuación del tratamiento con quinolonas, infecciones por Kingella kingae, exantemas, antibióticos en ganadería, repelentes frente a malaria, vacunación materna, antimicrobianos en diarrea, calendario vacunal AAP y más… 

Top ten

Resumen: revisando datos desde 1911 a 2016, encuentran que en los dos últimos años, Inglaterra ha vivido un incremento nunca conocido de casos de escarlatina, en todas las partes de Inglaterra (620 brotes descritos), con un aumento de ingresos por escarlatina del 97% entre 2013 y 2016, y un ingresado por cada 40 casos para tratar potenciales complicaciones. La mediana de la edad ha sido de 4 años (rango intercuartílico: 3 a 7). Se analizaron 303 cepas (el número de casos en 2016 fue de 19.206) y hubo diversidad de tipos emm (43% emm3; 15% emm12; 11% emm1; 9% emm4)

¿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.

Healthy infants should be vaccinated with the hepatitis B within 24 hours of birth and physicians should not delay vaccination until after discharge, according to new recommendations from the US Advisory Committee on Immunization Practices (ACIP) and the US Centers for Disease Control and Prevention (CDC). Previously, the recommendations allowed for newborn vaccination after discharge.

Most people infected with hepatitis B develop chronic infections and may not know they are infected. Chronic infections increase the risk of developing cirrhosis or liver cancer. Since 1991, the ACIP has recommended universal hepatitis B vaccinations for all US infants as part of a comprehensive strategy to eliminate transmission of the hepatitis B virus. The strategy also recommended routine testing for hepatitis B surface antigen (HBsAg) for all pregnant women, prophylaxis for infants born to infected mothers, routine vaccination of older children and adolescents, and vaccinations for adults at risk. The new recommendations emphasize steps to further reduce mother-to-child transmission and increase vaccinations for vulnerable groups.

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.

Resumen: actualización de las recomendaciones sobre vacunas infantiles de la Academia Amerivana de Pediatría, los CDC, la Academia Americana de Médicos de Familia y el Colegio Americano de Ginecòlogos y Obstetras. Mantienen el esquema de primovacunación 2-4-6 meses booster a los 15-18 (no suprimen una dosis como hacemos en la actualidad en España y la mayoría de países europeos). Diferencias con el nuestro es que incluyen recomendación de vacunación anual de gripe a todos los niños de más de 6 meses (no recomiendan vacunar con la viva inactivada), Hepatitis A dos dosis separadas 6 meses a partir del año de edad, y como vacunación antimeningocócica rutinaria recomiendan Tetravalente a los 12 y 16 años. No recomiendan Antimeningocócica B más que a grupos de riesgo y tampoco vacunan en niños pequeños frente a Meningococo C. Hacen pauta 3+1 de antineumocócica. El link al resumen del calendarios ( https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-combined-schedule-bw.pdf )

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.

The resolution on sepsis by the United Nations World Health Assembly in May 2017 recognizes sepsis as a global threat in adults and children and a priority for the World Health Organization to address during the next decade.1 This resolution on sepsis acknowledges that sepsis represents a major contributor to childhood morbidity and mortality and the associated economic burden. The United Nations Sustainable Development Goal 3 (https://sustainabledevelopment.un.org/sdg3) defined specific targets for infections and pandemics.2 Despite the huge burden that sepsis imposes on the health of children,3,4 current definitions of pediatric sepsis are of limited value to bedside clinicians to identify cases of sepsis. Moreover, these definitions have poor predictive value and have not been validated, thus lessening their utility in benchmarking, performance monitoring, and patient stratification. These shortcomings have been increasingly recognized since the definitions were crafted by consensus in 20052 and aligned with the 2001 adult Sepsis Consensus (Sepsis-2) definitions. The goal of the 2005 expert consensus was to identify children with sepsis who were unresponsive to initial therapy, and thus at high risk for mortality, to be enrolled in a trial. Sepsis-2 highlighted the need for sensitive criteria allowing early recognition of and intervention for sepsis, with an emphasis on a clinician-defined spectrum of disease. Presumed or proven infection with systemic inflammation (SIRS) was defined as sepsis, with progressive organ dysfunction defined as severe sepsis and cardiovascular dysfunction as septic shock. However, SIRS is very commonly manifested in otherwise well febrile children, and even in children without infections, leading to low specificity and thus limited use to clinicians.5 During the winter months, more than half the population of children in emergency departments present with runny noses due to viral infections, which would satisfy the present criteria for sepsis. Apart from the stress on resources even in high-income countries, many health care facilities in low- and middle-income countries do not have the resources to perform white blood cell counts (a requirement for diagnosing SIRS); hence, the present definition is of limited benefit in many parts of Asia and sub-Saharan Africa, where the burden of sepsis is highest and the most mortality from sepsis occurs. The difficulties in applying the definitions of sepsis have led to considerable variability in sepsis reporting. Accordingly, studies have identified considerable discrepancies in applying definitions of pediatric sepsis, leading to a large variation in incidence estimates when comparing clinical, administrative, and research data. Too often, sepsis was used interchangeably with severe sepsis, despite clear criteria for organ dysfunction, which is the final common pathway to adverse patient outcomes.

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.

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.

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.

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

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-

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.

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.

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).


 

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.

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.

Casos clínicos

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 …

Niña de 11 años que consulta por una lesión cutánea en su mejilla izquierda que había estado presente durante 3 semanas. Vivía en un área suburbana en Polonia y tenía contacto directo con gatos. La herida comenzó como una pústula y evolucionó a una úlcera necrótica. Había recibido antibioterapia empírica sin mejoría

A 66-year-old woman presented to her primary care physician’s office with a 2-week history of dry cough and severe pain in the right flank. Five days before presentation, she had received a diagnosis of viral upper respiratory tract infection, but her symptoms had not abated with supportive treatment. Physical examination revealed a large ecchymosis across her right flank (Panel A) and tenderness on palpation over the chest wall on the right side. Computed tomography of the chest and abdomen (Panel B) revealed a displaced fracture of the lateral aspect of the ninth rib on the right side (arrow). Nasopharyngeal culture confirmed infection with Bordetella pertussis

Para profundizar

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.

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.

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.

Introducción; El objetivo del estudio fue determinar un punto de corte de la titulación de IgG mediante ELISA en el diagnóstico de parotiditis. Métodos: Se estudiaron sueros de 85 casos de parotiditis (confirmados por PCR en saliva) y de 2.351 controles de la población de la Comunidad de Madrid. Resultados: La detección de IgM fue positiva en 21 casos (sensibilidad del 24,7). El mejor punto de corte de IgG correspondía a títulos ≥4.900 (sensibilidad del 64,7% y especificidad del 86,1%). De 42 pacientes vacunados con ≥1 dosis de triple vírica se detectó IgM en 4, mientras que la detección de IgG ≥4.900 fue positiva en 29 (sensibilidad del 69,0%). Conclusiones: Un resultado de IgG ≥4.900 fue casi 5 veces más probable en un paciente con parotiditis que en otro sujeto no infectado. La detección de títulos elevados de IgG frente a parotiditis puede mejorar el rendimiento diagnóstico de la IgM en vacunados.

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.

Mosquito repellents provide protection from mosquito bites. There are three different types of repellents: topical repellents, which can be applied on the skin; insecticide-treated clothing, through impregnation of clothing with repellent compounds; and spatial repellents, such as mosquito coils. Malaria has decreased in many countries because people have been given highly effective long-lasting insecticide bed nets (Llins). However people are still being bitten before they go to bed. There is a need to find a way to offer protection from malaria during these hours. Mosquito repellents may address this gap.

There is insufficient evidence to conclude topical or spatial repellents can prevent malaria. There is a need for better designed trials to generate higher certainty of evidence before well-informed recommendations can be made. Adherence to daily compliance remains a major limitation. Insecticide-treated clothing may reduce risk of malaria infection in the absence of insecticide-treated nets; further studies on insecticide-treated clothing in the general population should be done to broaden the applicability of the results.

Osmotic therapies increase the concentration of the blood by exerting an osmotic pressure across a semi-permeable membrane (such as a cell wall or blood vessel lining in the brain). This draws water from the brain into the blood, thereby reducing pressure in the brain. Potentially osmotic therapies could increase the rate of survival, or they could do harm.

Glycerol was the only osmotic therapy evaluated, and data from trials to date have not demonstrated an effect on death. Glycerol may reduce neurological deficiency and deafness.

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.

Actualidad bibliográfica febrero 2018

Este mes: Enfermedades por Estreptococo, vacunas antigripales, Hepatitis B, contaminación de fórmula para lactantes por Salmonella, diagnóstico de neumonía, citomegalovirus congénito, calendario vacunal en niños tratados con quimioterapia, botulismo, síndrome PFAPA, casos clínicos y más.

TOP TEN

Introducción. En los últimos años se han descrito cambios en la epidemiologías del Streptococcus pyogenes o estreptococo del grupo A (EGA) , con un aumento de las infecciones invasivas.

Métodos: Estudio retrospectivo-descriptivo < 15 años con infección por EGA y sus complicaciones, desde febrero de 2004 a abril de 2014.
Resultados: Se obtuvieron 2.192 cultivos positivos, siendo el 92,7% faringoamigdalares. Ingresaron 29 pacientes: 4 complicaciones supurativas, 7 postinfecciosas, 14 infecciones invasivas y 4 probables. Los aislamientos no invasivos fueron más frecuentes en invierno y primavera , siendo el 68,3% de los pacientes menores de 5 años.
La incidencia de infecciones invasivas fue de 2,1/100.000 niños/año. No mostraron estacionalidad y ocurrieron en niños de menor edad . El diagnóstico más frecuente fue la neumonía y el lugar de aislamiento fue la sangre . Ocho precisaron cuidados intensivos. Se trataron empíricamente con cefalosporinas de segunda/tercera generación o penicilina intravenosas. Las neumonías precisaron mayor tiempo de tratamiento que el resto . Todos los EGA fueron sensibles a penicilina, el 10,6% resistentes a eritromicina. Ningún paciente falleció.
Conclusiones:La faringoamigdalitis por EGA sigue siendo frecuente en la infancia y su incidencia está aumentando en menores de 5 años. En la actualidad, las complicaciones postinfecciosas son raras. Las infecciones invasivas son más frecuentes en niños de menor edad.

Revisión de fondo del Comité asesor de Vacunas de USA con exposición de la epidemiologia, historia natural, modos de transmisión, interpretación de la serología y estrategias de prevención de la enfermedad.

Recomendaciones nuevas o actualizadas en las estrategias vacunales

· . Vacunación universal contra la hepatitis B(HB) en las primeras 24h de vida a todos los neonatos estables y con peso igual o mayor a 2000 gr.

· Determinación de Ag HBs a todas las embarazadas y estudio de DNA viral si positividad del antígeno.

· Hijos de madre con infección por virus HB:

o Administración de la vacuna y de la inmunoglobulina especifica en las primeras 12 h de vida.

o Realizar serología tras la pauta completa de vacunación, también indicada en el caso de desconocimiento indefinido de la serología materna (adopciones etc.)

o Una dosis extra de vacuna si el niño resulta no respondedor en el control serológico.

(Tabla con indicación de numero de dosis de vacunación, administración de IGHB según el peso del neonato y el estado inmunológico de la madre incluido el desconocido)

· Vacunación de niños y adolescentes< 19 años no vacunados previamente.

· Vacunación de cualquier adulto con enfermedad hepática crónica, (infección por virus de la hepatitis C, cirrosis, hígado graso, hepatopatía alcohólica y elevación mantenida de GOT y GPT -mas de dos veces el valor normal. -)

· Vacunación de adultos con factores de riesgo para contraer la infección por VHB, e incluso de los adultos que soliciten la vacunación, aunque no demuestren un factor de riesgo especifico.

En este informe también se resumen las recomendaciones de la American Associaton For The Study of Liver Diseases con respecto al tratamiento antiviral de las madres gestantes para reducir la transmisión perinatal del virus de la hepatitis B

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.

The widespread recall of several infant formula products made by a French processing company is likely to significantly reduce the risk of infants being infected by Salmonella Agona, according to the risk assessment published today by ECDC and the European Food Safety Authority (EFSA). However, as long as there are potentially contaminated products circulating, new cases may still be detected.

Pneumonia remains a major cause of childhood mortality and morbidity globally. Accurate diagnosis and attribution of the causes of pneumonia are important for measuring the burden of disease, implementing appropriate preventive or treatment strategies, and developing more effective interventions. This review summarizes recent diagnostic advances in radiological techniques, specimen collection, and laboratory methods. Although chest ultrasound and chest magnetic resonance imaging are promising modalities for radiological diagnosis, their role in clinical management and their impact on outcomes need further study. Rapid, highly sensitive, multiplex laboratory tests performed on upper respiratory tract samples or induced sputum can detect nucleic acid from potential pathogens in most children with pneumonia. However, it may be difficult to attribute causality because it is often impossible to distinguish between organisms colonizing or infecting the upper respiratory tract and those causing pneumonia. Currently available host biomarkers lack accuracy for distinguishing bacterial or mixed bacterial-viral infections from viral infections. New biomarkers derived from host transcriptional profile analysis may be more accurate but require validation. Prospective studies with appropriate control populations, including studies of clinical impact, are needed to improve our understanding of the role of tests. Although progress has been made in radiological techniques and laboratory testing, current methods for diagnosing and attributing the causes of pneumonia are suboptimal.

Congenital cytomegalovirus (cCMV) is the most common congenital infection in the developed world. Reported prevalence varies between cohorts but is approximately 7 per 1000 births.1 About half of cytomegalovirus (CMV)-infected babies with clinically detectable disease at birth are destined to have significant impairments in their development, and cCMV infection is implicated in approximately 25% of all children with sensorineural hearing loss (SNHL).1,2 Meta-analysis shows that although long-term sequelae, especially SNHL, are more common in those with clinically detectable disease at birth, they are also found in 13% of those without clinical features attributable to CMV on initial examination.1

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.

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)?

Casos

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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.

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.

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.

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.

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 medical governance in a nurse-led HiTH service.

Administration of accines outside recommended minimum and maximum ages is rare, reflecting a general adherence to recommendations. Error rates were higher for several vaccines, some requiring revaccination. Vaccine schedule complexity and confusion among similar products might contribute to errors. Minimization of errors reduces wastage, excess cost, and inconvenience for parents and patients.
 

Actualidad bibliográfica enero 2018

Este mes: actualización en TBC, antibióticos en GEA, utilidad del test rápido estreptocócico, sinusitis, etiología de neumonía, zika en España, causas infecciosas de microcefalia, miositis, tratamiento de bronquiolitis, probióticos y más…

Top ten

  • Actualización del tratamiento de la tuberculosis en niños An Pediatr (Barc).2018;88:52.e1-52.e12 - Vol. 88 Núm.1 DOI: 10.1016/j.anpedi.2017.05.013
    La TB pediátrica ha sido una epidemia oculta por su escasa capacidad infectiva y menor incidencia comparada con adultos. El informe-OMS 2015 estimó un millón de niños enfermos de TB en el mundo y 169.000 fallecidos. En Europa, el problema acuciante es la tuberculosis multirresistente, con tasas del 16% en nuevos diagnósticos, especialmente en países del este. En 2014, 219.000 niños se infectaron por cepas-MDR en Europa, 2.120 desarrollaron enfermedad. España es el país de Europa con mayor número de casos pediátricos, con una incidencia en 2014: 4,3/100.000 habitantes. La mortalidad por TB pediátrica en nuestro país es excepcional, pero las formas extrapulmonares ocasionan importantes complicaciones. La TB resistente en niños en España presenta una prevalencia > 4%, superando incluso la notificada en adultos. Las dificultades diagnósticas del niño y la falta de formulaciones pediátricas óptimas son el mayor desafío para control de TB infantil. El Grupo de expertos de TB pediátrica realiza un análisis de las nuevas tendencias internacionales y guías terapéuticas de tuberculosis en niños, según nuevas evidencias disponibles; y considera una prioridad actualizar las guías pediátricas nacionales de exposición a TB, infección tuberculosa latente y enfermedad, y particularmente los casos de resistencia a fármacos. Este documento, por tanto, sustituye a todos los previos en cuanto a las pautas terapéuticas, aunque siguen estando vigentes las indicaciones diagnósticas.

  • Calendario de vacunaciones de la Asociación Española de Pediatría (CAV-AEP): recomendaciones 2018 An Pediatr (Barc).2018;88:53.e1-9 - Vol. 88 Núm.1 DOI: 10.1016/j.anpedi.2017.10.001

En cuanto a las vacunas financiadas, se recomienda emplear el esquema 2+1 (2, 4 y 11-12 meses) con vacunas hexavalentes (DTPa-VPI-Hib-VHB) y con antineumocócica conjugada 13-valente. Se aconseja un refuerzo a los 6 años, preferentemente con DTPa, junto a una dosis de polio para aquellos que recibieron esquemas 2+1, así como vacunación con Tdpa en adolescentes y en cada embarazo, entre la 27 y 32 semanas. Se emplearán esquemas de dos dosis para triple vírica (12 meses y 2-4 años) y varicela (15 meses y 2-4 años). De haber disponibilidad, la segunda dosis se podría aplicar como vacuna tetravírica. Se deben incrementar las coberturas frente al papilomavirus en niñas de 12 años con dos dosis (0, 6 meses), así como informar y recomendar la vacunación de los varones, dados los beneficios potenciales de la misma. La nueva vacuna de 9 genotipos ya está disponible, ampliando la cobertura para ambos sexos. Respecto a vacunas no financiadas, se recomienda la antimeningocócica B, con esquema 3+1, solicitando su entrada en calendario. Se recomienda individualmente la vacuna antimeningocócica conjugada tetravalente (MenACWY) en adolescentes (14-18 años) que vayan a residir en países con vacunación sistemática frente a los serogrupos ACWY. También en mayores de 6 semanas de vida con factores de riesgo o viajeros a países de elevada incidencia. Es recomendable vacunar a todos los lactantes frente al rotavirus.

Resumen:Objetivo: investigar el impacto de la utilización del test rápido de detección de antígeno estreptocócico sobre la prescripción de antibióticos en niños.Pacientes y métodos: estudio observacional, de cohortes retrospectivo, a partir de los registros clínicos informatizados de 10 cupos de Pediatría de centros de salud de la provincia de Zaragoza (España) en los años 2012 y 2013. Se hace una valoración del tratamiento antibiótico y de las complicaciones en el mes siguiente al episodio de faringoamigdalitis comparando los episodios en los que se realizó test rápido de detección de antígeno estreptocócico con los que no se realizó.Resultados: de 17 455 episodios registrados, se seleccionaron 851 que cumplían los criterios de inclusión (tres o cuatro criterios de Centor). En los episodios en los que se realizaron test rápidos de detección de antígeno, la reducción en la prescripción antibiótica fue del 42% (reducción absoluta de riesgo: 42%; intervalo de confianza del 95% [IC 95]: 37 a 48; p < 0,001). Comparando el abordaje entre los pediatras que disponían y utilizaban el test (4), con los que no (6), la reducción absoluta de riesgo fue del 29% (IC 95: 24 a 34; p < 0,001). Se presentaron complicaciones infecciosas en el 12% de los tratados y en el 8% de los no tratados (riesgo relativo: 1,49; IC 95: 0,88 a 2,52; p = 0,178). Se prescribió significativamente más penicilina V que amoxicilina cuando se realizó test diagnóstico (riesgo relativo: 1,30; IC 95: 1,10 a 1,55; p = 0,004).Conclusiones: en la práctica clínica, el uso de una prueba rápida de detección de antígeno en pacientes pediátricos preseleccionados por criterios clínicos de faringoamigdalitis estreptocócica contribuye de forma determinante al uso racional de antibióticos.

  • Enteropatógenos y antibióticos (Revisión) : Enferm Infecc Microbiol Clin. 2015 Aug 12. pii: S0213-005X(15)00273-6. doi: 10.1016/j.eimc.2015.06.015. PMID:26277207
    -Salmonella entérica no typhi: Los datos analizados muestran Hasta la fecha bajas tasas de resistencia a los antibióticos considerados de elección, fundamentalmente en el caso de cefalosporinas de tercer generación y azitromicina. Con respecto a las quinolonas, la resistencia de alto nivel a ciprofloxacino
    sigue siendo excepcional; no así la resistencia a ácido nalidíxico.
    -Yersinia enterocolitica: Actualmente la mayoría de las cepas se mantienen sensibles a un gran número de antibióticos, entre los que se encuentran cefalosporinas de tercera y cuarta generación, carbapenemas, aminoglucósidos y fluoroquinolonas. De acuerdo con los datos analizados, podemos Concluir que los tratamientos de elección anteriormente mencionados siguen manteniendo por el momento una excelente actividad in vitro frente a Y.enterocolitica, aunque merece una especial atención el incremento en la resistencia a ácido ,nalidíxico Por su posible implicación en la resistencia a fluoroquinolonas en un futuro.
    -Shigella: En Europa la Infección por Shigella se asocia principalmente a Viajes recientes a zonas endémicas. Debido a la gran variabilidad geográfica entre los diferentes patrones de resistencia e fundamental conocer las características epidemiológicas del paciente para instaurar u tratamiento empírico adecuado. Actualmente no se han detectado resistencias a carbapenems y cefalosporinas de 3º generación mantiene habitualmente unas tasas de resistencia bajas. Fluoroquinolonas y azitromicia son una alternativa como tratamiento oral.
    - campylobacter: A pesar del aumento de la resistencia que se ha producido en los últimos años , los macrólidos se mantienen como la principal opción de tratamiento frente a Campylobacter. Sin embargo las alternativas por vía oral se encuentran limitadas debido a las actuales tasas de resistencias a quinolonas y tetraciclinas

  • Question 2: Are three malaria tests necessary in children returning from the tropics with fever? Arch Dis Child. 2018 Jan;103(1):1-3

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.

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.

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.

Resumen: excelente actualización/revisión de las causas infecciosas de microcefalia por infección intraútero

Casos

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.

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 …

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  • Experiencia inicial en infección importada por virus Zika en España. Enferm Infecc Microbiol Clin.2018;36:4-8 - DOI: 10.1016/j.eimc.2016.08.003 PMID:27743683
    Estudio descriptivo de los viajeros retornados de área endémica para ZIKV en la Unidad de Medicina Tropical del Hospital La Paz-Carlos III en Madrid, de enero a abril de 2016. Se cribaron para ZIKV un total de 185 pacientes (59,9% mujeres, mediana de edad de 37,7±10,3 años). El propósito por el que habían realizado el viaje fue por turismo a Colombia, Brasil y México. El 73% de los inicialmente cribados presentaron síntomas, fundamentalmente fiebre y cefalea. Se diagnosticó infección por ZIKV a 13 pacientes (7% de los cribados); 4 de ellos eran gestantes. Todos los casos con infección confirmada estaban sintomáticos, y la mayoría eran inmigrantes colombianos. El diagnóstico se basó en la presencia de anticuerpos neutralizantes positivos (8 casos, 61,6%) y RT-PCR positiva en diferentes fluidos orgánicos (7 casos, 53,8%). A las 4 gestantes infectadas se les realizó neurosonografía fetal seriada cada 3 semanas, no detectándose alteraciones en ninguna de ellas. En 3 casos se realizó RT-PCR en líquido amniótico, que fue negativo. Uno de los niños ha nacido, y está completamente sano.

  • Increasing Prevalence of Hepatitis C among Hospitalized Children Is Associated with an Increase in Substance Abuse Arch Dis Child. 2018 Jan;103(1):71-72

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.

Resumen:La miositis viral aguda es un proceso clínico muy típico con dolor e impotencia funcional en extremidades inferiores, después o durante una infección vírica con una elevación muy significativa de la creatinfosfoquinasa y una evolución clínica autolimitada con recuperación completa. Presentan ocho casos con edades entre cuatro y nueve años,de miositis aguda, en relación con la temporada gripal 2015-2016.En todos los casos la recuperación fue completa en 2-4 días.
 

Infants with colic treated with L reuteri for 30 days had a significantly decreased crying time and an increased FOXP3 concentration, resulting in a decreased RORγ/FOXP3 ratio. The treatment reduced fecal calprotectin.

Resumen: metaanálisis financiado por la asociación de fabricantes de probióticos en el que se agrupan cuatro ensayos clínicos con un número pequeño de casos en global. Encuentran como principal resultado que a los 21 días de tratamiento la disminución en el tiempo de llanto o de irritabilidad del niño es 25,4 minutos mayor en el grupo reuteri que en el placebo (IC 95%, amplio aunque significativo: -47,3 a -3,5 minutos). La consideración de éxito en el tratamiento fue casi el doble en el grupo placebo que en el control (tasa de incidencia ajustada al día 21: 1,7 [IC del 95%: 1,4 a 2,2])

Based on this systematic review and meta-analysis of 31 randomizedcontrolled trials including 8672 patients, moderate certainty evidence suggests that probiotics are effective for preventing CDAD (NNTB = 42 patients, 95% CI 32 to 58). Our post hoc subgroup analyses to explore heterogeneity indicated that probiotics are effective among trials with a CDAD baseline risk >5% (NNTB = 12; moderate certainty evidence), but not among trials with a baseline risk ≤5% (low to moderate certainty evidence). Although adverse effects were reported among 32 included trials, there were more adverse events among patients in the control groups. The short-term use of probiotics appears to be safe and effective when used along with antibiotics in patients who are not immunocompromised or severely debilitated. Despite the need for further research, hospitalized patients, particularly those at high risk of CDAD, should be informed of the potential benefits and harms of probiotics.
 

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.

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.

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.

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.

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

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.

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.

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.

Since the last epidemiological update on this multi-country hepatitis A outbreak published on 29 September 2017, 22 EU/EEA countries (Austria, Belgium, Croatia, the Czech Republic, Denmark, Estonia, Finland, France, Germany, Greece, Ireland, Italy, Latvia, Luxembourg, Malta, the Netherlands, Norway, Portugal, Slovenia, Spain, Sweden and the United Kingdom-England & Wales) have reported 950 new outbreak-confirmed cases. Outbreak-confirmed cases are EU/EEA residents with laboratory-confirmed hepatitis A virus (HAV) genotype IA and a sequence with ≥99.3% homology to one of the three HAV genotype IA outbreak strains (VRD_521_2016; RIVM-HAV16-090; and V16-25801) based on overlapping fragments at the VP1-2a region.

  • Changes in the prevalence of human papilloma virus following a national bivalent human papilloma virus vaccination programme in Scotland: a 7-year cross-sectional study. Lancet InfectDis. 2017;17(12):1293-1302.

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)

  • A genetically inactivated two-component acellular pertussis vaccine, alone or combined with tetanus and reduced-dose diphtheria vaccines, in adolescents: a phase 2/3, randomized controlled non-inferiority trial. Lancet InfectDis. 2018;18(1):58-67.

Resumen: una nueva vacuna acelular contra pertusis (con dos componentes: toxina inactivada y hemaglutinina filamentosa) parece mostrar no inferioridad frente a la convencional acelular, tanto usada de forma aislada como asociada a toxiude diftérico y tetánico. 450 participantes en este estudio de fase 2/3.