Bibliografía de 2019

Bibliografía  abril 2019

Top ten

Diversos autores cuestionan la realización sistemática de una ecografía renal en los lactantes con una primera infección del tracto urinario (ITU), dada la alta sensibilidad de las ecografías prenatales para la detección de malformaciones mayores y la baja prevalencia de hallazgos clínicamente significativos. Los objetivos de este trabajo son valorar el rendimiento diagnóstico de la ecografía renal realizada después de la primera ITU en pacientes menores de 2 años y analizar posibles factores de riesgo (FR) de presentar una ecografía renal alterada.

Estudio retrospectivo. Se incluyen los pacientes menores de 2 años diagnosticados de ITU en Urgencias entre julio de 2013 y diciembre de 2014. Se excluyen aquellos con enfermedad nefrourológica, ITU previas y sin ecografía renal prenatal o postinfección. Se considera ecografía renal alterada la presencia de dilatación de las vías urinarias y/o anomalías estructurales. Los posibles FR evaluados son: sexo masculino, edad inferior a 3 meses, fiebre y microorganismo distinto a Escherichia coli. Se realiza estudio univariante y por regresión logística multivariante.

Se incluyen 306 pacientes. Presentan ecografía renal alterada 35 (11,4%; IC 95% 8,3-15,5): 24 (68,6%) dilatación de las vías urinarias y 11 (31%) alteraciones estructurales. De las ecografías alteradas, el 68,6% corresponden a varones, el 51,4% a una edad inferior a 3 meses, el 74,3% a ITU febriles y el 31,4% por microorganismo distinto a E. coli, respecto al 45% (p=0,009), el 31,7% (p=0,021), el 78,2% (p=0,597) y el 10% (p=0,001) de las ecografías normales. En el análisis multivariante se mantienen como FR la edad inferior a 3 meses (OR 2,1; IC 95% 1,0-4,3; p=0,05) y un microorganismo distinto a E. coli (OR 3,8; IC 95% 1,7-8,7; p=0,002).

El rendimiento de la ecografía renal después de la primera ITU es bajo. Se debería individualizar su indicación según la presencia de FR: edad inferior a 3 meses y microorganismo distinto a E. coli.

Casos clínicos

A 3-year-old boy presented to the emergency department for evaluation of 4 days of rash associated with fever and cough. A, Pink papules with scant yellow crusts on the cutaneous lips and oral commissures. B, Dark red targetoid papules and plaques with central vesicles on the right forearm, with sharp borders at the site of a cast. C, Targetoid morphology on the left hand.

A 1-year-old boy presented with a 2-day history of fever and vomiting. His vaccination status was up to date, including 4 doses of the 13-valent pneumococcal conjugate vaccines and Hemophilus influenza type b vaccines. At presentation, there were no physical signs suggesting respiratory or circulatory compromise. His heart rate and respiratory rate were 150 beats per minute and 44 times per minute, respectively. His body temperature was 39.6°C…

An 11-year-old girl presented with abdominal pain and lethargy. Chest X-ray revealed a well-defined opacity in the right lower zone, projected over the medial aspect of the right hemidiaphragm (figure 1). She was treated with two courses of antibiotics but remained symptomatic with a cough. Repeat X-rays demonstrated no change in the opacity.

A 12-year-old farmer’s boy presented with 4 weeks of left flank pain. On examination, a palpable mass below the right costal margin was noted. Investigations, including full blood count, C-reactive protein, and kidney and liver tests, were normal, except for mild eosinophilia (0.53×109/L). Immunological work-up was normal including immunoglobulins, lymphocyte subsets and serology for HIV. Ultrasonography and abdominal CT revealed an extensive lesion originating from segment V/VI to segment VIII with encasement and stenosis of the portal vein (figure 1). The boy reported contact with animals on the family’s farm, such as dogs

En los últimos años ha aumentado el número de niños que viajan con sus familias, ya sea por turismo o por regreso a su país de origen. Este hecho supone un incremento de las consultas de este tipo de pacientes en los servicios de urgencias, lo que abre el abanico de posibilidades diagnósticas. La incidencia de la glomerulonefritis posinfecciosa ha disminuido considerablemente en las últimas décadas. En nuestro medio, la faringoamigdalitis estreptocócica continúa siendo la principal causa; sin embargo, en niños procedentes de países menos desarrollados, se debe tener en cuenta que las infecciones cutáneas también representan un origen frecuente de esta patología. Se presenta el caso de un niño de 11 años que acudió al servicio de urgencias por lesiones cutáneas y hematuria.

La psoriasis es una enfermedad inflamatoria crónica, sistémica y recidivante de la piel, caracterizada por pápulas y placas eritemato-escamosas, con características clínicas variables. La forma de presentación más frecuente en los niños es la denominada en placas; existen otras formas más raras, pero con mejor pronóstico, como la psoriasis guttata. La patogénesis de la enfermedad es desconocida, el factor desencadenante más frecuente en los niños es la infección por estreptococo β-hemolítico del grupo A. Presentamos el caso de una niña con dermatitis perianal estreptocócica como principal desencadenante de psoriasis guttata.

La linfangitis aguda es la inflamación de los conductos linfáticos, y la etiología infecciosa es la más frecuente en la edad pediátrica. Se presentan dos casos clínicos de linfangitis tubular aguda, ambos con una lesión inicial por la picadura de un insecto.

La varicela es una enfermedad de distribución universal. La vacunación universal ha disminuido la incidencia de varicela en los últimos años. El herpes zóster en los vacunados es posible, pero su incidencia es entre 4 y 12 veces menor que entre los no vacunados. En la infancia, el herpes zóster suele ser leve, autolimitado, bien tolerado y habitualmente solo requiere tratamiento sintomático. Se presenta un caso de herpes zóster en una niña vacunada cinco meses antes, con buena evolución.

La acrodermatitis papulosa infantil se considera una dermatosis paraviral secundaria a diversas infecciones y antígenos vacunales. El diagnóstico es clínico y el tratamiento sintomático, con pronóstico excelente, ya que el cuadro es autolimitado y se resuelve sin lesiones residuales. Presentamos el caso de un niño que desarrolló una acrodermatitis papulosa infantil tras una infección por el virus de Epstein-Barr.

La parotiditis recurrente juvenil puede tener multitud de causas, es importante tener en cuenta, dentro de la etiología, el estudio de las subpoblaciones linfocitarias, ya que puede haber una relación patogénica con la deficiencia de células natural killer. Se presenta el caso clínico de una paciente de diez años con parotiditis recurrente secundaria a dicho proceso.

La neumonía adquirida en la comunidad es una causa importante de morbilidad y mortalidad en Pediatría. La gran mayoría de las neumonías se resuelven de forma ambulatoria, sin necesidad de realizar un diagnóstico etiológico. La edad es el parámetro que mejor se correlaciona con el agente causal, sin embargo, hasta un 20-30% de los casos se debe a una infección mixta por diferentes gérmenes. Lo más frecuentemente descrito son coinfecciones por virus y bacterias, especialmente virus respiratorio sincitial con Streptococcus pneumoniae y Mycoplasma pneumoniae. La asociación de tres o más patógenos es excepcional. El papel de la coinfección es desconocido en cuanto a pronóstico y evolución, ni se puede precisar si los agentes son concomitantes en el tiempo o agravantes evolutivos. Presentamos el caso de una niña con una neumonía por Mycoplasma pneumoniae que presenta clínica y radiografía compatible con Streptococcus pneumoniae y además serología positiva IgM para virus de Epstein-Barr y parvovirus B19.

Lactante 20 meses de edad que ingresa en el servicio de urgencias por cuadro de 6 horas de evolución, consistente en: aparición de lesiones ampollosas y esfacelación de la piel que inicia en región genital, posteriormente en axilas, región perioral y cuello asociado a irritabilidad, sin picos febriles. La superficie final comprometida fue del 40% de la superficie corporal total, por lo que requirió manejo en unidad de cuidados intensivos pediátricos (UCIP).

Como antecedente de importancia, fue diagnosticado de otitis media aguda y tratado con amoxicilina durante 7 días.

Al examen físico inicial se encuentra irritable, con lesiones ampollosas que corresponden al 3% de la superficie corporal total, signo de Nicolsky positivo. Afebril

Exploraciones complementarias: Hemograma muestra leucocitosis con neutrofilia, Prueba rápida de estreptococo beta hemolítico grupo A negativo. Cultivo faríngeo positivo para SAMS sensible a clindamicina.

Tratamiento y evolución: Se inició manejo antibiótico con ampicilina/sulbactam. A los tres días de estancia hospitalaria las lesiones progresan en cara, tórax, espalda y extremidades, sin compromiso de palmas, plantas o mucosas por lo que se modifica tratamiento por oxacilina y clindamicina. Se trasladó a la unidad de cuidados intensivos pediátricos (UCIP) dado compromiso del 40% de la superficie corporal total. No precisó soporte vasopresor ni ventilatorio durante los seis días. Posteriormente evolución favorable con mejoría de lesiones en piel (figura 3) y egreso a los 14 días de hospitalización.

Para profundizar

The human microbiome—the collection of microorganisms that inhabit our bodies—has been suggested to play a role in a vast number of diseases, as well as in the maintenance of normal health. There has been an exponential rise in such reports, in part because of new rapid and affordable sequencing technologies. However, developing our understanding from qualitative description to quantitative modeling is essential for incorporation into routine clinical care. Here, we cover the basics of microbiome research and discuss some important examples relevant for pediatric infectious diseases.

To develop a parent-reported Pediatric Rhinosinusitis Symptom Scale (PRSS) that could be used to monitor symptoms of young children with acute sinusitis in response to therapy.

We developed an 8-item symptom severity scale and evaluated its internal reliability, construct validity, and responsiveness in children 2-12 years of age with acute sinusitis. Parents of 258 children with acute sinusitis completed the PRSS at the time of diagnosis, as a diary at home, and at the follow-up visit at days 10-12. Based on psychometric results and additional parent feedback, we revised the scale. We evaluated the revised version in 185 children with acute sinusitis.

Correlations between the scale and reference measures on the day of enrollment were in the expected direction and of the expected magnitude. PRSS scores at the time of presentation correlated with radiographic findings (P < .001), functional status (P < .001), and parental assessment of overall symptom severity (P < .001). Responsiveness (standardized response mean) and test–retest reliability of the revised scale were good (2.17 and 0.75, respectively).

We have developed an outcome measure to track the symptoms of acute sinusitis. Data presented here support the use of the PRSS as a measure of change in symptom burden in clinical trials of children with acute sinusitis.

La enfermedad de Kawasaki (EK) es una vasculitis multisistémica asociada a lesiones en las arterias coronarias. Las infecciones podrían ser un desencadenante de la inflamación. Nuestro objetivo fue describir la presencia de infecciones en los niños con EK y analizar las características clínicas y la presencia de alteraciones coronarias en estos casos.

Análisis retrospectivo de los pacientes incluidos en la red KAWA-RACE entre 2011 y 2016. Se estudió tanto a los pacientes que tuvieron una identificación microbiológica confirmada (IMC) en el periodo agudo como a los que presentaron antecedente de infección previa reciente (IPR) las 4 semanas anteriores.

Se incluyó a un total de 621 niños, de los cuales 101 (16,3%) tuvieron una IMC y 107 (17,2%) una IPR. Encontramos una significativa menor afectación ecocardiográfica en el grupo de IPR respecto a los niños sin infección previa (23 vs. 35%; p 0,01), con menor proporción no significativa de las alteraciones coronarias globales (16 vs. 25%; p 0,054). Sin embargo, no se detectaron diferencias en la proporción de aneurismas en ninguno de los 2grupos (IMC o IPR) respecto al resto de los pacientes sin infecciones asociadas.

En nuestro estudio no encontramos diferencias en la incidencia de aneurismas coronarios en niños con y sin IMC o IPR, por lo que ante la sospecha de EK debe iniciarse siempre tratamiento, aunque se tenga infección confirmada microbiológicamente.

Integrated antibiotic resistance (AR) surveillance is one of the objectives of the World Health Organization global action plan on antimicrobial resistance. Urban wastewater treatment plants (UWTPs) are among the most important receptors and sources of environmental AR. On the basis of the consistent observation of an increasing north-to-south clinical AR prevalence in Europe, this study compared the influent and final effluent of 12 UWTPs located in seven countries (Portugal, Spain, Ireland, Cyprus, Germany, Finland, and Norway). Using highly parallel quantitative polymerase chain reaction, we analyzed 229 resistance genes and 25 mobile genetic elements. This first trans-Europe surveillance showed that UWTP AR profiles mirror the AR gradient observed in clinics. Antibiotic use, environmental temperature, and UWTP size were important factors related with resistance persistence and spread in the environment. These results highlight the need to implement regular surveillance and control measures, which may need to be appropriate for the geographic regions.

In this secondary analysis of the Randomized Intervention for Children with Vesicoureteral Reflux cohort, we found that daily prophylaxis with trimethoprim-sulfamethoxazole was not associated with an increased or decreased risk of skin and soft tissue infections, pharyngitis or sinopulmonary infections in otherwise healthy children 2–71 months of age.

La incidencia de cicatrices renales tras una infección urinaria febril en niños sanos es baja, en torno al 6%. No hay diferencias entre el grupo tratado profilácticamente con antibióticos y el grupo control Los resultados de este estudio permiten concluir que no está indicada la profilaxis antibiótica generalizada

tras una ITU en términos de prevención de nuevas cicatrices renales. Habría que valorar la eficacia en pacientes con anomalías congénitas del riñón y el tracto urinario.

El objetivo del estudio era determinar si el tratamiento para las infecciones del tracto urinario en niños se podría individualizar utilizando biomarcadores que diferenciaran la pielonefritis aguda de la cistitis.

Los marcadores urinarios que mejor diferenciaron la pielonefritis de la cistitis incluían el ligando de quimiocina (C-X-C motif) ligando (CXCL)1, CXCL9, CXCL12, C-C motif quimiocina ligando 2, INF γ e IL-15 . La procalcitonina sérica fue el mejor marcador sérico para la pielonefritis. Los genes en la vía del interferón-γ se regulan al alza en el suero de niños con pielonefritis. La presencia de genes de virulencia de E. coli no se correlacionó con la pielonefritis.

La respuesta inmune a la pielonefritis y la cistitis difiere cuantitativa y cualitativamente; Esto puede ser útil para diferenciar estas 2 condiciones.

While adverse events following immunization (AEFI) are frequent, there are limited data on the safety of reimmunizing patients who had a prior AEFI. Our objective was to estimate the rate and severity of AEFI recurrences.

We analyzed data from the AEFI passive surveillance system in Quebec, Canada, that collects information on reimmunization of patients who had a prior AEFI. Patients with an initial AEFI reported to the surveillance system between 1998 and 2016 were included. Rate of AEFI recurrence was calculated as number of patients with recurrence/total number of patients reimmunized.

Overall, 1350 patients were reimmunized, of which 59% were 2 years of age or younger. The AEFI recurred in 16% (215/1350) of patients, of whom 18% (42/215) rated the recurrence as more severe than the initial AEFI. Large local reactions extending beyond the nearest joint and lasting 4 days or more had the highest recurrence rate (67%, 6/9). Patients with hypotonic hyporesponsive episodes had the lowest rate of recurrence (2%, 1/50). Allergic-like events recurred in 12% (76/659) of patients, but none developed anaphylaxis. Of 33 patients with seizures following measles mumps rubella with/without varicella vaccine, none had a recurrence. Compared with patients with nonserious AEFIs, those with serious AEFIs were less often reimmunized (60% versus 80%; rate ratio: 0.8; 95% confidence interval: 0.66–0.86).

Most patients with a history of mild or moderate AEFI can be safely reimmunized. Additional studies are needed in patients with serious AEFIs who are less likely to be reimmunized.

  • We found 55 relevant studies with 216,480 participants. The trials took place in several locations worldwide. These studies compared a rotavirus vaccine versus placebo or versus no vaccine for infants and young children. The vaccines tested were RV1 (36 trials with 119,114 participants), RV5 (15 trials with 88,934 participants), and Rotavac (four trials with 8432 participants). Fifty-one studies were funded or co-funded by vaccine manufacturers, while four were independent of manufacturer funding.

  • In the first two years of life, RV1:

  • ●prevents more than 80% of severe cases of rotavirus diarrhoea in countries with low death rates (high-certainty evidence)
    ●prevents 35% to 63% of severe rotavirus diarrhoea in countries with high death rates (high-certainty evidence)
    ●probably prevents 37% to 41% of severe cases of diarrhoea from all causes (such as any viral infection, bacterial infection, or parasitic infection) in countries with low death rates (moderate-certainty evidence)
    ●probably prevents 18% to 27% of severe cases of diarrhoea from all causes in countries with high death rates (moderate- to high-certainty evidence).

  • In the first two years of life, RV5:

  • ●probably prevents 82% to 92% of severe cases of rotavirus diarrhoea in countries with low death rates (moderate-certainty evidence)
    ●prevents 41% to 57% of severe cases of rotavirus diarrhoea in countries with high death rates (high-certainty evidence)
    ●probably prevents 15% of severe cases of diarrhoea from all causes in countries with high death rates (moderate- to high-certainty evidence); we did not identify any studies that reported on diarrhoea from all causes in countries with low death rates.

  • In the first two years of life, Rotavac:

  • ●probably prevents more than 50% of severe cases of rotavirus diarrhoea in India, a country with high death rates (moderate-certainty evidence)
    ●probably prevents 18% of severe cases of diarrhoea from all causes in India (moderate-certainty evidence). Rotavac has not been evaluated in a randomized controlled trial in a country with low death rates.

  • We found little or no difference in the number of serious adverse events (moderate- to high-certainty evidence), or intussusception cases (low- to very low-certainty evidence), between those receiving RV1, RV5, or Rotavac compared with placebo or no intervention

To monitor parental vaccine attitudes, a survey was conducted in 2008 and in 2016. In both years (90%–89%) reported full immunization of their children, and a stable majority (71%–66%) supported documentation of vaccination before entering kindergarten. However, a declining confidence in official recommendations from 87% to 72% (P < 0.0001) in 2008 and 2016, respectively, was documented, requiring effort to rebuild it.

We included five studies (162 participants); three were conducted in hospital dermatology departments. Participants were 12 to 77 years old (100 males; 62 females). One study was funded by a pharmaceutical company. The severity of the condition ranged from mild to severe. Streptococcus bacteria were found in the throats of 14% of people.

We found only five trials (N = 162), which assessed the effects of five comparisons (systemic antibiotic treatment (penicillin, azithromycin) or tonsillectomy). Two comparisons (erythromycin compared to no treatment, and rifampicin compared to placebo) did not measure any of the outcomes of interest. There was very low-quality evidence for the outcomes that were measured, Therefore, we are uncertain of both the efficacy and safety of antistreptococcal interventions for guttate and chronic plaque psoriasis.

The included trials were at unclear or high risk of bias and involved only a small number of unrepresentative participants, with limited measurement of our outcomes of interest. The studies did not allow investigation into the influence of Streptococcal infection, and a key intervention (amoxicillin) was not assessed.

Further trials assessing the efficacy and tolerance of penicillin V or amoxicillin are needed in children and young adults with guttate psoriasis.

During 2000 to 2018, 1831 children were screened as part of tuberculosis contact investigation at the Stockholm Northern Clinic. The risk of a child having a positive tuberculin skin test was 33% and positive interferon-gamma release assay 12%. The risk of tuberculosis disease was 6.1% (tuberculin skin test) and 13% (interferon-gamma release assay) in positive-testing children.

Molecular diagnostic methods enhance the sensitivity and broaden the spectrum of detectable respiratory viruses in febrile infants ≤90 days of life. We describe the occurrence of respiratory viruses in this population, as well as the rates of serious bacterial infection (SBI) and respiratory viral coinfection with regard to viral characteristics.

This was a prospective observational cohort study performed in the emergency department that included previously healthy febrile infants ≤90 days of life. Clinical and historical characteristics were documented, and a respiratory nasal wash specimen was obtained from each patient. This sample was tested for 17 common respiratory pathogens, and a chart review was conducted to ascertain whether the infant was diagnosed with an SBI.

In a 12-month period, 67% of the 104 recruited febrile infants were positive for a respiratory virus. The most commonly detected viruses were rhinovirus, respiratory syncytial virus, enterovirus and influenza. The rate of respiratory viral and SBI coinfection was 9% overall, and infants with either a systemic respiratory virus or negative viral testing were 3 times more likely to have an SBI than those with viruses typically restricted to the respiratory mucosa (95% confidence interval: 1.1, 9.7).

Respiratory viruses are readily detectable via nasopharyngeal wash in febrile infants ≤90 days of life. With the enhanced sensitivity of molecular respiratory diagnostics, rates of coinfection of respiratory viruses and SBI may be higher than previously thought. Further investigation utilizing molecular diagnostics is needed to guide usage in febrile infants ≤90 days.

La detección de enterovirus debería formar parte de las guías de práctica clínica sobre la fiebre sin foco en niños de 2 años o menos. Esta prueba podría disminuir la duración de la estancia hospitalaria y reducir la exposición a antibióticos para pacientes de bajo riesgo ingresados desde el Servicio de Urgencias con enfermedad febril.

Respiratory illnesses are a major contributor to pediatric hospitalizations, with influenza and respiratory syncytial virus (RSV) causing substantial morbidity and cost each season. We compared the characteristics and outcomes of children 0–59 months of age who were hospitalized with laboratory-confirmed influenza or RSV between 2009 and 2014 in Ontario, Canada.

We included hospitalized children who were tested for influenza A, influenza B and RSV and were positive for a single virus. We characterized individuals by their demographics and healthcare utilization patterns and compared their hospital outcomes, in-hospital cost and postdischarge healthcare use by virus type and by presence of underlying comorbidities.

We identified and analyzed 7659 hospitalizations during which a specimen tested positive for influenza or RSV. Children with RSV were the youngest whereas children with influenza B were the oldest [median ages 6 months (interquartile range: 2–17 months) and 25 months (interquartile range: 10–45 months), respectively]. Complex chronic conditions were more prevalent among children with all influenza (sub)types than RSV (31%–34% versus 20%). In-hospital outcomes were similar by virus type, but in children with comorbidities, postdischarge outcomes varied. We observed no differences in in-hospital cost between viruses or by presence of comorbidities [overall median cost: $4150 Canadian dollars (interquartile range: $3710–$4948)].

Influenza and RSV account for large numbers of pediatric hospitalizations. RSV and influenza were similar in terms of severity and cost in hospitalized children. Influenza vaccination should be promoted in pregnant women and young children, and a vaccine against RSV would mitigate the high burden of RSV.

La gripe es una enfermedad común de las vías respiratorias, que afecta a todas las edades. Los lactantes son población de alto riesgo, en la que no está autorizado el uso de antivirales. La utilización de vitamina D está muy extendida con diversas pautas y a diferentes edades. En este estudio que analizamos se evalúa la efectividad y seguridad de altas dosis de vitamina D en lactantes. La vitamina D se muestra eficaz y segura en la prevención de la gripe a dosis de 1200 unidades día, pero estos datos son poco confiables por las deficiencias metodológicas del estudio analizado.

Although maternal tetanus immunisation has been effectively implemented for many years in the developing world,1 there has been a renewed global interest in maternal immunisation programmes over the past several years.2–5 This has been driven partly by the severity of the 2009 H1N1 influenza pandemic in pregnant women and the safety provided by the widespread maternal immunisation programme implemented in response to the pandemic.6 7 It has also been increasingly appreciated that maternal immunisations are an excellent way to provide protection to young infants before their own primary immunisation series would begin. There are several reasons that immunising pregnant women is an attractive vaccination strategy. First, by immunising the pregnant woman there is the potential to prevent the targeted infection in both the pregnant woman and her infant. This approach is often referred to as a ‘two-fer’ with protection for two individuals with the administration of only one vaccine. Second, there is a particular window of susceptibility in infants before the onset of infant immunisation that maternal immunisation could help to bridge. Third, during gestation, pregnant women are often more accessible to medical care than in other times of their lives, making vaccine implementation during this time more efficient. Finally, pregnant women should not be excluded from potentially beneficial vaccines based solely on their pregnancy status. They should ethically reap the benefits of effective vaccines.

The goal of this report is to focus on four specific vaccines that are targeted for maternal immunisation. Two of the vaccines, influenza and pertussis, are already being administered to pregnant women as part of recommended national immunisation programmes. Two additional vaccines, group B Streptococcus (GBS) and respiratory syncytial virus (RSV) vaccines, are in clinical trials in pregnant women and it is anticipated that one or both would be available for routine use in the …

Passive transplacental immunity against respiratory syncytial virus (RSV) appears to mediate in the protection of the infant for the first 6 months of life. Lower environmental exposure in pregnant women to RSV epidemic may influence the susceptibility of these infants to infection by lowering the levels of antibodies that are transferred to the fetus.

To contrast the risk of severe disease progression in infants with acute bronchiolitis by RSV, according to the mother's level of exposure to epidemic.

Retrospective cohort study of previously healthy infants with RSV-acute bronchiolitis during 5 epidemics was made. We compared the severity of the infection in those born during the period of risk (when is less likely the mother's exposure to epidemic and the transfer of antibodies to the fetus: October 15th–December 15th in our latitude) with the rest of acute bronchiolitis. Bivariate analysis was performed regarding birth in period of risk and the rest of variables, using the Chi-square test. Multivariate logistic regression analysis was performed to study possible classical confounding factors.

695 infants were included in the study. 356 infants were born during the period of risk. Of the 56 patients requiring admission to PICU, 40 of them (71.4%) were born in this period (p=0.002). In the multivariate analysis, the birth in the period of risk showed a 6.5 OR (95% CI: 2.13–19.7) independently of the rest of variables.

The worst clinical disease progression of the acute bronchiolitis by the RSV in less than 6 months age is related to lower exposure of the pregnant woman to the RSV epidemic.

To evaluate the clinical manifestations, management, and outcomes of Mycobacterium bovis Bacillus Calmette-Guérin (BCG) osteitis/osteomyelitis.

We reviewed 71 cases of BCG osteitis/osteomyelitis registered in Taiwan's vaccine injury compensation program (VICP) in 1998-2014. Demographic, clinical, laboratory, treatment, and outcome data were compared according to site(s) of infection.

Involvement of a long bone of the lower extremity was present in 36.6% of the children, followed by foot bone (23.9%), rib or sternum (15.5%), upper extremity long bone (9.9%), hand bone (7%), multiple bones (4.2%), and vertebrae (2.8%). Children with lower extremity long bone involvement had a longer interval from receipt of BCG vaccine to presentation (median, 16.0 months; P = .02), and those with foot bone infection had higher rates of swelling (94.1%; P = .02) and local tenderness (76.5%; P = .004). Surgical intervention was performed in 70 children, with no significant difference in the number of procedures by site (median, 1.0 procedure per patient). Among the 70 children who received antimicrobial therapy, those with vertebral and multifocal infections had a longer duration of treatment (P < .001) and/or second-line antituberculosis medications (P = .002). Three children with vertebral and multifocal infections had major sequelae with kyphosis or leg length discrepancy. Outcomes were good for children with involvement of the ribs, sternum, and peripheral bones without multifocal involvement. The average time for functional recovery was 6.2 ± 3.9 months.

Children with BCG osteitis/osteomyelitis in different bones had distinct presentations and outcomes. Pediatricians should consider BCG bone infection in young vaccinated children with insidious onset of signs and symptoms, and consider affected site(s) in the management plan.

Los datos de este estudio son aplicables a nuestro medio. Los resultados de este aconsejan mantener la recomendación de la amoxicilina-clavulánico como tratamiento de primera elección en niños con bronquiectasias y exacerbación leve o moderada (sin fibrosis quística ni infección por Pseudomonas aeruginosa) hasta disponer de más estudios que confirmen estos resultados. La azitromicina podría ser una alternativa en casos de resistencia a β-lactámicos, alergias a amoxicilina, efectos adversos o riesgo de falta de cumplimiento del tratamiento.

Al hilo de la obligatoriedad de las vacunas para entrar en las escuelas infantiles de la red pública en Galicia me pareció interesante este artículo:

Ante un brote de sarampión de seis meses, el Condado de Rockland en Nueva York declaró el estado de emergencia y prohibió que los niños menores de 18 años no vacunados ingresaran en escuelas, tiendas, restaurantes y lugares de culto. No se incluyen espacios al aire libre como parques infantiles. "La multa por violar la orden es de hasta seis meses de cárcel o una multa de $ 500 (£ 379; € 444) o ambas”.

El objetivo era conseguir que los padres vacunen a sus hijos. La tasa de vacunación para el Condado de Rockland es de 72.9%, por debajo de la tasa estatal.

“Es una oportunidad para que todos en nuestra comunidad hagan lo correcto. "Debemos hacer todo lo que esté a nuestro alcance para poner fin a este brote y proteger la salud de quienes no pueden ser vacunados por razones médicas y de los niños que son demasiado pequeños para ser vacunados".

La rubéola es una enfermedad contagiosa prevenible por vacunación que causa que aproximadamente 100,000 niños nazcan con el síndrome de rubéola congénita cada año en todo el mundo. Destacar estos brotes para evidenciar que estas enfermedades inmunoprevenibles siguen teniendo una incidencia y prevalencia muy importante en un mundo globalizado.

En Etiopía se produjeron 18 brotes de rubéola cada año. El 8 de febrero de 2018, la oficina de manejo de emergencias de salud pública de Yeka sub-city woreda reportó dos casos sospechosos de sarampión. Al investigar el brote para identificar su etiología, describirlo e implementar medidas de control, se confirmó que el brote era de rubeola

En Etiopía, actualmente, la vacuna contra la rubéola no se ha incluido en los programas de inmunización rutinarios infantiles.

Tras el estudio del brote se recomienda establecer un sistema de vigilancia de rubéola, realizar un estudio de seroprevalencia de rubéola en mujeres en edad fértil y establecer una vigilancia del síndrome de rubeola congénita para proporcionar información basada en la evidencia para la introducción de la vacuna de la rubeola.

A 22-day-old baby presents at your emergency department with a 3-hour history of poor feeding and fever. Blood and cerebrospinal fluid cultures reveal late-onset group B streptococcal (LOGBS) meningitis and bacteraemia. This child has a dizygotic twin who is asymptomatic. You wonder if it is necessary to test, hospitalise and give antibiotics to the asymptomatic twin?

In an asymptomatic child whose twin has an LOGBS infection (patient), is it necessary to do immediate evaluation, discontinue breast feeding and prescribe antibiotics (intervention) to avoid serious complications of group B streptococcal (GBS) disease (outcome)?

The global resurgence of pertussis in countries with high vaccination coverage has been a concern of public health.

Nasopharyngeal swabs were collected for Bordetella pertussis culture from children with suspected pertussis. Clinical and vaccination information were reviewed through electronic medical chart and immunization record. Antibiotics susceptibility was evaluated using E-test for erythromycin, azithromycin, clarithromycin and sulfamethoxazole/trimethoprim. The MLST genotypes and 7 antigenic genes (ptxP, ptxA, ptxC, Prn, fim3, fim2 and tcfA) of Bordetella pertussis were identified by polymerase chain reaction amplification and sequencing.

During January 2016 to September 2017, a total of 141 children 1–48 months of age were culture-confirmed with pertussis, of whom 98 (69.5%) were younger than 6 months, 25 (17.7%) had completed at least 3 doses of DTaP and 75 (53.2%) had a clear exposure to household members with persistent cough. Fully vaccinated cases manifested milder disease than unvaccinated and not-fully vaccinated cases. All strains were MLST2. High-virulent strains characteristic of ptxP3/prn2/ptxC2 constituted 41.1% (58/141) and were all susceptible to macrolides while low-virulent strains characteristic of ptxP1/prn1/ptxC1 constituted 58.9% (83/141) and 97.6% (81/83), respectively, were highly resistant to macrolides.

Pertussis is resurging among infants and young children in Shanghai, and household transmission is the main exposure pathway. The high-virulent strains harboring ptxP3/prn2/ptxC2 and the macrolide-resistant Bordetella pertussis strains are quite prevalent. These issues impose a public health concern in Shanghai. Our findings are important to modify the DTaP vaccination strategy and the management guideline of pertussis in China.

Background: Childhood tuberculosis (TB) is acquired after exposure to an infectious TB case, often within the household. We prospectively screened children 6–59 months of age, exposed and unexposed to an infectious TB case within the same household, for latent tuberculosis infection (LTBI), in Dar es Salaam, Tanzania.

We collected medical data and clinical specimens (to evaluate for helminths, TB and HIV coinfections) and performed physical examinations at enrollment and at 3-month and 6-month follow-up surveys. LTBI was assessed using QuantiFERON-TB Gold (QFT) at enrollment and at 3 months.

In total, 301 children had complete data records (186 with TB exposure and 115 without known TB exposure). The median age of children was 26 months (range: 6–58); 52% were females, and 4 were HIV positive. Eight children (3%) developed TB during the 6-month follow-up. We found equal proportions of children with LTBI among those with and without exposure: 20% (38/186) versus 20% (23/115) QFT-positive, and 2% (4/186) versus 4% (5/115) indeterminate QFT. QFT conversion rate was 7% (22 children) and reversion 8% (25 children). Of the TB-exposed children, 72% initiated isoniazid preventive therapy, but 61% of parents/caregivers of children with unknown TB exposure and positive QFT refused isoniazid preventive therapy.

In this high burden TB setting, TB exposure from sources other than the household was equally important as household exposure. Nearly one third of eligible children did not receive isoniazid preventive therapy. Evaluation for LTBI in children remains an important strategy for controlling TB but should not be limited to children with documented TB exposure.

Tuberculosis (TB) remains a major public health issue among children worldwide. Data on TB transmission in children living in low-incidence countries is limited.

We studied TB transmission in ethnic Danish children younger than 15 years of age between 2000 and 2013. Identification of children with TB disease and information on demographics and TB contacts were retrieved from the national TB surveillance register and the International Reference Laboratory of Mycobacteriology.

In total, 88 children with TB disease were identified in the study period, corresponding to a mean annual incidence of 6.9 per 1,000,000 children younger than 15 years of age. The male to female ratio was 1.3. Median age was 5 years (interquartile range, 3–8.5). Seventy-three (83%) children had a known TB contact of which 60% was among household contacts with recent TB, predominantly parents. Sixty-six (75%) children were classified as part of epidemiologic clusters. Thirty-five (40%) children had culture verified TB of which information on genotypes was available for 34 (97%). Of these, 35% belonged to cluster C2/1112–15, the most prevalent cluster among adult Danes.

We found on-going TB transmission in Danish children within the households of a low TB incidence population. These findings emphasize the need for early diagnosis of TB in children, thorough contact tracing and increased focus on risk groups.

The Pediatric Infectious Disease Journal. 38(4):384-389, April 2019.

Antimicrobial resistance is low in Norway, but to prevent an increase, the Norwegian Government has launched a National Strategy including a 30% reduction of broad-spectrum antibiotics (BSA) in hospitals within 2020. BSA are defined as second- and third-generation cephalosporins, carbapenems, piperacillin/tazobactam and quinolones. There are no recent studies of antibiotic use in Norwegian hospitalized children. The aim of this study was to describe the use of antibiotics with emphasis on BSA in Norwegian hospitalized children and neonates to detect possibilities for optimization.

Data were extracted from 8 national point prevalence surveys of systemic antibiotic prescriptions in Norwegian hospitals between 2015 and 2017. The choices of antibiotics were compared with the empirical recommendations given in available Norwegian guidelines. In total, 1323 prescriptions were issued for 937 patients.

Twenty-four percent of pediatric inpatients were given antibiotics. Adherence to guidelines was 48%, and 30% (95% confidence interval: 27%–33%) of all patients on antibiotics received BSA. We identified only small variations in use of BSA between hospitals. One-third of the patients on antibiotic therapy received prophylaxis whereof 13% were given BSA. In 30% of prescriptions with BSA, no microbiologic sample was obtained before treatment.

This study reveals an excess of prescriptions with BSA in relation to the low resistance rate in Norway. Our findings reveal areas for improvement that can be useful in the forthcoming antibiotic stewardship programs in Norwegian pediatric departments.

 

Bibliografía  marzo 2019

TOP TEN

·Pertussis (whooping cough) BMJ 2019;364:l401

Es un artículo que hace una revisión exhaustiva del manejo de la tosferina y presentan evidencia y orientación recientes sobre la prevención a través de la vacunación, haciendo un amplio repaso de la literatura. Se hace eco de la facilidad para la pérdida diagnóstica o el retraso ya que la tosferina imita la presentación de una infección viral del tracto respiratorio superior y, en ocasiones, puede presentarse de forma atípica.

Este artículo tiene un interés añadido al finalizar desde la perspectiva del paciente: La aportación de un padre sobre el caso clínico de su hija afectada por la tosferina, reflexionando sobre las secuelas a largo plazo de la tos ferina y el tratamiento de la tos asociada a esta enfermedad infecciosa.

·Beta-Hemolytic Nongroup A Streptococcal Pharyngitis in Children. J Pediatr. 2018 Dec 6. pii: S0022-3476(18)31555-5

To evaluate the epidemiology, clinical features, and antibiotic prescribing patterns for nongroup A streptococci (NGAS) in children.

Study design

Throat cultures obtained for pharyngitis were assessed at a large community-based health system over 10 years. Epidemiologic and clinical features of children with NGAS were compared with children with group A Streptococcus (GAS) and negative cultures. Antibiotic prescribing patterns were evaluated.

Results

A total of 224 328 rapid streptococcal antigen tests and 116 578 throat cultures were performed. Clinical analysis was completed for 602 GAS-positive patients, 535 NGAS-positive patients, and 480 patients with negative cultures. Incidence of NGAS did not vary annually or by season but increased with age from 2% at ≤5 years to 7% at 18 years of age. Patients with NGAS were more likely than those with negative cultures to have tonsillar exudate (20.3% vs 13.1%, P = .003) and enlarged tonsils (28.6% vs 19.3%, P < .001). Modified Centor scores did not differ between groups (score ≥2, P = 1.0; score ≥3, P = .50). Patients with GAS were more likely than those with NGAS to have fever (32.6% vs 24.5%, P = .003), palatal petechiae (14.0% vs 3.1%, P < .001), and modified Centor score ≥2 (47.8% vs 27.1%; P < .001). Of patients with NGAS, 65% were prescribed antibiotics.

Conclusions

NGAS likely exist in both carriage and infectious states and incidence increases with age. Infections associated with NGAS are milder than with GAS, and complications are rare. Laboratory reporting of NGAS results in high antibiotic use, despite current recommendations against treatment.

·Future Research in the Immune System of Human Milk. J Pediatr. 2018 Dec 6. pii: S0022-3476(18)31670-6

Apart from a few discoveries in the 19th and early 20th centuries, little was known about the complex immune system in human milk and its many benefits to the recipient infant. Research during the latter part of the 20th century and this century demonstrated that the human milk immune system is significantly different from that produced by other mammals and that breastfeeding protects against many common infections, reduces inflammation, and lessens the likelihood of certain chronic diseases in later life.

Osteoarticular infection frequently remains microbiologically unconfirmed in the pediatric age. Kingella kingae has emerged as a major etiological agent of osteomyelitis and septic arthritis in children aged less than 4 years. Recently, the implementation of molecular detection assays (MDA) has established the real role of this microorganism in osteoarticular infections.
We conducted a retrospective study in a cohort of pediatric patients. Only 40% strains of K. kingae were identified by one of the culture methods used  but 100%of them tested positive by real-time PCR. In patients aged over 4 years (54.8% with septic arthritis) S. aureus was the most frequent pathogen and was found in 54.8% out of 31 cases. Most S. aureus isolates (15 out of 18) grew both in BCB and routine culture, while the other 3 were only isolated in BC. Etiological diagnosis was exclusively attributable to real-time PCR in 17 out of 49 cases (34.7%). Overall, patients with arthritis were younger (1.5 vs 6.5 years) and more often diagnosed with K. kingae infections (34.3% vs 9.5%) than those affected with osteomyelitis. This study shows that the bacterial etiology of osteoarticular infections in children is closely related to the age of patient, and clearly outlines three different periods. During the first months of life osteoarticular infection is an infrequent event but usually caused by group B streptococci, as in late-onset neonatal sepsis . K. kingae almost exclusively affects infants and toddlers, in fact, in 22 out of 25 (88%) K. kingae cases, patients were aged between six months and two years. Because K. kingae osteoarticular infections usually associate negative gram stain (100% in this study), mild clinical symptoms and mild alteration of plasmatic inflammation markers, differential diagnosis with noninfectious causes of arthritis (i.e. transient synovitis of the hip) is difficult. In these cases, culture in SBCB is important to isolate the microorganism, but MDA are critical for proper diagnosis and early treatment. That is why, specific K. kingae MDA should be available as a routine test in hospitals with pediatric patients. MDA also improve the detection of S. pneumoniae and N. meningitidis. In patients aged >4 years, S. aureus remains the main cause of both arthritis and osteomyelitis,5 in our study 94.4% cases. Due to the efficiency of routine cultures for S. aureus, inoculation of samples in BCB does not improve the isolation rate. Moreover, previous studies have shown that S. aureus-specific PCR assays offer no advantages over classical cultures.

 

Casos clínicos

·Recurrent Vulvar Ulcers and “Cradle Cap” in a 2-Year-Old. J Pediatr. 2018 Oct 12. pii: S0022-3476(18)31373-8

A 2-year-old white female with recurrent methicillin-resistant Staphylococcus aureus otitis media and persistent “cradle cap” was referred for dermatologic evaluation of recurrent, painful vaginal ulcers present for 10 months. The symptoms began with severe vaginal pain during urination and diaper changes. She subsequently developed painful, solitary, bilateral ulcers on the labia majora that responded minimally to topical menthol-zinc oxide and clobetasol. Observation without treatment led to resolution of the ulcers within 3 weeks; the ulcers reoccurred 2 months later.

Niña de 7 años, que estando previamente bien, presenta acceso de tos intensa con un vómito posterior. Tras el mismo, aprecian dificultad respiratoria grave. A su llegada a urgencias tras estabilización se realiza radiografía de tórax donde se aprecia una gran lesión quística derecha con nivel hidroaéreo e imágenes ondulantes, «signo del nenúfar» sugestivas de quiste hidatídico pulmonar (QHP) complicado.
Se amplía estudio con TC  y, ante la mala situación clínica, se decide exéresis quirúrgica urgente . Los estudios microbiológicos y anatomopatológicos confirman la etiología hidatídica del quiste.
La hidatidosis es una zoonosis producida por Echinococcus granulosus. España es un área de alta endemicidad2. En niños la afectación pulmonar es más frecuente ya que las características elásticas del pulmón permiten un crecimiento más rápido3. Pueden ser asintomáticos y diagnosticarse de forma casual o presentar un cuadro clínico grave al romperse hacia el árbol bronquial o pleura. La cirugía del QHP, asociada al tratamiento con albendazol, es el manejo terapéutico habitual.

La cerebelitis aguda (CA) es una disfunción cerebelosa aguda (ataxia, nistagmo o dismetría) asociada a menudo a fiebre, cefalea, náuseas y alteración del nivel de consciencia1,2. Suele ocurrir como trastorno infeccioso, postinfeccioso o posvacunación, aunque hay casos en los que no se evidencia ningún desencadenante3-5.
Se  denomina ataxia cerebelosa aguda a aquellos casos en los que no hay traducción en la neuroimagen, y CA a aquellos casos en que sí encontramos .  La RM cerebral la prueba diagnóstica de elección. La TC craneal en el momento agudo es útil para descartar otra etiología.
La inflamación del cerebelo puede comprimir el tallo cerebral e inducir alteraciones del nivel de consciencia, que pueden enmascarar la etapa inicial de signos cerebelosos, pudiendo presentarse incluso como coma y disfunción autonómica. Esta entidad, en la que predominan los síntomas de hipertensión intracraneal (HTIC) sobre los cerebelosos, y que se asocia a importante componente inflamatorio, se conoce como cerebelitis aguda fulminante1 y es una entidad a tener en cuenta en los casos de HTIC de aparición brusca1.
En los casos leves sin progresión de la clínica, ni imágenes radiológicas propias de los casos fulminantes, una actitud conservadora con monitorización estrecha suele ser suficiente. En casos moderados y graves, los corticoides son la primera línea de tratamiento  e incluso puede ser necesario un drenaje ventricular externo (DVE) frente a la hidrocefalia.
Se presentan 3 pacientes diagnosticados de CA, con edades comprendidas entre los 7 y 12 años, sin antecedentes de interés.
El primer paciente consultó por vómitos y decaimiento, presentando a su llegada un cuadro vagal con disminución de la consciencia, hipotonía y deterioro neurológico. En TC craneal se apreció hipodensidad subcortical en el hemisferio cerebeloso izquierdo . Ingresó en UCI-P, donde se solicitó una RM cerebral planteándose el diagnóstico diferencial entre un proceso isquémico de fosa posterior, encefalitis y CA, por lo que se monitorizó y se inició tratamiento antiagregante, aciclovir y corticoides. A las 12h de su ingreso presentó un aumento de la presión intracraneal y anisocoria, por lo que se realizó TC cranea y tras los hallazgos se decidió craniectomía descompresiva con colocación de un DVE, con estabilidad posterior. Se inició rehabilitación, presentando tendencia a la mejoría neurológica pero con secuelas presentes en el control a los 4 meses (también secuelas en RM  de control) .
Tanto el segundo como el tercer paciente consultaron por cefalea de aprox 1  semana que se había intensificado, limitando las actividades diarias e impidiendo el sueño junto con vómitos. Tanto la exploración física como la TC craneal fueron normales, por lo que ingresaron para analgesia. Dada la ausencia de mejoría se decidió realizar RM cerebral, tras la cual fueron diagnosticados de CA y fueron monitorizados y tratados con corticoides. Evolucionaron favorablemente ( también RM).

Para profundizar

Objectives

We aimed to describe the knowledge, attitudes and beliefs primary care professionals involved in administration of childhood vaccines in Barcelona have about vaccines and vaccination.

Methods

In 2016/17, surveys were administered in person to every public primary care centre (PCC) with a paediatrics department (n = 41). Paediatricians and paediatric nurses responded to questions about disease susceptibility, severity, vaccine effectiveness, vaccine safety, confidence in organisations, key immunisation beliefs, and how they vaccinate or would vaccinate their own children. We used standard descriptive analysis to examine the distribution of key outcome and predictor variables and performed bivariate and multivariate analysis.

Results

Completed surveys were returned by 277 (81%) of 342 eligible participants. A quarter of the respondents reported doubts about at least one vaccine in the recommended childhood vaccination calendar. Those with vaccine doubts chose the response option ‘vaccine-hesitant’ for every single key vaccine belief, knowledge and social norm. Specific vaccine knowledge was lacking in up to 40% of respondents and responses regarding the human papilloma virus vaccine were associated with the highest degree of doubt. Being a nurse a risk factor for having vaccine doubts (adjusted odds ratio (ORa) = 2.0; 95% confidence interval (95% CI): 1.1–3.7) and having children was a predictor of lower risk (ORa = 0.5; 95% CI: 0.2–0.9).

 

To the Editor:

Ambroggio et al1 report on lung ultrasonography as a viable alternative to chest radiography to detect pneumonia in children.2 They emphasize both the higher specificity of chest radiography for many findings compared with lung ultrasonography and the operator's skill in the diagnostic process.

In a large, well-conducted meta-analysis on the role of imaging for the diagnosis of pediatric pneumonia, Balk et al3 analyzed data from 12 studies including 1510 patients and calculated the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of chest radiography and lung ultrasonography. Despite a significantly better sensitivity of lung ultrasonography (95.5% vs 86.8%), values for specificity (95.3% vs 98.2%), PPV (99.0% vs 99.6%), and NPV (63.1% vs 43.6%) were comparable between lung ultrasonography and chest radiography. The authors point out the limitation in measuring PPV and NPV in their meta-analysis, because the included studies were reflective not of the general population, but rather of a population of patients with high clinical suspicion for community-acquired pneumonia. PPV and NPV are dependent on the disease incidence, which thus influences validation of data. Furthermore, most studies included chest radiography in the diagnostic criteria for pneumonia in addition to clinical presentation, thereby skewing chest radiography results to higher specificity and inflating the intrinsic value itself. Performing studies that do not include chest radiography as part of diagnostic standard may overcome this problem.

There is a growing evidence of the accuracy of lung ultrasonography over chest radiography in the diagnosis of pneumonia. However, the real impact in the clinical practice of substituting chest radiography with lung ultrasonography has not been adequately studied. Until this step is completed, lung ultrasonography may be particularly useful in the detection of pneumonia in clinical settings were chest radiography is not readily available.

Ambroggio, L., Shah, S.S., and Coley, B.D. Reply. J Pediatr. 2018; 196: 329–330

Background: To examine whether inappropriate antibiotic treatment for an initial bout of acute bronchitis in childhood affects patterns of future healthcare utilization and antibiotic prescribing.

Methods: We conducted a retrospective analysis of children with at least 1 acute bronchitis episode, defined as the 14-day period after an acute bronchitis visit, born in 2008 and followed through 2015 in a nationally representative commercial claims database. We predicted the likelihood of returning for a subsequent acute bronchitis episode, and being prescribed an antibiotic as part of that episode, as a function of whether or not the child was prescribed an antibiotic as part of the first acute bronchitis episode controlling for patient, provider and practice characteristics.

Results: Children prescribed an antibiotic as part of their initial acute bronchitis episode were more likely both to have a subsequent acute bronchitis episode (hazard ratio = 1.23; 95% confidence interval: 1.17–1.30) and to be prescribed an antibiotic as part of that second episode (hazard ratio = 2.13; 95% confidence interval: 1.99–2.28) compared with children who were not prescribed as part of their first episode. Children diagnosed with asthma were more likely to experience a second visit for acute bronchitis, but less likely to receive an antibiotic as part of that second episode.

Conclusions: Inappropriate antibiotic prescribing for a child’s initial acute bronchitis episode of care predicted likelihood of subsequent acute bronchitis episodes and antibiotic prescriptions. Providers should consider the downstream effect of inappropriate antibiotic prescribing for acute bronchitis in childhood.

Setenta personas, la mayoría de ellas niños, han muerto de sarampión en Filipinas desde comienzos de 2019, el 79% de los muertos este año no estaban vacunados. Ahora se extiende por la capital densamente poblada de Manila, así como en otras cuatro regiones, y el gobierno insta a los padres a que vacunen a sus hijos de forma gratuita.

La mayor brecha en Europa ha sido en Ucrania, donde el estallido de la guerra en 2014 interrumpió gravemente los programas de inmunización. Ucrania es líder mundial en casos de sarampión, con 53 218 casos en 2018, o 121 por cada 100 000 personas. En la última semana se registraron unos 3142 casos en Ucrania. Pero el paciente promedio es mayor que en Filipinas, y ha habido menos muertes, 16 desde que comenzó el 2019.

En este mismo artículo se menciona que la Academia Americana de Pediatría ha pedido a Facebook que haga más para eliminar toda la información engañosa sobre las vacunas de su sitio web. Facebook ha aceptado ingresos por publicidad de grupos como Vax Truther, Anti-Vaxxer y Vaccines Revealed. El periódico británico The Guardian obtuvo acceso a grupos cerrados en Facebook donde los miembros reciben información falsa contra las vacunas, a menudo por personas con un claro interés financiero en desacreditar las vacunas. Uno de estos grupos, llamado Vitamina C y Medicina Ortomolecular para una Salud Óptima, le dice a sus 49000 miembros que "no es un grupo anti-vax", pero su administrador escribió en un mensaje: "Hasta que se vuelvan seguras y no se guíen por el dinero, evitaría todas las vacunas ". Katie Gironda, que dirige otro grupo de Facebook llamado Vitamina C contra el daño de las vacunas figura en LinkedIn como directora ejecutiva de un negocio en línea llamado Revitalize Wellness, que vende dosis altas de vitamina C. Las advertencias sobre las vacunas se intercalan con las instrucciones para "comprar ahora" para la vitamina C.

La efectividad directa de la vacunación contra el rotavirus infantil implementada en 2006 en los Estados Unidos se ha evaluado ampliamente, sin embargo, la comprensión de la efectividad de la vacuna a nivel de la población aún es incompleta.

Se ha visto que los beneficios de la vacuna se extendieron a individuos no vacunados en todos los grupos de edad, lo que sugiere que los bebés son importantes impulsores de la transmisión de la enfermedad en toda la población y por lo tanto también la vacunación protege a toda la población.

La evidencia reciente sugiere que las infecciones virales están involucradas en un modelo animal de enfermedad celíaca. Estudios prospectivos han mostrado una mayor prevalencia de infecciones en niños antes del diagnóstico de enfermedad celíaca. Los estudios previos de adenovirus y enterovirus se han limitado a diseños transversales, y la causalidad inversa es una posible explicación para estas observaciones.

En este estudio longitudinal, encuentran que una mayor frecuencia de infecciones por enterovirus se asoció con un mayor riesgo de enfermedad celíaca. En conjunto, sus resultados son compatibles con un mecanismo por el cual las infecciones virales pueden romper la barrera de la mucosa con un aumento de la translocación de los péptidos de gluten a la mucosa como el evento inicial en la pérdida de tolerancia. Especulan que los enterovirus pueden proporcionar una señal de peligro que activa las células dendríticas que actúan como células presentadoras de antígenos para las células T reactivas al gluten CD4 en presencia de péptidos de gluten modificados con transglutaminasa.

Dado el número limitado de casos, se necesitan estudios similares y, preferiblemente, estudios de intervención para llegar a conclusiones sobre la causalidad. La identificación de virus específicos como desencadenantes de la enfermedad celíaca puede tener implicaciones para las estrategias preventivas y justificar estudios futuros para aclarar los mecanismos

At present, the evidence on the effectiveness and safety of antibiotic treatment for newborns with confirmed, highly probable or possible congenital syphilis is sparse, implying that we are uncertain about the estimated effect. One trial compared benzathine penicillin with no intervention for infants with possible congenital syphilis. Low-quality evidence suggested penicillin administration possibly reduce the proportion of neonates with clinical manifestations of congenital syphilis, penicillin administration increased the serological cure at the third month. These findings support the clinical use of penicillin in neonates with confirmed, highly probable or possible congenital syphilis. High- and moderate-quality evidence suggests that there are probably no differences between benzathine penicillin and procaine benzylpenicillin administration for the outcomes of absence of clinical manifestations of syphilis or serological cure.

El estreptococo del grupo B ( Streptococcus agalactiae, GBS) es la causa más común de sepsis neonatal y meningitis en muchos países desarrollados. En el Reino Unido, el GBS causa una enfermedad invasiva en los primeros seis días de vida en aproximadamente uno de cada 2000 nacidos vivos. Para prevenir la enfermedad de inicio temprano, el tratamiento recomendado a nivel internacional es la profilaxis antibiótica intraparto, generalmente penicilina intravenosa. El Reino Unido recomienda una estrategia basada en el riesgo, en la cual a las mujeres embarazadas que presentan factores de riesgo para una infección por GBS de inicio temprano se les ofrece profilaxis antibiótica durante el parto.

Los defensores del cribado universal apuntan a los países de Europa y América del Norte donde se recomienda el cribado y donde se han observado reducciones en la infección por EGB de inicio temprano. Pero la evidencia muestra que la efectividad del cribado, es incierto y que la detección tiene daños potenciales. En el artículo explican por qué el Comité Nacional de Detección del Reino Unido decidió no introducir la detección de rutina: tratamiento excesivo, peligros potenciales desconocidos de la detección y tratamiento profiláctico con antibióticos durante el parto, y beneficio incierto.

El enfoque actual llevaría a que el 99.8% de las mujeres con resultado positivo en la prueba de detección y sus bebés reciban una profilaxis innecesaria con antibióticos durante el parto. La falta de evidencia de alta calidad sobre los resultados clínicos hace que sea imposible cuantificar si la prueba de detección de GBS universal tendría algún beneficio y evaluar si la profilaxis con antibióticos intraparto a gran escala es segura. Ellos concluyen que actualmente no se puede recomendar un programa universal de detección de cultivos prenatales.

 Introducción. El objetivo del estudio fue evaluar la seguridad y la eficacia de la combinación de ledipasvir/sofosbuvir en la infección crónica por el genotipo 1 y 4 del virus de la hepatitis C (VHC) en pacientes pediátricos. Métodos. Se incluyó a pacientes de entre 6 y 18 años. La duración y la dosis de los fármacos antivirales se administraron según la edad del paciente, el estadio de fibrosis y los tratamientos previos con interferón pegilado y ribavirina. La variable principal de eficacia fue el porcentaje de pacientes con una respuesta virológica sostenida 12 semanas (RVS12) después del tratamiento. Resultados Nueve pacientes con una mediana de edad de 14,8 años fueron tratados con combinación de ledipasvir/sofosbuvir. Cinco pacientes habían recibido previamente tratamiento con interferón pegilado+ribavirina. Ocho pacientes tenían algún grado de fibrosis. La mediana de la carga viral previa al tratamiento fue de 6,2 log con negativización del ARN del VHC 6 semanas después de comenzar el tratamiento en el 100% de los pacientes. Todos los pacientes mantuvieron una respuesta viral sostenida a las 12 semanas. Tres pacientes (33,3%) tuvieron algún tipo de efecto adverso (2 dolores de cabeza y un afta oral). La mediana de seguimiento posterior al tratamiento fue de 24 semanas.

Conclusiones. El tratamiento con ledipasvir/sofosbuvir en pacientes pediátricos con infección crónica por VHC de genotipo 1 y 4 es seguro y efectivo con RVS12, similar a lo reportado en adultos.

Euro Surveill. 2019 Feb;24(7). doi: 10.2807/1560-7917.ES.2019.24.7.1700857

Worldwide, under-fives mortality has halved since 1990 from 93 to 41 deaths per 1000 live births in 2016. However, progress has been very uneven. Child mortality is still highest in Africa (76 per 1000 live births) (figure 1) and neonatal mortality has declined at a slower rate so is now approaching 50% of all under-fives mortality.1 Research and programmatic efforts are focussed on reducing child mortality in the highest burden areas. An intriguing and controversial idea to reduce mortality has arisen from mass antimicrobial distribution programmes for the prevention of blindness caused by trachoma.

A 6-year-old boy presents to Accident and Emergency with fever, lethargy and a spreading purpuric rash. Despite fluid resuscitation with 40 mL/kg he remains clinically shocked with tachycardia, cool peripheries, prolonged capillary refill time and lactic acidosis. Anaesthetics arrive to intubate and you as the paediatric registrar are asked to prescribe a peripheral vasoactive drug infusion. You remember that the advanced paediatric life support course you recently attended advised starting either dopamine or epinephrine in the setting of cold shock but wonder if there is evidence to support one over the other.

Structured clinical question

In children with septic shock unresponsive to 40 mL/kg fluid resuscitation (population) does initial peripheral venous administration of epinephrine (intervention) compared with dopamine (comparison) improve mortality (outcome)?

The Pediatric Infectious Disease Journal. 38(3):e54-e56

Hemophagocytic lymphohistiocytosis (HLH) is not one condition but descriptive of a life-threatening, hyper-inflammatory syndrome with multiorgan involvement with a variety of triggers, both genetic and environmental. It is described as primary HLH (familial HLH) and secondary HLH (acquired following malignancy, rheumatologic disorders, primary immune deficiencies or infection alone). Infections commonly precipitate HLH in those with primary HLH, in combination with an underlying disease (malignancy, rheumatologic or primary immune deficiency) or may be the sole trigger.1 Many people with “secondary” HLH may also have potentially pathogenic polymorphisms in an HLH- associated gene.2 Rapid diagnosis of HLH and initiation of appropriate treatment is essential to reduce mortality from this condition

Los anticuerpos monoclonales contra el virus sincitial respiratorio (VRS; palivizumab) se recomiendan para la profilaxis de los bebés de alto riesgo durante las temporadas de bronquiolitis, pero no para el tratamiento de la bronquiolitis por VRS. Nuestro objetivo fue determinar si palivizumab sería útil en niños pequeños con bronquiolitis aguda por VRS.

Se incluyeron 420 niños en el estudio, de los cuales completaron 413.

CONCLUSIONES: El palivizumab intravenoso no parece ayudar o dañar a los bebés pequeños con bronquiolitis aguda por VRS positiva.

·Cerebrospinal Fluid Shunt Infection: Emerging Paradigms in Pathogenesis that Affect Prevention and Treatment. J Pediatr. 2018 Dec 6. pii: S0022-3476(18)31673-1

In this medical progress report, we outline the epidemiology and healthcare utilization associated with cerebrospinal fluid (CSF) shunt-associated infections in the US, the clinical features of CSF shunt infection, and our evolving understanding of the prevention and treatment of CSF shunt infection. We describe an emerging paradigm in CSF shunt infection under active investigation.

  • Trends and Predictors of Clostridium difficile Infection among Children: A Canadian Population-Based Study. J Pediatr. 2018 Nov 15. pii: S0022-3476(18)31548-8

To assess time trends in Clostridium difficile infection (CDI) rates, and predictors of CDIs, including recurrent CDIs, in children.

Study design

Data were extracted from Manitoba Health Provider Claims, and other population registry datasets from 2005 to 2015. CDI was identified from the Manitoba Health Public Health Branch Epidemiology and Surveillance population-based laboratory-confirmed CDI dataset. Children aged 2-17 years with CDI were matched by age, sex, area of residence, and duration of residence in Manitoba with children without CDI. The rates and time trends of CDIs using previously recommended definitions were determined. Predictors of CDI subtypes were determined using multivariable logistic regression models. Cox regression analysis was used to assess for the potential predictors of recurrent CDI.

Results

Children with and without CDI were followed for 828 and 2753 persons-years, respectively. The overall CDI rate during the study period was 7.8 per 100 000 person-years. There was no significant change in CDI rates over the observation period. Comorbid conditions, more prevalent among children with CDI than matched controls, included Hirschsprung disease (P < .001) and inflammatory bowel disease (P < .0001). Recurrent CDIs (>2 occurrences) were responsible for 10% of CDI episodes (range, 2-6 infections). Predictors of recurrence included malignancy (hazard ratio, 3.0, 95% CI, 1.1-8.8), diabetes (hazard ratio, 4.8; 95% CI, 1.1-21.4), and neurodegenerative diseases (hazard ratio, 8.4; 95% CI, 1.9-37.5).

Conclusions

The incidence of CDI is stable among children in Manitoba. Children with Hirschsprung disease and inflammatory bowel disease are more susceptible to CDI, and those with malignancy, diabetes. and neurodegenerative disorders are more likely to develop recurrent CDI.

Background: Fluoroquinolone (FQ) prescription rates have increased over the last 10 years despite recent warnings of serious adverse effects such as peripheral neuropathy and tendinopathy. Currently, there are no published data on the extent or appropriateness of FQ prescribing in children.

Methods: Drug prescription data from the PharMetrics Plus health claims database (United States) were analyzed to examine dispensing of ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin, or gemifloxacin to children from 2006 to 2015. Based on American Academy of Pediatrics recommendations, an algorithm was created to quantify inappropriate FQ prescriptions, which was further stratified by age and FQ type.

Results: Among a cohort of 2,754,431 children, 372,357 prescriptions for an oral FQ were dispensed between 2006 and 2015. An increase was observed in FQ prescriptions from 2006 to 2013, with numbers coming down in 2014 and 2015. Ciprofloxacin was the most frequently prescribed FQ (334,268 prescriptions) followed by levofloxacin (19,386), moxifloxacin (18,434) and combined ofloxacin/gemifloxacin prescriptions (369). Of the FQ prescriptions in children, 48% were prescribed to those 10 years of age or younger, and 22% were deemed inappropriate.

 

Conclusions: Our study suggests an increase in the prescribing of FQs, mostly ciprofloxacin, over a 10-year period, although numbers have decreased slightly in 2014 and 2015. At least 1 in 5 prescriptions were deemed unnecessary. In light of recent FQ safety warnings and lack of long-term safety data with FQ use in children and potential risk of increasing antibiotic resistance, clinicians are advised to refrain from using FQs for uncomplicated community-acquired infections.

 

Actualidad bibliográfica febrero 2019

Top ten

·Guía de uso de antimicrobianos en niños con tratamiento ambulatorio. Servicio madrileño de Salud. Consejería de Sanidad e la Comunidad de Madrid. Disponible en http://www.comunidad.madrid/publicacion/ref/20261

·Scabies: New Opportunities for Management and Population Control. The Pediatric Infectious Disease Journal. 38(2):211-213

Scabies is a skin condition caused by infestation with the microscopic mite Sarcoptes scabiei var hominis. Common scabies causes severe itch, mite burrows and secondary skin lesions. Scabies has a strong causal relationship with impetigo1 which can lead to more severe skin and soft tissue infections, invasive bacterial infections and post-streptococcal sequelae.2 Crusted scabies is a rare form, usually affecting people with immunosuppression and characterized by hyperkeratotic skin containing thousands to millions of mites.

The World Health Organization (WHO) adopted scabies as a neglected tropical disease (NTD) in 2017.3 This recognition has led to increasing global awareness and efforts toward scabies control and even elimination as a public health problem. The 2018 meeting of the WHO NTD Strategic Technical Advisory Group Working Group on Monitoring and Evaluation noted “strong initial evidence for ivermectin-based mass drug administration (MDA) for control of scabies in endemic populations and that simplified clinical case definitions for field surveys are available; however, there is currently no global strategy for scabies control.”4 With an increasing global focus on scabies, it is timely to review recent advances in the understanding of scabies epidemiology, diagnosis, treatment and public health control.

·Antibiotic Recommendations for Acute Otitis Media and Acute Bacterial Sinusitis: Conundrum No More. Pediatr Infect Dis J. 2018 Dec;37(12):1255-1257

There has been a substantial change in the prevalence and microbiologic characteristics of cases of acute otitis media secondary to the widespread use of pneumococcal conjugate vaccines. Current trends in nasopharyngeal colonization and the microbiology of acute otitis media support a change in the recommendation for antibiotic management of acute otitis media and acute bacterial sinusitis in children.

·Antibiotic Recommendations for Acute Otitis Media and Acute Bacterial Sinusitis. The Pediatric Infectious Disease Journal. 38(2):217

·Streptococcal Infections and Exacerbations in PANDAS: A Systematic Review and Meta-analysis. The Pediatric Infectious Disease Journal. 38(2):189-194

Background: The pediatric autoimmune neuropsychiatric disorders associated with streptococcal infection (PANDAS) hypothesis suggests an association between group A beta-hemolytic streptococcus (GABHS) infections and subsequent onset or exacerbation of neuropsychiatric symptoms, such as obsessive-compulsive disorder or tic disorders.

Methods: We performed a systematic review and meta-analysis including longitudinal, prospective studies on exacerbations of neuropsychiatric symptoms associated with GABHS infections in children with PANDAS. We searched PubMed and EMBASE through August 14, 2017. Two independent reviewers extracted data and we used random-effects analysis to calculate rate ratios (RR).

Results: Three studies were included with a total of 82 PANDAS cases and 127 control children with obsessive-compulsive disorder or chronic tic disorder. PANDAS cases had a nonsignificantly increased RR of 2.33 [95% confidence interval [CI]: 0.63–8.70, P = 0.21, I 2 = 28.3%] for exacerbations of neuropsychiatric symptoms in temporal proximity to a GABHS infection and no increased risk of GABHS infections (RR = 0.99, 95% CI: 0.56–1.73, P = 0.97, I 2 = 45%) compared with the control children. However, PANDAS cases had an increased risk of neuropsychiatric exacerbations in general with a RR of 1.54 (95% CI: 1.12–2.11, P = 0.008, I 2 = 0%) compared with the control children. The studies had methodologic heterogeneity, high risk of selection bias and differed concerning case definition and infection measures.

Conclusions: Our findings did not show significant evidence concerning higher rates of temporally associated GABHS infections and exacerbations of neuropsychiatric symptoms in children with PANDAS. The included studies were small and limited by low GABHS rates and exacerbations. Future studies with large population sizes and routine evaluations are needed to thoroughly examine the PANDAS hypothesis.

Más de 80 000 personas en 47 de los 53 países europeos contrajeron el sarampión en 2018, con un 61% hospitalizados y 72 muertes Según la OMS.

El número total de personas infectadas con el virus en 2018 fue el más alto de esta década: tres veces el total informado en 2017 (23 927 casos) y 15 veces el mínimo histórico registrado en 2016 (5273 casos).

A pesar de que en la región europea haya más niños vacunados contra la enfermedad que nunca, el progreso en la vacunación es desigual entre los países y dentro de ellos. Esto deja a los grupos de personas susceptibles desprotegidas, particularmente en los países de ingresos medios

El Plan Europeo de Acción de Vacunas 2015-2020 (EVAP) establece una estrategia respaldada por los 53 estados miembros para eliminar el sarampión y la rubéola. Al menos el 95% de cada población debe ser inmune, a través de dos dosis de vacunación o exposición previa al virus, para garantizar la protección de la comunidad para todos, incluidos los bebés demasiado pequeños para ser vacunados y otros que no pueden ser inmunizados debido a enfermedades existentes y enfermedades médicas.

Background: Implementing matrix-assisted laser desorption ionization–time of flight and multiplex polymerase chain reaction has been associated with decreased mortality and hospital length of stay in adults, but the impact in pediatrics is less understood.

Methods: This pre–post quasi-experimental study compared antibiotic prescribing for positive blood cultures in patients ≤21 years of age collected in 2012 (preintervention) and in 2015 (after matrix-assisted laser desorption ionization–time of flight/multiplex polymerase chain reaction). Time to effective and optimal antimicrobial therapy was evaluated using Cox proportional hazards regression. Time to ideal optimal therapy was estimated as the earliest potential initiation of optimal therapy. Antibiotic use and clinical outcomes were measured.

Results: There were 242 and 192 positive monomicrobial blood cultures in 2012 and 2015, respectively. Postintervention, time to optimal therapy (73.8 vs. 48.8 hours; P < 0.001) and organism identification (55.6 vs. 29.5 hours; P < 0.001) were reduced, and patients were more likely to receive optimal therapy by 7 days (hazard ratio, 1.85; P < 0.001). In the ideal scenario in 2015, there was an 8.8-hour delay in initiating optimal therapy based on the time that sufficient microbiologic data were available. Postintervention, time to effective therapy (2.8 vs. 2.7 hours; P = 0.782) and clinical outcomes did not differ. Unnecessary antibiotic duration for probable contaminants (skin flora) (43.1 vs. 29.7 hours; P = 0.027), vancomycin for methicillin-sensitive Staphylococcus aureus (54.0 vs. 41.3 hours; P = 0.008) and nonpenicillin/ampicillin antibiotics for group A Streptococcus, group B Streptococcus and Enterococcus faecalis (87.2 vs. 33.4 hours; P < 0.001) were reduced postintervention.

Conclusions: Rapid diagnostics reduced time to optimal antimicrobial therapy and unnecessary antibiotic use without worse clinical outcomes.

Introducción: La información existente sobre el impacto de la gripe en la población infantil española es escasa. El trabajo pretende estudiar la incidencia de hospitalización, clínica, comorbilidades y el estado vacunal en los niños hospitalizados.

Métodos: Estudio retrospectivo, observacional, por revisión de historias clínicas, en menores de 15 años hospitalizados por gripe adquirida en la comunidad, confirmada microbiológicamente, durante 2temporadas gripales (2014-2015 y 2015-2016). El estudio se realizó en 10 hospitales de 6 ciudades, que atienden aproximadamente al 12% de la población infantil española.

Resultados: Fueron hospitalizados 907 niños con gripe (447<2 años), con una tasa media anual de incidencia de hospitalización de 0,51 casos/1.000 niños (IC del 95% 0,48-0,55). El 45% presentó enfermedades subyacentes consideradas factores de riesgo para gripe grave, y la mayor parte de ellos (74%) no habían sido vacunados. El porcentaje con enfermedades subyacentes aumentó con la edad, desde el 26% en menores de 6 meses al 74% en mayores de 10 años. El 10% de los casos (n=92) precisaron cuidados intensivos pediátricos por fallo respiratorio agudo.

Conclusión: La gripe es causa importante de hospitalización en la población infantil española. Los menores de 6 meses de edad y los niños con enfermedades subyacentes constituyen una parte mayoritaria (> 50%) de los casos. Una gran parte de las formas graves de gripe en población infantil podrían ser evitada si se cumplieran las indicaciones de vacunación.

Casos clínicos

Neonato de de 2 semanas de vida. Consultan por secreción purulenta de ambo. Recien nacido a término, parto vaginal espontáneo. No había recibido profilaxis ocular después del parto, y la madre no se había sometido a pruebas prenatales para detectar la infección por clamidia o gonorrea. Una muestra de secreción ocular obtenida del bebé y un hisopo endocervical obtenido de la madre dieron positivo para el ADN de Chlamydia trachomatis y negativo para el ADN de Neisseria gonorrhoeae por reacción en cadena de la polimerasa. La transmisión perinatal de C. trachomatis o N. gonorrhoeae puede causar conjuntivitis neonatal, conocida como oftalmia neonatorum. El paciente recibió 2 semanas de eritromicina oral, y además se una dosis única de azitromicina oral a sus padres. Los síntomas del se resolvieron dentro de los 5 días posteriores al inicio del tratamiento. 

Staphylococcus aureus y estreptococos del grupo viridans son los organismos causantes más comunes, mientras que el estreptococo del grupo A (SGA) es menos frecuente.

1er caso: niña de 14 años previamente sana, presenta tres días de fiebre, fatiga y cambios en el estado mental y un día de cojera.

Signos vitales: Tª 39,8ºC; FC 130 lpm; TA 100/71 mmHg; FR 18 rpm y SatO2 98%.

Exploración: Estaba orientada pero extrañamente charlatana y grosera. La úvula y la faringe posterior estaban cubiertas de hemorragias petequiales que sugerían faringitis estreptocócica. No se auscultaron soplos cardíacos. El segundo y el quinto dedos del pie izquierdo presentaban coloración negruzca, tenía petequias en la palma de la mano derecha y plantas de pies y el dorso del pie izquierdo estaba eritematoso, cálido e hinchado

Laboratorio: Signos de coagulación intravascular diseminada (CID) con un recuento elevado de glóbulos blancos y una proteína C reactiva elevada

En dos de los tres cultivos de sangre creció Streptococcus pyogenes (T6 M6, emm 6.104).

Se estableció el diagnóstico de celulitis y esta infección de la piel y los tejidos blandos del dedo del pie y del pie causaban bacteriemia y CID.

Se sospechó que la SGA era el microorganismo causante y se inició tratamiento con ampicilina / sulbactam intravenosa (IV) y clindamicina.

Sobre la base de los resultados del antibiograma, la ampicilina / sulbactam se cambió por ampicilina y se continuó con clindamicina

Su estado mental casi se había normalizado al final del primer día de hospitalización y estaba completamente despierta y alerta el día 3.

Al tercer día se escuchó un soplo sistólico de eyección y la ecocardiografía mostró regurgitación mitral con vegetación de la válvula mitral.

También tuvo hallazgos de infartos en la corteza temporal izquierda profunda, el bazo y el riñón.

Dos semanas después, desarrolló una erupción eritematosa en todo el cuerpo. Se sospechó una erupción por drogas y se cambió de ampicilina y clindamicina a cefotaxima.

Debido a la gravedad resultante de la regurgitación mitral, se sometió a una reparación de la válvula mitral después de 10 semanas de tratamiento con antibióticos.

 

2º caso: Un niño de 17 meses se presentó en un hospital municipal por fiebre. Tenía antecedentes de cierre espontáneo de un defecto del tabique ventricular (CIV) a los 5 meses de edad con insuficiencia mitral leve residual. Presentaba un historial de 2 días de fiebre y de irritabilidad de 1 día. Fue remitido a nuestro hospital debido a un recuento elevado de glóbulos blancos y una proteína C reactiva elevada.

Los signos vitales iniciales fueron: Tª 40.6 ° C, TAS 100 mmHg, FC 157 latidos / min, FR 60 respiraciones / min y Sat. 97%. No tenía petequias conjuntivales, ni hemorragias en astillas de las uñas, ni erupción. No se auscultaban soplos.

La evaluación inicial de laboratorio mostraba un recuento de glóbulos blancos de 14.300 células / ml y un nivel de proteína C reactiva de 30.89 mg / dL. Se extrajeron hemocultivos tanto en el hospital municipal como en nuestro hospital con 12 horas de diferencia, y se inició tratamiento empírico con ampicilina IV y cefotaxima por una posible bacteriemia.

En dos cultivos de sangre crecieron S. pyogenes (T4 M4, emm 4.0).

En el día 5 de ingreso, la ecocardiografía mostró una vegetación en un aneurisma septal membranoso del lado derecho y se le diagnosticó de endocarditis infecciosa. Sobre la base de los resultados de las pruebas de susceptibilidad, se retiró la cefotaxima y solo se continuó con ampicilina. Mientras recibía terapia con antibióticos, no desarrolló ninguna complicación, como hipertensión pulmonar o embolia pulmonar. La ampicilina IV se continuó durante 4 semanas adicionales después de que se determinó que los hemocultivos de seguimiento eran negativos y finalmente fue dado de alta. El paciente no ha mostrado signos de insuficiencia cardíaca durante el período de seguimiento de 2 años

Conclusión: El SGA es un organismo etiológico raro de la EI, y hay pocos informes de endocarditis por SGA con información específica sobre los tipos de serotipos (de la proteína M) / emm (genes que codifican la proteína M). En general, la mayoría de los tipos de serotipos/emm asociados con SGA generalmente causan solo una infección leve, pero como muestra este informe, también puede asociarse con una enfermedad invasiva grave como la EI.

En relación al segundo caso destacar que las directrices de profilaxis antibiótica de la Academia Americana del Corazón de 2007 para la prevención de la EI, ya no consideran que las lesiones cardíacas congénitas no reparadas tengán un riesgo alto o moderado de EI. Sin embargo Knirsch et a.l sostienen que deben considerarse un riesgo de por vida las cardiopatías congénitas no operadas, reparadas o solucionadas espontaneamente, incluyendo la CIV

An 18-year-old was admitted to our hospital in December 2017 after 2 days of fever, caugh and dyspnea. NO clinical relevant history, no recent travel and a completed vaccination calendar. The patient accomplished sepsis clinical criteria, and examination revealed no neurologic findings or skins lesions. Laboratory findings were leucopenia, coagulopathy and elevation of acute phase reagents. Torax X-ray showed a bilateral infiltrate. The patient evolved to acute respiratory failure, which required admission to our Intensive Care Unit for respiratory support. Empirical antimicrobial treatment with meropenem, levofloxacin and oseltamivir was started after collection of blood and urine cultures and nasopharyngeal exudate for PCR testing for Influenza viruses. Urine and nasopharyngeal samples were negative.In blood culture, the isolate was Neisseria meningitidis serogroup C/W. The strain was susceptible to Cefotaxime (MIC ≤ 0.016 g/mL). Clinicians were informed and the patient underwent targeted therapy with Cefotaxime at a dose of 2 g/8 h for 7 days, with favorable outcome (any clinical consequence of the infection) . The isolate was identified as N. meningitidis serogroup W, genosubtype P1.5,2 (PorA VR1:5, VR2:2). The disease is seasonal, being more frequent in the winter months. In Spain we have attended a similar scenario tan in the restnof Europe: on the one hand a decrease on the incidence of IMD by serogroup C and B. On the other hand, the number of IMD due to non-frequent serogroups (W and Y) has also increased (8.2% of W and 5.2% of Y in 2015–2016 season).These serogroups are nowadays considered as emerging and they should be considered in patients with clinical suspicion of meningococcal infection. The possibility of quadrivalent conjugate vaccine implementation in Spain should be evaluated. This case report illustrates the emerging importance of these local-acquired non-B/C meningococcal infections which have to be considered as a differential diagnosis in patients with either sepsis of respiratory origin with or without neurological or skin findings.

Neonato de 9 días que consulta por fiebre de 38 ◦C de 2 h, irritabilidad y rechazo de apoyo sobre el lado izdo. No otra sintomatología. Antecedentes perinatales : SGB positivo, con profilaxis antibiótica incompleta, sin clínica de infección neonatal en maternidad. Hermano de 6 anos normovacunado y sin clínica infecciosa. EF: zona eritematosa e indurada en región malar izquierda, caliente y dolorosa, que engloba el ángulo submandibular. No se observan puertas de entrada superficiales ni en mucosa oral. Leve oclusión ocular izquierda, sin lateralización de la comisura bucal. Resto normal. En la analítica destacan leucocitosis con neutrofilia con series roja y plaquetaria normales. Ionograma, perfiles renal y hepático y amilasa normales. PCR 11 mg/l y PCT 0,11 ng/ml. Las citoquímicas de orina y LCR fueron normales. EN ecografía de partes blandas, se aprecia un aumento de tamaño de la parótida izda, hipervascularizada, y con ganglios intra y extra parotídeos, de aspecto reactivo, sin colecciones que sugieran abscesos ni dilataciones ductales Ingresa con sospecha de parotiditis neonatal con tto iv empírico con ampicilina y cefotaxima. A las 12 h comienza con secreción a través del conducto de Stenon; se recoge muestra del exudado y se sustituye la antibioterapia por cloxacilina y cefotaxima. Tanto en el cultivo de este exudado, como en el hemocultivo se identifican SARM, Staphylococcus mitis y Staplylococcus salivaris, por lo que se completa tratamiento con cloxacilina intravenosa durante 10 días. Los cultivos de orina y LCR resultan negativos. P ermanece afebril desde las 48 h del ingreso, con mejoría progresiva de la induración y del eritema mandibular, desapareciendo la secreción purulenta por el conducto de Stenon hasta el 4.◦ día de ingreso. El hemocultivo de control y la serología IgM de parotiditis resultan negativos.

La parotiditis bacteriana es excepcional en neonatos y lactantes debido a los anticuerpos maternos. La infección puede producirse por flujo bacteriano retrógrado a través del conducto de Stenon, y con menor frecuencia por siembra hematógena . El S. aureus es el microorganismo aislado más común. En segundo lugar, y con mayor asociación con clínica generalizada y meningitis, se encuentra la infección por SGB. También se han descrito infecciones por otros bacilos gramnegativos, anaerobios y estreptococos. El diagnóstico es clínico. La afectación unilateral es la más frecuente. La fiebre se encuentra en menos de la mitad de los casos, habitualmente asociada a bacteriemia. El nivel sérico de amilasa se eleva en pocas ocasiones, debido a la inmadurez de esta actividad de la isoenzima salival en recién nacidos. El cultivo positivo del exudado purulento del conducto ipsilateral de Stenon o de la aspiración de la glándula afectada es patognomónico. Cuando este resulta negativo, el crecimiento bacteriano del hemocultivo en este contexto clínico sugiere altamente el diagnóstico. La prematuridad, el sexo masculino, la necesidad de sonda nasogástrica y la deshidratación son factores de riesgo. El pronóstico es bueno. Algunos autores consideran la cloxacilina como tto de elección dada la alta frecuencia de S. aureus como agente causal, no obstante, cuando exista la posibilidad de infección por SGB, el tto empírico debe ser una C3G hasta resultado de cultivos. Complicaciones: septicemia y meningitis, fístulas salivales y abscesos, parálisis facial y mediastinitis, que pueden llegar a precisar cirugía

 

Para profundizar

Probiotics, usually in the form of live Lactobacillus species, have become popular as both a treatment and a preventative agent for a wide variety of childhood conditions. For example, there is evidence that they work in antibiotic-related diarrhoea, necrotising enterocolitis and possibly infantile colic. So if the diarrhoea that occurs in straightforward viral gastroenteritis is partly due to an altered intestinal microbiome, would you expect them to help this as well? You might, but two robust new studies suggest that they don’t. The NEJM published two large randomised double-blind placebo-controlled …

La producción de biopelículas por Haemophilus influenzae y Streptococcus pneumoniae se ha relacionado con la patogénesis de la otitis media, principalmente en casos crónicos y recurrentes. Se estudió “in vitro” la producción de biopelículas por estas 2 especies aisladas en solitario o juntas de la nasofaringe de niños con otitis media aguda. En general, 89/94 (94.6%) de los casos con aislamiento combinado de S. pneumoniae o H. influenzae mostraron producción de biopelículas. Este estudio enfatiza la alta proporción de producción de biopelículas por cepas de H. influenzae y S. pneumoniae aisladas de la nasofaringe de niños con otitis media aguda, lo que refuerza los resultados de estudios que sugieren la importancia de las biopelículas en la patogénesis de la otitis media aguda.

Resumen: Las infecciones respiratorias agudas (IRA) representan una causa importante de morbilidad y mortalidad en los niños, y siguen siendo un importante problema de salud pública, y afectan especialmente a los niños menores de 5 años de países de bajos ingresos. Se realizó un análisis de datos secundarios de un estudio transversal previo realizado en niños con un diagnóstico probable de tos ferina desde enero de 2010 hasta julio de 2012. Todas las muestras se analizaron mediante reacción en cadena de la polimerasa (PCR) para las siguientes etiologías: Influenza-A, Influenza -B, RSV-A, RSV-B, Adenovirus, virus Parainfluenza 1, virus Parainfluenza 2, virus Parainfluenza 3, Mycoplasma pneumoniae y Chlamydia pneumoniae En un total de 288 pacientes el patógeno aislado más común fue el adenovirus (49%), seguido de Bordetella pertussis (41%), neumonía por Mycoplasma (26%) y la Influenza B (19,8%). Las coinfecciones se informaron en el 58% de las muestras y la asociación más común se encontró entre B. pertussis y Adenovirus (12.2%).

Hubo una alta prevalencia de adenovirus, Mycoplasma pneumoniae y otras etiologías en pacientes con un diagnóstico probable de tos ferina. A pesar de la presencia de tos persistente que dura por lo menos dos semanas y otras características clínicas altamente sospechosas de tos ferina, se deben considerar las etiologías secundarias en niños menores de 5 años para brindar un tratamiento adecuado.

Objective Traveller’s diarrhoea (TD) is one of the most frequent illnesses affecting children returning from tropical countries. The purpose of this study was to assess the distribution of pathogens associated with TD in children using a multiplex PCR assay on stool samples.

Design All the children admitted for TD in two university hospitals from 1 August to 15October during 2014 and 2015 were included in a prospective study. Stool samples were tested by a multiplex PCR FilmArray GI panel detecting 22 pathogens. Performances for the detection of major enteropathogenic bacteria (Salmonella, Shigella and Campylobacter spp) by multiplex PCR and conventional culture methods were compared. The prevalence of extended spectrum beta-lactamase (ESBL)-producing Enterobacteriaceae was also determined.

Results Fifty-nine children were included. In 58 cases (98%), at least one pathogen was identified, including 9 different enteropathogenic bacteria, 5 viruses and 2 parasites. Multiplex PCR enhanced the enteropathogenic bacteria detection by 25%. The most frequent pathogens were enteroaggregative Escherichia coli (n=32), enteropathogenic E. coli (n=26), enterotoxigenic E. coli (n=19), Salmonella enterica, enteroinvasive E. coli/Shigella (n=16 each), Cryptosporidium, sapovirus (n=11 each), Campylobacter jejuni, norovirus (n=10 each), rotavirus (n=9), Giardia (n=8) and Shiga-toxin-producing E. coli (n=4). Fifty-two coinfections were observed, notably including bacteria and viruses (n=21), multiple bacteria (n=14), or bacteria and parasites (n=10). ESBL were detected in 28 cases. Multiplex PCR could optimise the number of treated patients by 27% compared with stool cultures.

Conclusion Multiplex PCR on stools revealed a high prevalence of diverse enteric pathogens and coinfections in children with TD. Major enteropathogenic bacteria were more frequently detected by multiplex PCR compared with conventional culture. Finally, this technique allows the start of appropriate and early antibiotic treatment and seems to optimise the number of correctly treated patients.

Background: Outpatient parenteral antimicrobial therapy offers the option of treating children requiring intravenous antibiotics for acute urinary tract infection (UTI)/pyelonephritis at home. We aimed to determine the outcomes of treating patients with UTI/pyelonephritis using outpatient parenteral antimicrobial therapy directly from the emergency department (ED) without admission to hospital.

Methods: This was a retrospective study (August 2012–July 2016) of children with UTI/pyelonephritis treated with parenteral antibiotics via a peripheral cannula directly from ED to home under a hospital-in-the home (HITH) program. Data collection included demographics, clinical features, length of stay, complications, and readmissions to hospital.

Results: There were 62 patient episodes of UTI/pyelonephritis transferred directly from ED to HITH. Fifty-eight (94%) had systemic features including fever, vomiting and/or tachycardia. Eighteen (29%) patients had an underlying condition. Nine (15%) received intravenous fluids and 8 (13%) antiemetics in ED. The outpatient parenteral antimicrobial therapy course was successfully completed in 56 (90%) patients. Of 6 (10%) patients who were readmitted, 2 were discharged within 24 hours, and none were severely unwell. Two (3%) had a blocked cannula, with no antibiotic complications. HITH patients were treated for a combined total of 142 days at home resulting in a cost saving of Australian dollar 108,914 (US dollar 82,775). However, only 8% of children deemed to require a course of intravenous antibiotics were transferred directly home from ED. Compared with patients concurrently admitted to hospital, fewer on HITH were less than 1 year of age (13% vs. 33%; odds ratio: 0.3; P < 0.01).

Conclusions: Selected patients presenting to ED with UTI/pyelonephritis may be treated directly via HITH, including some with underlying conditions and/or systemic features.

·Risk Factors for Delayed Antimicrobial Treatment in Febrile Children with Urinary Tract Infections. J Pediatr. 2019 Feb;205:126-129.

To identify factors associated with delayed antimicrobial treatment in febrile children with urinary tract infection (UTI).

We reviewed data from 802 children with UTI enrolled in 2 previously conducted prospective studies (Randomized Intervention for Children with Vesicoureteral Reflux and Careful Urinary Tract Infection Evaluation) and extracted data on possible predictors of delayed treatment including age, sex, history of UTI, ethnicity, race, primary caregiver's education level, insurance, and income. We used univariate and multivariable analyses to investigate the relationship between these predictors and treatment delay.

We included 660 febrile patients with a mean age of 17.0 months old. Older age and commercial insurance were associated with delayed treatment on univariate analysis. Compared with younger children, treatment was delayed by an average of 26.2 hours in children ≥12 months of age. This relationship remained significant on multivariable analysis. Treatment also was delayed by an average of 12.6 hours in patients with commercial insurance. Race, ethnicity, primary caregiver's education level, and income were not associated with delayed treatment.

Conclusions

Older age was a consistent predictor of delayed antimicrobial treatment. Delays in the initiation of antimicrobial therapy for UTI has previously been associated with renal scarring. Educating parents with older children regarding the management of fever as well as providers regarding prompt evaluation and management may help to reduce renal scarring.

Resumen: en una revisión sistemática sobre 565 estudios en relación a resistencias antibióticas y factores relacionados, encuentran que los factores principalmente relacionados son la exposición previa a antibióticos, padecer alguna enfermedad subyacente y haber sido sometido a procedimientos invasivos. LA transmisión a través de alimentos de origen animal y la transmisión a través de aguas no limpias, estuvieron también con frecuencia implicadas.

Resumen: Análsisi de ventas de antibiótico de 70 países para niños, en función de la calificación de la OMS en grupos (AWaRe: Access, Watch y Reserve). LA prescripción en España sale muy bien parada comparativamente con el resto de paises, ya que presecribimos gran cantidad de antibióticos del grupo access, siendo el 4º pais (Tras Eslovenia, Hoanda y Brasil) en mejor adecuación de la prescripción a la propuesta de la OMS de los grupos AWaRe

Background: The Antibiotic Resistance Monitoring in Ocular Microorganisms (ARMOR) study is a nationwide longitudinal antibiotic resistance surveillance program specific to bacterial pathogens commonly encountered in ocular infections. We evaluated in vitro resistance rates and trends among isolates obtained from pediatric patients (≤17 years of age).

Methods: Clinical centers across the United States were invited to submit ocular isolates of Staphylococcus aureus, coagulase-negative staphylococci (CoNS), Streptococcus pneumoniae, Haemophilus influenzae and Pseudomonas aeruginosa to a central laboratory. Minimum inhibitory concentrations for various antibiotic classes were determined by broth microdilution per Clinical and Laboratory Standards Institute guidelines and interpreted as susceptible, intermediate or resistant based on available breakpoints. Longitudinal trends were analyzed using a Cochran-Armitage test for linear trends in a proportion.

Results: Of 4829 isolates collected from January 2009 to December 2016, 995 isolates, sourced primarily from hospitals and referral centers, were obtained from pediatric patients (n = 286 H. influenzae, n = 284 S. aureus, n = 213 CoNS, n = 150 S. pneumoniae and n = 62 P. aeruginosa). With few exceptions, P. aeruginosa and H. influenzae were generally susceptible to the antibiotics tested. Of S. aureus and CoNS isolates, respectively, 56% and 72% were resistant to azithromycin and 24% and 47% were methicillin-resistant (MR); concurrent resistance to other drug classes and multidrug resistance (≥3 drug classes) were prevalent among MR staphylococci. Of S. pneumoniae isolates, 38% and 35% demonstrated resistance to azithromycin and penicillin, respectively. Besifloxacin had the lowest minimum inhibitory concentration against the Gram-positive isolates.

Conclusions: These in vitro data suggest antibiotic resistance is common among staphylococcal and pneumococcal isolates collected from pediatric patients with ocular infections. Methicillin resistance was prevalent among staphylococci with many strains demonstrating multidrug resistance. These findings may not be representative of resistance trends in community-based practices.

CONCLUSIONES: En este estudio, en el que se muestran las tendencias del VPH en una comunidad de EE. UU.> 10 años después de la introducción de la vacuna 4-valente contra el VPH y después de la introducción de la vacuna 9-valente, se encontró evidencia de la efectividad de la vacuna y  protección de rebaño. Se necesita más investigación para evaluar las tendencias en la vacuna VPH 9-valente después de alcanzarse mayores tasas de vacunación de esta última.

CONCLUSIONES: A partir de este análisis de datos individuales agrupados a nivel de pacientes, encontramos una reducción de efectividad de LAIV4 contra la influenza A / H1N1pdm09 en comparación con la vacuna inactivada, que es consistente con los resultados publicados de los estudios individuales incluidos.

·Is primary meningococcal arthritis in children more frequent than we expect? Two pediatric case reports revealed by molecular test. BMC Enfermedades Infecciosas 2018 18 : 703

La presentación clínica de los dos niños (6 y 9 años) se caracterizó por signos de artritis. Por reacción en cadena de la polimerasa en tiempo real (RT-PCR), identificamos el serogrupo Y de N. meningitidis en el líquido articular en ambos casos. Después del tratamiento antimicrobiano específico, las condiciones clínicas de los dos pacientes mejoraron rápidamente durante la hospitalización. Conclusiones. Creemos que la incidencia de la artritis meningocócica se puede subestimar en los entornos donde el uso de la RT-PCR es limitado

La artritis meningocócica primaria es una enfermedad infecciosa rara que ocurre en menos del 3% de las infecciones meningocócicas y se caracteriza por artritis sin meningitis, fiebre, erupción o inestabilidad hemodinámica. Es una forma infrecuente de enfermedad meningocócica que se presenta como artritis séptica aislada sin ningún otro signo de enfermedad meningocócica invasiva (EMI). Es clínicamente imposible diferenciar la AMP de otros tipos de artritis séptica. El cultivo de líquido sinovial y las pruebas moleculares son fundamentales para la confirmación de la AMP. Se discuten dos casos de AMP diagnosticados por reacción en cadena de polimerasa en tiempo real (RT-PCR) luego del ingreso de dos niños en enero y marzo de 2017.

·Chest physiotherapy for pneumonia in children. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD010277. DOI: 10.1002/14651858.CD010277.pub3

We included three new RCTs for this update, for a total of six included RCTsinvolving 559 children aged from 29 days to 12 years with pneumonia who were treated as inpatients. Pneumonia severity was described as moderate in one trial, severe in two trials, and was not stated in three trials. The studies assessed five different interventions: effects of conventional chest physiotherapy (3 studies, 211 children), positive expiratory pressure (1 study, 72 children), continuous positive airway pressure (CPAP) (1 study, 94 children), bubble CPAP (bCPAP) (1 study, 225 children), and assisted autogenic drainage (1 studies, 29 children). The included studies were conducted in Bangladesh, Brazil, China, Egypt, and South Africa. The studies were overall at low risk of bias. Blinding of participants was not possible in most studies, but we considered that the outcomes were unlikely to be influenced by the lack of blinding.

We could draw no reliable conclusions concerning the use of chest physiotherapy for children with pneumonia due to the small number of included trials with differing study characteristics and statistical presentation of data. Future studies should consider the following key points: appropriate sample size with adequate power to detect expected differences, standardisation of chest physiotherapy techniques, appropriate outcomes (such as duration of leukocytosis, and airway clearance), and adverse effects.

·Adverse events in people taking macrolide antibiotics versus placebo for any indication. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD011825. DOI: 10.1002/14651858.CD011825.pub2

People treated with a macrolide antibiotic experienced gastrointestinal adverse events such as nausea, vomiting, abdominal pain, and diarrhoea more often than those treated with placebo.

Taste disturbances were reported more often by people taking macrolides than those taking a placebo. However, as very few studies reported on these adverse events, these results should be interpreted with caution.

Hearing loss was reported more often by people taking macrolide antibiotics, however only four studies reported this outcome.

Macrolides caused less cough and fewer respiratory tract infections than placebo.

We did not find any evidence that macrolides caused more cardiac disorders, liver disorders, blood infections, skin and soft tissue infections, changes in liver enzymes, appetite loss, dizziness, headache, respiratory symptoms, itching, or rashes than placebo.

We did not find more deaths in people treated with macrolides than in those treated with placebo.

Very limited information was available to assess if people treated with a macrolide antibiotic were at greater risk of developing resistant bacteria than those treated with placebo. However, bacteria that did not respond to macrolide antibiotics were more commonly identified immediately after treatment in people taking a macrolide than in those taking a placebo, but differences in resistance thereafter were inconsistent.

·Antiamoebic drugs for treating amoebic colitis. Cochrane Database of Systematic Reviews 2019, Issue 1. Art. No.: CD006085. DOI: 10.1002/14651858.CD006085.pub3

This review included 41 studies, most of which were conducted in countries considered to be highly endemic for amoebiasis. Most trials were old: 30 were conducted before 1998. Trials varied in the inclusion criteria used to enrol participants and in the definition and timing of measured outcomes. Stool microscopy with direct wet saline smear was the method used most often to detect the presence of E histolytica in stools. Study participants ranged in age from seven months to 80 years. Included trials reported a variety of comparisons and involved 25 individual drugs, two herbal products, and 15 different combinations.

The review shows that in individuals with amoebic colitis, tinidazole may be better for reducing clinical symptoms (low-certainty evidence) and probably results in fewer adverse events when compared with metronidazole (moderate-certainty evidence). However, we do not know whether it is more effective for eradicating amoebae from the stools. Combination drug therapy may be more effective than metronidazole alone for eradicating amoebae (low-certainty evidence), but we are uncertain which drug combination is most effective, and if combination treatment will lead to more rapid resolution of clinical symptoms or in more adverse events (very low-certainty evidence). Evidence is insufficient to allow conclusions regarding efficacy of the other antiamoebic drugs.

·Adenovirus-Associated Central Nervous System Disease in Children. J Pediatr. 2019 Feb;205:130-137

To characterize the spectrum and salient clinical features of adenovirus-associated neurologic disease in immunocompetent children.

Study design

Previously healthy children (aged 1 month-18 years) with central nervous system (CNS) disease associated with adenovirus infection were identified via the Encephalitis Registry (1996-2016) and Microbiology Database (2000-2016) at The Hospital for Sick Children, Toronto, and by systematic review of the literature. The data were pooled and analyzed to identify the spectrum of illness, clinical outcome, and risk factors for death or neurologic impairment.

Results

Neurologic complications associated with adenovirus infection in our institution included febrile seizures, encephalitis, acute disseminated encephalomyelitis, and aseptic meningitis. A total of 48 immunocompetent children with adenovirus-associated CNS disease were included in the pooled analysis—38 from the literature and 10 from our institution. In 85% of cases, the virus was detected in the respiratory or gastrointestinal tract, but not the cerebrospinal fluid. Eighteen of the 48 (38%) patients either died or suffered permanent neurologic sequelae. Predictors of adverse outcome included younger age, coagulopathy, the absence of meningismus, serotype 2 virus, and the presence of seizures. After multivariable adjustment, only seizures remained a significant risk factor.

Conclusion

Adenovirus is a rare cause of CNS disease in immunocompetent children. Disease spectrum is variable, ranging from mild aspetic meningitis and fully reversible encephalopathy to severe, potentially fatal, acute necrotizing encephalopathy.

Resumen: las infeciones por paraecovirus son la segunda causas más probable de meningitis viral en niños, principalmente en menores de 90 días. Esta revisión pretende ofrecer una propuesta sobre el conocimiento de la infección, sus manifestaciones clínicas y los procedimientos diagnósticos, para favorecer su abordaje basado en la evidencia y desvelar las principales prioridades en investigación. Las manifestaciones clínicas incluyen encefalitis, meningitis, miocarditis y septicemia que pueden determinar importantes secuelas neurológicas en lactantes pequeños. EL diagnóstico se puede hacer mediante PCR para detectar trazas de ácido nucléico del virus.

·Longitudinal Association Between Human Parechovirus Central Nervous System Infection and Gross-Motor Neurodevelopment in Young Children. The Pediatric Infectious Disease Journal. 38(2):110-114

Background: A paucity of studies investigated the association between human parechovirus (HPeV) central nervous system (CNS) infection and motor and neurocognitive development of children. This study describes the gross-motor function (GMF) in young children during 24 months after HPeV-CNS infection compared with children in whom no pathogen was detected.

Methods: GMF of children was assessed with Alberta Infant Motor Scale, Bayley Scales of Infant and Toddler Development or Movement Assessment Battery for Children. We conducted multivariate analyses and adjusted for age at onset, maternal education and time from infection.

Results: Of 91 included children, at onset <24 months of age, 11 had HPeV-CNS infection and in 47 no pathogen was detected. Nineteen children were excluded because of the presence of other infection, preterm birth or genetic disorder, and in 14 children, parents refused to consent for participation. We found no longitudinal association between HPeV-CNS infection and GMF (β = −0.53; 95% confidence interval: −1.18 to 0.07; P = 0.11). At 6 months, children with HPeV-CNS infection had suspect GMF delay compared with the nonpathogen group (mean difference = 1.12; 95% confidence interval: −1.96 to −0.30; P = 0.03). This difference disappeared during 24-month follow-up and, after adjustment for age at onset, both groups scored within the normal range for age. Maternal education and time from infection did not have any meaningful influence.

Conclusions: We found no longitudinal association between HPeV-CNS infection and GMF during the first 24-month follow-up. Children with HPeV-CNS infection showed a suspect GMF delay at 6-month follow-up. This normalized during 24-month follow-up.

Los parechovirus humanos (HPeV) son unos virus sin envoltura y altamente resistes a las condiciones ambientales que presentan un genoma ARN y pertenecen a la familia Picornaviridae. Se han descrito 16 tipos distintos aunque los HPeV-1, 2 y 3 parecen ser los que presentan un mayor tropismo por el ser humano. La mayoría de infecciones causadas por estos virus son leves (síndromes febriles, cuadros respiratorios) aunque pueden llegar a determinar procesos sépticos y afectaciones del sistema nervioso central. Afectan preferentemente a la población infantil con una edad inferior a los 2 meses [1,2]. Existe en nuestro país todavía pocos estudios

·Comparing the Clinical Severity of Disease Caused by Enteroviruses and Human Parechoviruses in Neonates and Infants. The Pediatric Infectious Disease Journal. 38(2):e36-e38

Enteroviruses (EVs) are well-known causes of sepsis in neonates and infants. In recent years, the extent to which parechoviruses may be contributing to neonatal and infant morbidity and mortality has begun to emerge.1–3

EVs and human parechoviruses (HPeVs) are nonenveloped, single-stranded, positive-sense RNA viruses and members of the Picornavirus family. They are common causes of neonatal and infant sepsis, worldwide.

EVs exist as multiple serotypes, subdivided into various genus, including echoviruses, Coxsackie A and B viruses and the numbered EVs. HPeVs exist in at least 17 genotypes, of which genotypes 1–6 are most commonly found in humans, with genotype 3 being most commonly responsible for sepsis in neonates and infants.

Whereas most episodes of EV and HPeV neonatal and infant sepsis are self-limiting, more severe illness can occur, and there are current concerns regarding longer term sequelae, particularly in HPeV infections, where there is more significant neurologic involvement. Previous studies have found that the clinical presentation of the 2 viruses are often indistinguishable.1 , 3

Our diagnostic virology laboratory has only recently (since mid 2014) introduced routine testing for parechoviruses as part of our neonatal and infant sepsis workup. We examined the demographics, laboratory results and clinical notes for pediatric patients admitted with sepsis with laboratory-confirmed human EV or HPeV infections of the cerebrospinal fluid (CSF), during February 2014 to August 2017.

·Implementing Universal Varicella Vaccination in Europe: The Path Forward. The Pediatric Infectious Disease Journal. 38(2):181-188

Varicella is a common vaccine-preventable disease that usually presents as a mild disorder but can lead to severe complications. Before the implementation of universal varicella vaccination (UVV) in some European countries, the burden of varicella disease was broadly similar across the region. Despite this, countries adopted heterogeneous varicella vaccination strategies. UVV is currently recommended in 12 European countries. Known barriers to UVV implementation in Europe include (1) a perceived low disease burden and low public health priority; (2) cost-effectiveness and funding availability; (3) concerns related to a shift in varicella disease and incidence of herpes zoster and (4) safety concerns related to measles, mumps, rubella and varicella–associated febrile seizures after the first dose. Countries that implemented UVV experienced decreases in varicella incidence, hospitalizations and complications, showing overall beneficial impact. Alternative strategies targeting susceptible individuals at higher risk of complications have been less effective. This article discusses ways to overcome the barriers to move varicella forward as a truly vaccine preventable disease.

Existe una controversia sobre el efecto potencial de la vacunación infantil contra la varicela en la incidencia de Herpes Zoster (HZ). El objetivo de este estudio es explorar el efecto de varias suposiciones sobre el aumento de la inmunidad VZV exógena y endógena en la incidencia de HZ en la población general después de la introducción de la vacunación rutinaria contra la varicela infantil. Una posible razón de la disparidad entre los modelos matemáticos y los datos epidemiológicos puede deberse al papel del refuerzo endógeno, resultante de la reactivación asintomática del VZV [ 17 , 34 ], desde el modelo inicial de Brisson et al. y modelos posteriores, enfocados solo en el refuerzo exógeno. Por lo tanto, el refuerzo endógeno podría explicar en parte la divergencia entre la evidencia del mundo real sobre la carga de HZ en los países que utilizan la vacunación contra la varicela infantil y las proyecciones de modelos basadas en supuestos de aumento exógeno.

Las infecciones respiratorias agudas (IRA) de etiología viral son una entidad que predomina en la edad pediátrica. Aunque las causadas por el VRS y los virus gripales son las prevalentes en la época invernal, las técnicas de amplificación molecular ha permitido comprobar que el 20-40% son coinfecciones1,2.

Durante el período 2014-2017 se ha estudiado la presencia de virus respiratorios en todos los pacientes < 2 años con sospecha de IRA, tanto de vías altas como bajas, que acudían a urgencias. La detección de los virus respiratorios se realizó mediant RT-PCR múltiple (Anyplex™ RV16, Seegen, Corea) que detecta de forma simultánea y diferencial 16 virus distintos.

A lo largo del estudio se han detectado 803 casos de gripe: gripe A 64,1% y gripe B 25,9%; así mismo se han detectado 992 casos de infección por el VRS: VRS-A 59,2% y VRS-B 40,8%.

Los casos de coinfección entre los virus gripales y el VRS han sido 48. Los 48 casos han representado el 5,9% de todos los virus gripales detectados (89,5% tipo A). Los casos de coinfección por el VRS representaron el 4,8% de todos los VRS ( 62,5% VRS-B).

El 58,3% de los casos se presentaron en menores de un año. El 43,7% de los casos se presentaron en diciembre, el 25% en enero, el 14,5% en febrero, el 12,5% en noviembre y el 4,1% en marzo.

Las IRA en estos pacientes fueron: síndrome gripal (41,6%), bronquiolitis (31,3%), bronquitis (18,7%) y neumonía (8,3%). Precisaron ingreso hospitalario 11 casos y ninguno falleció.

EN las últimas temporadas hemos observado una elevada incidencia del VRS-B representando cerca del 58%. Esta tendencia explicaría el mayor número de coinfecciones observado entre los virus gripales y el VRS-B (62,5%).

El virus gripal B, a pesar de que afectan preferentemente a la población infantil, es el que ha mostrado un menor número de coinfecciones (10,5%); este dato podría deberse a que este virus se presenta a partir de edades superiores a las del VRS4.

Parece pues que la asociación entre los virus gripales y el VRS es una entidad que se presenta con una incidencia muy baja y que es difícil de interpretar desde el punto de la implicación patogénica directa en las IRA en los menores de un año.

Introducción. La bronquiolitis aguda (BA) es una de las enfermedades respiratorias más frecuentes en los lactantes. Sin embargo, los criterios utilizados para su diagnóstico son heterogéneos. Métodos: Estudio de metodología Delphi con expertos españoles en BA, buscando los puntos de consenso sobre el diagnóstico de BA. Posteriormente se realizó un estudio transversal mediante encuesta on-line dirigida a todos los pediatras españoles, contactados a través de correo electrónico enviados por nueve sociedades científicas pediátricas. Se hizo análisis descriptivo y factorial de los resultados de la encuesta, buscando si los criterios diagnósticos empleados se relacionaban con variables demográficas, geográficas o con la subespecialidad pediátrica. Resultados: Los 40 expertos participantes alcanzaron un consenso en muchos aspectos (primer episodio de dificultad respiratoria y aumento de la frecuencia respiratoria, diagnóstico en cualquier estación del año, y utilidad de la identificación de virus para el diagnóstico), pero manteniendo opiniones enfrentadas en cuestiones importantes como la edad máxima aceptable para el diagnóstico. A la encuesta on-line respondieron 1297 pediatras. Los criterios diagnósticos que aplican son heterogéneos y están fuertemente asociados con la subespecialidad pediátrica. Su acuerdo con el consenso de expertos y con estándares internacionales es muy bajo. Conclusiones.Los criterios usados en España para el diagnóstico de BA son heterogéneos. Esas diferencias pueden causar variabilidad en la práctica clínica.

·BCG Vaccination and All-Cause Neonatal Mortality. The Pediatric Infectious Disease Journal. 38(2):195-197

Introducción. Helicobacter pylori constituye un problema de salud mundial principalmente por el elevado porcentaje de infección y la ineficacia en los tratamientos. Para prevenir la infección resulta clave conocer la edad de adquisición.

Pacientes. Participaron 67 madres y sus respectivos hijos. Para evaluar la presencia de H. pylori, las deposiciones de la madre y de su hijo fueron analizadas mediante el test HpSA.

Resultados. El 71,6% (48/67) de las embarazadas a término fueron H. pylori positivas. En los recién nacidos, el 8,96% (6/67) de ellos presentaron colonización/infección persistente para H. pylori. Durante el primer mes de vida se observó una prevalencia e incidencia de infección del 23,9 y 13%, respectivamente.

Conclusión. Los resultados, en conjunto, sugieren que durante el primer mes de vida existe un alto riesgo de infección por H. pylori, pudiendo ser esta incluso de tipo persistente.

Background: Coccidioidomycosis is not as well described in the pediatric population as it is in the adult population. We describe clinical findings, diagnosis and management of coccidioidomycosis in 108 pediatric patients seen in an outpatient clinic in the California Central Valley, an area endemic for coccidioidomycosis.

Methods: We reviewed medical records of a convenience sample of pediatric patients (≤17 years of age) diagnosed with coccidioidomycosis who visited an infectious diseases clinic in Madera, CA, during January 1 to October 1, 2012. We described demographic characteristics, symptoms, diagnostic testing, extent of infection (acute/pulmonary or disseminated), treatment and management.

Results: Of 108 patients, 90 (83%) had acute/pulmonary coccidioidomycosis and 18 (17%) had disseminated disease. The median age at diagnosis was 9 years (range, 5 months to 17 years). Only 3 (3%) patients were immunocompromised. Before coccidioidomycosis diagnosis, 72 (82%) patients received antibiotics, and 31 (29%) had at least 1 negative coccidioidomycosis serology at the time of or before diagnosis. Coccidioidomycosis was diagnosed significantly later after symptom onset among patients with disseminated (median, 57 days) than with acute/pulmonary (median, 16 days) disease (p < 0.01). A total of 104 (96%) patients received antifungal therapy, 51 (47%) visited an emergency room and 59 (55%) were hospitalized with a median stay of 44 days (range, 1–272 days).

Conclusions: Substantial acute/pulmonary and disseminated coccidioidomycosis was seen among pediatric patients at this infectious disease clinic in California. In endemic areas, increased coccidioidomycosis awareness and vigilance among families and providers is necessary to facilitate early diagnosis and appropriate management.

Objective To describe the risk of death and hospitalisation until adolescence of children after group B streptococcus (GBS) infection during infancy.

Design Population-based cohort study.

Setting New South Wales, Australia.

Patients All registered live births from 2000 to 2011.

Interventions Comparison of long-term outcomes in children with the International Statistical Classification of Diseases and Related Health Problems-10th Revision discharge codes corresponding to GBS infections and those without.

Main outcome measures Death and hospitalisation.

Results A total of 1206 (0.1%) children (936 (77.6%)≥37 weeks’ gestation) were diagnosed with GBS infection. Over the study period, infection rates decreased from 2.1 (95% CI 1.8 to 2.4) to 0.7 (95% CI 0.5 to 0.9) per 1000 live births. Infants with GBS infection were born at lower gestation (mean 37.6 vs 39.0 weeks), were more likely very low birth weight (<1500 g, OR 9.1(95% CI 7.4 to 11.3)), born premature (OR 3.9(95% CI 3.4 to 4.5)) and have 5 min Apgar scores ≤5 (OR 6.7(95% CI 5.1 to 8.8)). Children with GBS had three times the adjusted odds of death (adjusted OR (AOR) 3.0(95% CI 2.1 to 4.3)) or rehospitalisations (AOR 3.1(95% CI 2.7 to 3.5)). Thirty-six (3.0%) with GBS died, with >50% of deaths occurring <28 days. Children with GBS were hospitalised more frequently (median 2 vs 1), for longer duration (mean 3.7 vs 2.2 days) and were at higher risk for problems with genitourinary (OR 3.1(95% CI 2.8 to 3.5)) and nervous (OR 2.0 (95% CI1.7 to 2.3)) systems.

Conclusions Despite decreasing GBS rates, the risk of poor health outcomes for GBS-infected children remains elevated, especially during the first 5 years. Survivors continue to be at increased risk of death and chronic conditions requiring hospitalisations, such as cerebral palsy and epilepsy.

The fetal repercussions of Zika virus (ZIKV) infection during pregnancy is of interest for maternal and child health.1 Studies on the psychomotor and neurodevelopment of children exposed in utero to arboviruses, especially non-microcephalic children, are lacking. At a maternity university hospital in Brazil, we started following the development of children, without microcephaly, born to mothers infected with ZIKV during pregnancy, searching for early warning signs of abnormalities. A normal head circumference for term newborns was defined, according to the 2016 WHO recommendation, as higher than 31.9 cm for boys and higher than 31.5 cm for girls.2 We used the Alberta Infant Motor Scale for the evaluation of motor development, and the Denver II test for tracking development in personal/social, fine motor/adaptive, language …

Short individualised treatment of paediatric bone and joint infections, based on clinical and laboratory response, has the potential to reduce the duration of antibiotic therapy, but only few data exist on this treatment.1–4 In Denmark, short individualised treatment was recommended from 2012.

This is a retrospective study of all children aged 3 months to 16 years with bone and joint infections treated between 2012 and 2016 at two paediatric departments in Copenhagen. Children with osteomyelitis (OM) were included if the diagnosis was confirmed by MRI, positron emission tomography-CT, technetium bone scintigraphy or X-ray. Children with septic arthritis (SA) …

·Screening and Serial Neutrophil Counts Do Not Contribute to the Recognition or Diagnosis of Late-Onset Neonatal Sepsis. J Pediatr. 2019 Feb;205:105-111

Objective

To determine the validity of screening and serial neutrophil counts in predicting the absence/presence of late-onset sepsis (LOS) in infants with central venous catheters.

Study design

Retrospective study of infants admitted to the neonatal intensive care unit (2009-2013) at Parkland Hospital with a central venous catheter and ≥1 LOS evaluations. Infants were categorized as proven or suspect LOS or uninfected based on results of blood cultures, clinical illness, and duration of antibiotics. Receiver operating curves (ROCs) were constructed to predict the absence or presence of LOS using Manroe reference ranges for total and immature neutrophils and the immature to total neutrophil ratio at 0, 12, and 24 hours after blood culture and the neutrophil value score, which assesses serial values.

Results

Of the 497 infants with a central venous catheter, 179 underwent ≥1 LOS evaluations, and 140 of 179 (78%) had ≥1 complete evaluations (2 blood cultures and neutrophil values at 0, 12, and 24 hours), resulting in 188 complete LOS evaluations. The gestational age was 28 ± 4 weeks and LOS evaluation occurred at 29 ± 34 days (SD; 4-197 days). Sixty-one (35%) infants had proven LOS, 48 (23%) were suspect, and 71 (38%) were noninfected. ROC comparing proven vs noninfected was ≤0.56 for total neutrophils, immature neutrophils, and immature to total neutrophil ratio at 0, 12, and 24 hours and similar for proven + suspect vs noninfected. ROC for neutrophil value scores and absence of LOS was 0.56.

Conclusions

Screening neutrophil values are poor predictors of LOS in neonates with a central venous catheter, as are serial neutrophils and the neutrophil value score. Alternative biomarkers are needed.

·Maternal Education Is Inversely Related to Vaccination Delay among Infants and Toddlers. J Pediatr. 2019 Feb;205:120-125

Objective

To determine the association between parents' level of education and delay in vaccination among infants and toddlers.

Study design

A case–control study done in 2015-2016. Charts of 2- to 4-year-old children vaccinated in 5 neighborhood Maternal-Child Health Centers (MCHCs) in southern Israel were examined for demographic variables. Five vaccination opportunities between age 7 months and 18 months were selected to test for delays. In each MCHC, children vaccinated at the longest time-period after planned vaccination dose (fifth quintile) were compared with those vaccinated during the middle quintile. Using this relative delay approach rather than absolute delay approach permitted us to adjust the findings to the prevailing environmental and to cultural and programmatic variations between the various neighborhoods. Each of the planned vaccination visits and overall, demographic and health behavior-related variables that were significantly associated to delays by univariate analysis were tested by multivariate analysis and further adjusted by using stepwise logistic regression, using goodness of fit measures.

Results

Data for 2072 subjects were collected (398-426 per MCHC). Fathers' education was not associated with delays. In contrast, mothers' education was inversely associated with the probability of vaccination delay by 4%-9% (depending on the vaccination visit) for each year of schooling beyond 10 years.

Conclusion

Using the relative delay approach, we demonstrated that maternal education, measured by schooling years, was independently inversely associated with risk of vaccination delay. This suggests that education can be regarded as an important positive component of the overall disease prevention planning at national and global levels.

We included three studies with a total of 122 children (62/60 in intervention/control arms) aged up to 12 months that investigated nasal CPAP compared with supportive (or "standard") therapy. We included one new trial (72 children) that contributed data to the assessment of respiratory rate and need for mechanical ventilation for this update. The included studies were single-centre trials conducted in France, the UK, and India. Two studies were parallel-group RCTs and one was a cross-over RCT. The evidence provided by the included studies was low quality; we assessed high risk of bias for blinding, incomplete outcome data, and selective reporting, and confidence intervals were wide.

The effect of CPAP on the need for mechanical ventilation in children with acute bronchiolitis was uncertain due to imprecision around the effect estimate (3 RCTs, 122 children; risk ratio (RR) 0.69, 95% confidence interval(CI) 0.14 to 3.36; low-quality evidence). None of the trials measured time to recovery. Limited, low-quality evidence indicated that CPAP decreased respiratory rate (2 RCTs, 91 children; mean difference (MD) -3.81, 95% CI-5.78 to -1.84). Only one trial measured change in arterial oxygen saturation, and the results were imprecise (19 children; MD -1.70%, 95% CI -3.76 to 0.36). The effect of CPAP on change in arterial partial carbon dioxide pressure (pCO₂) was imprecise (2 RCTs, 50 children; MD -2.62 mmHg, 95% CI-5.29 to 0.05; low-quality evidence). Duration of hospital stay was similar in both CPAP and supportive care groups (2 RCTs, 50 children; MD 0.07 days, 95% CI -0.36 to 0.50; low-quality evidence). Two studies did not report about pneumothorax, but pneumothorax did not occur in one study. No studies reported occurrences of deaths. Several outcomes (change in partial oxygen pressure, hospital admission rate (from emergency department to hospital), duration of emergency department stay, and need for intensive care unit admission) were not reported in the included studies.

 

Actualidad bibliográfica enero 2019

Top ten

En cuanto a las vacunas financiadas, se recomienda emplear el esquema 2+1 (2, 4 y 11 meses) con vacunas hexavalentes (DTPa-VPI-Hib-HB) y con antineumocócica conjugada13-valente. Se emplearán esquemas de 2 dosis para triple vírica (12 meses y 3-4 años) y varicela (15 meses y 3-4 años). La segunda dosis se podría aplicar como vacuna tetravírica.

Se recomienda vacunación sistemática universal frente al VPH, tanto a chicas como a chicos, preferentemente a los 12 años, debiéndose realizar un mayor esfuerzo para mejorar las coberturas. La nueva vacuna de 9 genotipos amplía la cobertura para ambos sexos.

Se recomienda que la vacuna antimeningocócica conjugada tetravalente (MenACWY) se introduzca en el calendario financiado a los 12 meses y a los 12-14 años, aconsejándose un rescate hasta los 19 años. Igualmente, se recomienda en los mayores de 6 semanas de edad con factores de riesgo o que viajen a países de elevada incidencia de estos serogrupos

Respecto a las vacunas no financiadas, se recomienda la antimeningocócica B, con esquema 2+1, solicitando su entrada en el calendario. Es recomendable vacunar a todos los lactantes frente al rotavirus.

A primeros del mes de diciembre del recién acabado 2018, los medios de comunicación informaron de un brote de una enfermedad exantemática entre trabajadores de un matadero en la localidad de Zuera (Zaragoza). Al final del mes, los servicios de salud pública de Aragón confirmaron que se trataba de rubeola y que el brote había afectado hasta ese momento a 12 personas. Son los primeros casos de rubeola en Aragón desde 2012, año en el que se registraron 28 casos en varias localidades de la región.

Lo destacable del caso es que este brote trunca la tendencia mostrada por la rubeola en España en los últimos años, con un total de 14 casos en el quinquenio 2013-2017, y 15 casos en 2018 (esta cifra es aún provisional).

Casos clínicos

Es un hongo dermatofito zoonótico ( pertenece a Trichophyton mentagrophytes complex). Su principal reservorio son pequeños roedores, en especial cobayas. También se ha aislado en perros y gatos. Puede causar tiña corporis, tiña faciei , querion de Celso y Excepcionalmente onicomicosis2. Se caracteriza por producir lesiones muy inflamatorias, sobre todo en niños. Además de en niños, su aislamiento es frecuente entre adolescentes e inmunodeprimidos. Al inicio de la infección, las lesiones cutáneas pueden ser confundidas con impétigo.

Niña de 3 años con lesión inflamatoria con secreción en la cabeza de 2 meses diagnosticada como querion de Celso. Inicialmente aparecieron lesiones en boca y nariz tratadas con antibiótico tóp. (sospecha de impétigo). Más tarde surgieron nuevas placas eritematosas con costra melicérica en zona parieto-occipital tratadas con mupirocina tóp. y amoxicilina-clavulánico vo. Se derivó a dermatología diagnosticándose de tiña capitis, con tto tópico: terbinafina crema y sertaconazol nitrato en gel. Antecedentes : tiña corporis del padre, poseían una cobaya, con lesiones dérmicas. Dos semanas después las lesiones abscesificaron . Se realizó drenaje c/ 48h, enviándose muestra de exudado y pelos al laboratorio. Nuevo tto itraconazol vo (62,5mg/día) + crema de miconazol/hidrocortisona durante 3 semanas.

Niña de 8 años con placa de alopecia en cuero cabelludo de más de un mes de evolución (las lesiones comenzaron en la mama izda. y se extendieron hasta el cuero cabelludo). Sus cobayas habían presentado alopecia. Se recogió muestra para cultivo y se pautó tratamiento con terbinafina 125mg/24h durante 1 mes y terbinafina crema por las mañanas más furoato de mometasona/ácido salicílico en crema por las noches.

En ambos casos, se identificó Arthroderma benhamiae .

Éste causa habitualmente afecciones leves que responden al tto tópico con ciclopirox, imidazoles o terbinafina. En los casos de afectación más extensa y tiña capitis se requiere tto v.o. En la mayoría de los casos se han usado terbinafina, griseofulvina, itraconazol o fluconazol durante un mínimo de 4-6 semanas4.

PVL genes are consistently associated with skin and soft-tissue infections2 in immunocompetent young patients .PVL toxin can be produced by both (MSSA) and MRSA strains and is associated with more severe infections, regardless of methicillin resistance.3 Case of 12-years old, healthy girl born in Venezuela with low socioeconomic status. She had been living in Spain for the last seven months. The patient started with progressive worsening flu-like symptoms, high fever and cough that progressed to haemoptysis in less than 24 h presenting sudden death at her home while sleeping. The autopsyestablished multiple organ failure after bilateral abscessed pneumonia as a cause of death. MRSA resistant to clindamycin and erythromycin, . Typing of MRSA strains was performed and detection of PVL genes by PCR: positive PVL and mecA genes.

The status of colonization of the patient's cohabitants was studied ( family members and 2 roommates from Ecuador) : swab of any suspicious lesion, nose, throat, perineum and inguinal area. Contacts underwent a five-day decolonization treatment: intranasal mupirocin ointment three times a day, gargle with an antiseptic solution and chlorhexidine 4% as liquid soap in place of body wash and shampoo. A sister of the deceased was found to be carrying MRSA in mucous, which was negative for the PVL gene. Additional measures: regular vacuuming, dusting, cleaning hard surfaces and soft furnishings with soap and water and/or 1:10 diluted bleach.

The emergence of PVL-MRSA is more recent in Spain (mainly from South America immigrants) than in the rest of Europe.1 One of the most important life-threatening conditions due to PVL-Staphylococcus aureus (PVL-SA) is hemorrhagic necrotizing pneumonia with a high mortality rate. A PVL-SA infection should be suspected if a patient with influenza-like illness associate haemoptysis, hypotension, high fever, leukopenia and/or multilobal lung infiltrates, which can be cavitated,9 especially in epidemic flu period.

Varón de 10 anos, sin antecedentes con lesión en la rodilla derecha de 4 meses sin clínica extracutáneas, tras una caída con abrasión cutánea. EF: una placa ovalada eritematosa de 6 cm, de color rojo-violáceo, con múltiples pápulas queratocostrosas de aspecto granulomatoso y sin exudación ni drenaje purulento . Inicialmente se diagnosticó como reacción a cuerpo extrano, ˜ pautándose corticoides tópicos de potencia muy alta sin objetivarse mejoría clínica. Tenía una tortuga en su domicilio con la que se había estado banando. SE tomó biopsia con punch y creció Mycobacterium marinum . Se inició tto con claritromicina (500 mg/12 h), consiguiendo la curación a los 3 meses y que se mantuvo 2 meses más. Su reservorio principal es el agua de mar y el agua estancada, siendo los principales factores de riesgo las actividades relacionadas con peces, así como el contacto con agua contaminada de acuarios, tanques de agua o piscinas= «granuloma de las piscinas o acuarios». Requiere puerta de entrada. Los cuadros diseminados o con afectación extracutánea son excepcionales, aunque localmente puede producir sinovitis u osteomielitis. El tto de elección es la antibioterapia sistémica empírica ( antibiograma si fracaso terapéutico). En aquellos casos con lesiones únicas, la exéresis quirúrgica puede ser una opción . Los fármacos más empleados son minociclina, doxiciclina, claritromicina, etambutol, rifampicina y cotrimoxazol (claritromicina = primera elección). La duración recomendada del tratamiento es de 6 meses o al menos hasta 2 meses tras curación . En los casos con afectación osteotendinosa se recomienda combinación de mín. 2 fármacos,: claritromicina junto con rifampicina o etambutol, precisando muchas veces el desbridamiento y mayor duración.

Cat-scratch disease (CSD) is a zoonotic infection caused by Bartonella henselae that usually results in lymphadenopathy.1 Although uncommon, CSD can also present as bone lesions.2

A 2-year-old girl was hospitalised for a fever of an unknown cause for >10 days. Physical examination revealed non-tender bilateral cervical lymphadenopathy. Tosufloxacin was administered. On the 12th day of hospitalisation, her fever resolved, but her mother noticed the child’s unusual gait. MRI revealed multiple small …

Para profundizar

Hemos leído con interés el artículo de Cano-Portero et al.1 sobre la epidemiología de la tuberculosis (TB) en Espana˜ en el ano˜ 2015. Según los autores, se declararon 335 casos de TB en menores de 15 anos ˜ en Espana. ˜ Sus datos difieren del Informe del ECDC del mismo año (270 casos pediátricos). Esta discrepancia senala ˜ la necesidad de mejorar la coordinación institucional para determinar con precisión el alcance de la TB pediátrica en nuestro país.

Espana˜ es un país de baja prevalencia de TB, con una incidencia de 10,5/100.000 habitantes en 2015, y un 7% de casos pediátricos. La TB infantil todavía es un problema significativo en nuestro medio, siendo Espana˜ el país de Europa Occidental con más casos pediátricos. Los niños ˜ son especialmente vulnerables a la TB, con mayor riesgo de desarrollar formas graves, especialmente los menores de 2 anos, ˜ donde la tasa de progresión alcanza el 50%3. En la cohorte pTBred (Red Espanola ˜ de TB Pediátrica (pTBred)4, 2014, integrada en la Red Europea pTBnet) hemos profundizado en el origen de los casos: país de nacimiento del 98,4% de los ninos ˜ (81,1% espanoles) ˜ y del 98,2% de sus progenitores (55,9% extranjeros). En nuestro registro, la tasa de confirmación es del 36,9%, coincidiendo con la literatura7. Un 11,2% de los ninos ˜ presentaron algún tipo de resistencia, siendo el 5,6% resistentes a isoniazida, y el 1% MDR. De forma destacada, el último informe anual del ECDC2 tampoco dispone de datos sobre TB resistente en Espana, ˜ a diferencia de otros países europeos, a pesar de ser Espana˜ uno de los países con mayor inmigración procedente de Europa del Este, donde la TB MDR es un problema de gran magnitud.

The epidemiology of Mycoplasma pneumoniae (Mp) among US children (<18 years) hospitalized with community-acquired pneumonia (CAP) is poorly understood.

Methods

In the Etiology of Pneumonia in the Community study, we prospectively enrolled 2254 children hospitalized with radiographically confirmed pneumonia from January 2010–June 2012 and tested nasopharyngeal/oropharyngeal swabs for Mp using real-time polymerase chain reaction (PCR). Clinical and epidemiological features of Mp PCR–positive and –negative children were compared using logistic regression. Macrolide susceptibility was assessed by genotyping isolates.

Results

One hundred and eighty two (8%) children were Mp PCR–positive (median age, 7 years); 12% required intensive care and 26% had pleural effusion. No in-hospital deaths occurred. Macrolide resistance was found in 4% (6/169) isolates. Of 178 (98%) Mp PCR–positive children tested for copathogens, 50 (28%) had ≥1 copathogen detected. Variables significantly associated with higher odds of Mp detection included age (10–17 years: adjusted odds ratio [aOR], 10.7 [95% confidence interval {CI}, 5.4–21.1] and 5–9 years: aOR, 6.4 [95% CI, 3.4–12.1] vs 2–4 years), outpatient antibiotics ≤5 days preadmission (aOR, 2.3 [95% CI, 1.5–3.5]), and copathogen detection (aOR, 2.1 [95% CI, 1.3–3.3]). Clinical characteristics were non-specific.

Conclusions

Usually considered as a mild respiratory infection, Mp was the most commonly detected bacteria among children aged ≥5 years hospitalized with CAP, one-quarter of whom had codetections. Although associated with clinically nonspecific symptoms, there was a need for intensive care in some cases. Mycoplasma pneumoniae should be included in the differential diagnosis for school-aged children hospitalized with CAP.

El neumomediastino espontáneo se define como la presencia de aire dentro del mediastino. Se origina generalmente por una fuga de aire por aumento de presión en el alveolo. La incidencia en la edad pediátrica se encuentra entre 1/8000 y 1/15 000, con dos picos de edad: menores de cuatro años y de entre 13 a 17 años. En el primer grupo suele asociarse a una infección del tracto respiratorio, una crisis asmática o por aspiración de cuerpo extraño, mientras que en el segundo suele originarse tras actividad física intensa. Se ha descrito la implicación de virus como influenza o bocavirus en la fisiopatología de esta entidad, pero hasta el momento muy pocos casos se han descrito en relación con el virus respiratorio sincitial. La clínica más frecuente es dolor torácico junto con disnea y enfisema subcutáneo como signo característico. El diagnóstico en casi todos los casos lo dará la radiografía de tórax. El manejo dependerá del grado de afectación y su repercusión, por lo que variará desde observación hasta ingreso en una Unidad de Cuidados Intensivos. El tratamiento será de soporte y el de las complicaciones asociadas, no se suelen dar recurrencias y el pronóstico suele ser bueno en la mayor parte de los casos.

In 1999, the United Kingdom (UK) was the first country to introduce meningococcal group C (MenC) conjugate vaccination. This vaccination programme has evolved with further understanding, new vaccines and changing disease epidemiology.

Aim

To characterise MenC disease and population protection against MenC disease in England.

Methods

Between 1998/99–2015/16, surveillance data from England for laboratory-confirmed MenC cases were collated; using the screening method, we updated vaccine effectiveness (VE) estimates. Typing data and genomes were obtained from the Meningitis Research Foundation Meningococcus Genome Library and PubMLST Neisseria database. Phylogenetic network analysis of MenC cc11 isolates was undertaken. We compared bactericidal antibody assay results using anonymised sera from 2014 to similar data from 1996–1999, 2000–2004 and 2009.

Results

MenC cases fell from 883 in 1998/99 (1.81/100,000 population) to 42 cases (0.08/100,000 population) in 2015/16. Lower VE over time since vaccination was observed after infant immunisation (p = 0.009) and a single dose at 1–4 years (p = 0.03). After vaccination at 5–18 years, high VE was sustained for ≥ 8 years; 95.0% (95% CI: 76.0– 99.5%). Only 25% (75/299) children aged 1–14 years were seroprotected against MenC disease in 2014. Recent case isolates mostly represented two cc11 strains.

Conclusion

High quality surveillance has furthered understanding of MenC vaccines and improved schedules, maximising population benefit. The UK programme provides high direct and indirect protection despite low levels of seroprotection in some age groups. High-resolution characterisation supports ongoing surveillance of distinct MenC cc11 lineages.

La carga de enfermedad derivada de las infecciones de transmisión sexual (ITS) compromete la salud sexual, reproductiva y del recién nacido. La presencia de unas ITS facilita la transmisión de otras, como el VIH, y provoca cambios celulares que preceden algunos tipos de cáncer. Todo ello hace de las ITS un problema de salud pública de primer orden no controlado. En España, la infección gonocócica sigue creciendo desde el inicio de la década del 2000, mientras que la sífilis se mantiene estable en unos niveles altos desde el 2011. Ambas son más frecuentes en varones. Chlamydia trachomatis es la ITS más prevalente, afectando principalmente a mujeres de 20-24 años.

Las unidades de ITS son el instrumento fundamental para abordar este problema. Tratan con poblaciones especialmente vulnerables a estas infecciones y son esenciales para su control mediante intervenciones que disminuyen la eficiencia de su transmisión y la duración de la infectividad. Además, son la principal fuente del conocimiento epidemiológico de las mismas.

Fosfomicina tiene un efecto sinérgico o, como mínimo, aditivo en combinación con casi todos los antimicrobianos ensayados merced a su elevada difusión y a su mecanismo de acción único. En la actualidad, la guía de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica de tratamiento de la infección persistente o complicada por SARM recomienda la combinación de fosfomicina y daptomicina 17 . Esta recomendación presumiblemente se verá reforzada cuando se publiquen los resultados de un ensayo en marcha que compara la actividad combinada de fosfomicina y daptomicina frente a daptomicina en monoterapia en el tratamiento de la infección por SARM 18 .

Por otra parte, la combinación de fosfomicina con otros antimicrobianos también ha demostrado sinergia in vitrofrente a microorganismos gramnegativos multirresistentes 19 y existe experiencia clínica publicada sobre su empleo a altas dosis y de forma combinada en el tratamiento de las enterobacterias productoras de carbapenemasas 202122 y de Pseudomonas spp. extensamente resistentes 23 .

Fosfomicina se considera como un antimicrobiano bastante seguro y bien tolerado. Una molécula que, siendo antigua, está aún por definir su total posicionamiento y que cuanto más conocemos de ella, más beneficios potenciales se encuentran

As one of the most frequent and serious adverse reactions during tuberculosis (TB) treatment, antituberculosis drug-induced liver injury (ATLI) in children has been studied insufficiently compared with adults. We aimed to determine the incidence and risk factors of ATLI in children during the first 2 months of TB therapy.

A total of 41 children with TB and treated with first-line anti-TB drugs were prospectively followed-up for the development of ATLI. Liver function tests were performed at baseline and after 2 weeks of therapy. Subsequent tests were conducted at 4, 6 and 8 weeks if the initial 2-week measurement was abnormal or if symptoms of hepatotoxicity were reported.

ATLI was detected in 11 (27%) patients within 14 to 42 days from the start of therapy, with most of them (54%) occurred after 2 weeks. TB treatment was stopped immediately in 6 of 11 patients who developed ATLI, and no recurrent hepatotoxicity after drug reintroductions in these patients. Univariate analysis showed that ATLI was significantly associated with TB meningitis ( P < 0.01), hypoalbuminemia ( P < 0.05) and hepatotoxic comedications ( P < 0.01). Age, sex, nutritional status, HIV status and baseline liver function abnormalities were not associated with ATLI. Multivariate analysis identified hypoalbuminemia and hepatotoxic comedications (both P < 0.1) tend to be independently associated with ATLI.

Children with hypoalbuminemia and use of hepatotoxic comedications are suggested to be monitored closely for the development of ATLI

Breve artículo sobre la epidemiología de los enterovirus relacionados con los brotes de parálisis flácida en el sudeste asiático y actualmente en EEUU. Se analiza la importancia de su reconocimiento y diagnóstico etiológico, así como las respuestas individuales de los huéspedes y las posibilidades terapéuticas frente a los enterovirus no polio, principalmente D68 y A71

Lung ultrasonography for the diagnosis of pneumonia has been around since as early as 1970,1 although it is only in recent years with the growing interest in point-of-care ultrasound that more studies have been published with regard to its use in children. Even though pneumonia is one of the most common and potentially serious illnesses that affects children throughout the world, studies of pneumonia are often difficult to interpret in context with each other because of the variability in definitions used, as well as the lack of an easy gold standard. Many organisations, such as the World Health Organization (WHO) and British Thoracic Society, define pneumonia solely based on clinical findings, which can largely over-represent true cases of pneumonia (eg, children with bronchiolitis or viral-induced wheezing will often meet the case definition of pneumonia). Attempts to refine the definition of pneumonia by adding radiographic criteria (eg, parenchymal infiltrates on chest radiography) to the clinical criteria are also problematic given the variable test characteristics of chest radiography for pneumonia,2 variabilities in interpretation even among radiologists,3 problems with ionising radiation exposure and cost, and given that many clinical guidelines do not require the use of chest radiography for the management of suspected community-acquired pneumonia.

Further complicating this issue is the fact that the causative pathogen of …

The numbers in this study are small and it is hard to draw firm conclusions, but it nonetheless raises the question of whether every child with a sonographic consolidation should receive an antibiotic course of treatment, and if not, what that threshold should be.

Of 97 included patients, CR was positive for pneumonia in 44/97 (45%) and lung ultrasound was positive in 57/97 (59%). Ultrasound sensitivity was 91% (95% CI 78% to 98%) and specificity was 68% (95% CI 54% to 80%). Ultrasound results displayed greater consistency with CR and patient outcomes when sonographic consolidation exceeded 1 cm. Thirteen of 57 patients with sonographic consolidation improved without antibiotics.

Conclusion Lung ultrasound may have a role as first-line imaging in patients with possible pneumonia, with higher specificity for consolidations exceeding 1 cm.

Conclusions Viral infection in febrile infants <60 days of age is associated with a decreased, but not negligible (30% relative) SBI risk, compared with non-viral-infected febrile infants.

A 4-month-old boy with Down syndrome (DS) attended the general paediatric clinic for routine follow-up. With winter approaching the registrar asked, as children with DS are at increased risk of respiratory tract infections (RTIs), should this baby receive palivizumab prophylaxis, even if there is no congenital heart disease (CHD)?

Should children with DS without CHD or prematurity (population) receive palivizumab prophylaxis (intervention) to improve outcome (outcome)?

Conclusion Although many of the studies above are either retrospective9 10 12 13 or prospective observational9 18 20 22–24 studies, and a well-designed randomised controlled trial would be desirable, a recent meta-analysis examining DS and the risk of severe RSV concluded that children with DS without additional risk factors were at significantly greater risk of worse clinical outcomes.25 Therefore, the available evidence supports that children with DS are at increased risk of hospitalisation from RSV-related RTI and have more severe disease, necessitating longer hospital stays and more often requiring ventilatory support.11–13 24 Importantly, this appears to be independent of cardiac history,7 9–12 24 25 and therefore we would advocate that every child with DS be offered prophylaxis to reduce morbidity and improve outcomes. Several studies completed show that palivizumab is efficacious in reducing the incidence of hospitalisation due to RSV in children with DS with and without CHD.21–23 Lastly, it has been suggested that RSV-related disease occurs for longer, in the second year of life and beyond in children with DS,10 12 so should these children receive the vaccine for a second bronchiolitis season as indicated?

As our understanding of b-lactam allergy evolves, the importance of avoiding nondiscriminantly labeling children as allergic as well as delabeling children who are not allergic becomes more important. Most children with recorded b-lactam allergy are not in fact allergic, and there are significant unintended health consequences of use of alternative antibiotics. An allergy evaluation for children with a history of allergy benefits both the child, the population and the health care system.

Between 2000 and 2012, the national estimated incidence rate of pediatric mastoiditis, a rare but serious complication of acute otitis media, was highest in 2006 (2.7/100,000 population) and lowest in 2012 (1.8/100,000 population). This measure provides a baseline for public health surveillance in the pneumococcal conjugate vaccine era as stewardship efforts target antibiotic use in acute otitis media

Large epidemiologic studies evaluating the etiologies, management decisions and outcomes of infants and children with meningitis and encephalitis in the United States are lacking.

Children 0–17 years of age with meningitis or encephalitis as assessed by International Classification of Diseases, Ninth Revision, codes available in the Premier Healthcare Database during 2011–2014 were analyzed.

Six thousand six hundred sixty-five patients with meningitis or encephalitis were identified; 3030 (45.5%) were younger than 1 year of age, 295 (4.4%) were 1–2 years of age, 1460 (21.9%) were 3–9 years of age, and 1880 (28.2%) were 10–17 years of age. Etiologies included enterovirus (58.4%), unknown (23.7%), bacterial (13.0%), noninfectious (3.1%), herpes simplex virus (1.5%), other viruses (0.7%), arboviruses (0.5%) and fungal (0.04%). The majority of patients were male [3847 (57.7%)] and healthy [6094 (91.4%)] with no reported underlying conditions. Most underwent a lumbar puncture in the emergency department [5363 (80%)] and were admitted to the hospital [5363 (83.1%)]. Antibiotic therapy was frequent (92.2%) with children younger than 1 year of age with the highest rates (97.7%). Antiviral therapy was less common (31.1%). Only 539 (8.1%) of 6665 of patients received steroids. Early administration of adjunctive steroids was not associated with a reduction in mortality ( P = 0.266). The overall median length of stay was 2 days. Overall mortality rate (0.5%) and readmission rates (<1%) was low for both groups.

Meningitis and encephalitis in infants and children in the United States are more commonly caused by viruses and are treated empirically with antibiotic therapy and antiviral therapy in a significant proportion of cases. Adjunctive steroids are used infrequently and are not associated with a benefit in mortality.

Globally, there is wide variation in streptococcal titer upper limits of normal (ULN) for antistreptolysin O (ASO) and anti-deoxyribonuclease B (ADB) used as an evidence of recent group A streptococcal infection to diagnose acute rheumatic fever (ARF).

We audited ASO and ADB titers among individuals with ARF in New Zealand (NZ) and in Australia’s Northern Territory. We summarized streptococcal titers by different ARF clinical manifestations, assessed application of locally recommended serology guidelines where NZ uses high ULN cut-offs and calculated the proportion of cases fulfilling alternative serologic diagnostic criteria.

From January 2013 to December 2015, group A streptococcal serology results were available for 350 patients diagnosed with ARF in NZ and 182 patients in Northern Territory. Median peak streptococcal titers were similar in both settings. Among NZ cases, 267/350 (76.3%) met NZ serologic diagnostic criteria, whereas 329/350 (94.0%) met Australian criteria. By applying Australian ULN titer cut-off criteria to NZ cases, excluding chorea, ARF definite cases would increase by 17.6% representing 47 cases.

ASO and ADB values were similar in these settings. Use of high ULN cut-offs potentially undercounts definite and probable ARF diagnoses. We recommend NZ and other high-burden settings to use globally accepted, age-specific, lower serologic cut-offs to avoid misclassification of ARF.

Enterovirus-D68 (EV-D68) is a respiratory virus within the genus Enterovirus and the family of Picornaviridae . Genetically, it is closely related to rhinovirus that replicates in the respiratory tract and causes respiratory disease. Since 2014, EV-D68 has been associated with the neurologic syndrome of acute flaccid myelitis (AFM).

In October 2016, questionnaires were sent out to a European network including 66 virologists and clinicians, to develop an inventory of EV-D68–associated AFM cases in Europe. Clinical and virologic information of case patients was requested. In addition, epidemiologic information on EV testing was collected for the period between March and October 2016.

Twenty-nine cases of EV-D68–associated AFM were identified, from 12 different European countries. Five originated from France, 5 from Scotland and 3 each from Sweden, Norway and Spain. Twenty-six were children (median age 3.8 years), 3 were adults. EV-D68 was detected in respiratory materials (n = 27), feces (n = 8) and/or cerebrospinal fluid (n = 2). Common clinical features were asymmetric flaccid limb weakness, cranial nerve deficits and bulbar symptoms. On magnetic resonance imaging, typical findings were hyperintensity of the central cord and/or brainstem; low motor amplitudes with normal conduction velocities were seen on electromyography. Full clinical recovery was rare (n = 3), and 2 patients died. The epidemiologic data from 16 European laboratories showed that of all EV-D68–positive samples, 99% was detected in a respiratory specimen.

For 2016, 29 EV-D68–related AFM cases were identified in mostly Western Europe. This is likely an underestimation, because case identification is dependent on awareness among clinicians, adequate viral diagnostics on respiratory samples and the capability of laboratories to type EVs

F. necrophorum was identified in 13% (19/149) of mastoiditis cases with an identifiable agent. Its incidence increased 7-fold from 2.8% in 2012 to 20.4% in 2015 ( P = 0.02). F. necrophorum infection had unique clinical, laboratory and prognostic features. The vast majority had complications and underwent surgical intervention. The predictive model used 4 parameters to define high-risk patients for F. necrophorum infection at admission: females, winter/spring season, prior antibiotic treatment and a C-reactive protein value >20 mg/dL (area under receiver operating characteristic curve 0.929).

Clinicians should be aware of the increasing incidence of F. necrophorum mastoiditis and consider anaerobic cultures and specific anaerobic coverage in high-risk patients

RESULTADOS: Observamos disminuciones dramáticas en la administración de antibióticos durante los 14 años de estudio. A pesar de la evidencia previa de una meseta en las tasas, hubo disminuciones adicionales sustanciales entre 2010 y 2014. Si bien las tasas de uso de antibióticos disminuyeron en general, la fracción de prescripción asociada con los diagnósticos individuales fue relativamente estable. La prescripción de diagnósticos para los cuales los antibióticos no están claramente indicados parece haber disminuido.


CONCLUSIONES: Estos datos revelaron otro período de marcado declive de 2010 a 2014 después de una meseta relativa durante varios años para la mayoría de los grupos de edad. Los esfuerzos para disminuir la prescripción innecesaria continúan teniendo un impacto en el uso de antibióticos en la práctica ambulatoria.

This is the largest cohort of HPeV3 cases with clinical data and pediatrician-assessed neurodevelopmental follow-up to date. Developmental concerns were identified in 11 children at early follow-up. Abnormal magnetic resonance imaging during acute infection did not specifically predict poor neurodevelopmental in short-term follow-up. Continued follow-up of infants and further imaging correlation is needed to explore predictors of long-term morbidity.

In this systematic review and meta-analyses, serious infections were uncommon and not significantly increased among patients with JIA receiving biologic agents compared with controls. However, the analyses were underpowered and study periods were relatively short. Ongoing careful monitoring for serious infections remains necessary for all patients with JIA, and particularly those receiving biologic agents.

 RESULTADOS: Se observaron un total de 1596 adolescentes elegibles durante el ensayo de 7 meses. Un tercio de los adolescentes visitó una clínica de intervención. Los adolescentes que asistieron a una clínica de intervención tenían más probabilidades de ser más jóvenes (11 a 12 años) que aquellos que asistieron a una clínica de control (72.4% vs 49.8%; P <.001). No se observaron diferencias en raza o sexo. La proporción de adolescentes con un cambio observado en el estado de la vacuna fue mayor para los que acudieron a una clínica de intervención (64,8%) en comparación con la clínica de control (50,1%; odds ratio, 1,82; intervalo de confianza del 95%, 1,47–2,25; p <0,001). Los adolescentes cuyos padres vieron el video tenían una probabilidad 3 veces mayor de recibir una dosis de la vacuna contra el VPH (78.0%; odds ratio, 3.07; intervalo de confianza del 95%, 1.47–6.42; P = .003).


CONCLUSIONES: Las intervenciones educativas realizadas en un entorno clínico prometen mejorar los comportamientos de vacunación.

Objective To improve the prediction of pediatric pneumonia by developing a series of models based on clinically distinct subgroups. We hypothesized that these subgroup models would provide superior estimates of pneumonia risk compared with a single pediatric model. Study design We conducted a secondary analysis of a prospective cohort being evaluated for radiographic pneumonia in an urban pediatric emergency department (ED). Using multivariate modeling, we created 4 models across subgroups stratified by age and presence of wheezing to predict the risk of pneumonia. Results A total of 2351 patients were included in the study. In this series, the prevalence of pneumonia was 8.5%, and 21.6% were hospitalized. The highest prevalence of pneumonia was in children aged >2 years without wheezing (13.3%). Children aged <2 years with wheezing had the lowest prevalence of pneumonia (4.0%). The most

accurate model was for children aged <2 years with wheezing (area under the curve [AUC], 0.80), and the poorest performing model was for those aged <2 years without wheezing (AUC, 0.64). The AUC of a combination of the 4 subgroup models was 0.76 (95% CI, 0.72-0.80). The precision of the models’ estimates (expected vs observed) was + 3.7%.

Conclusions Using 4 complementary prediction models for pediatric pneumonia, an accurate risk of pneumonia can be calculated. These models can provide the basis for clinical decision making support to guide the use of chest radiographs and promote antibiotic stewardship.

The prevalence of serious bacterial infection is lower in infants aged ≤60 days with a history of fever compared with those who are febrile on arrival to the ED. The small risk reduction in this group is unlikely to alter decision making.

Among febrile infants ≤60 days old with IBI, prematurity, ill appearance, and bacterial meningitis (vs bacteremia without meningitis) were associated with adverse outcomes. These factors can inform clinical decision-making for febrile young infants with IBI.

Las biopelículas bacterianas se han relacionado con infecciones del tracto respiratorio superior y resistencia a los antibióticos, lo que genera serias preocupaciones con respecto al tratamiento de dichas infecciones. Varios estudios en niños propensos a la otitis demostraron que la administración intranasal de Streptococcus salivarius 24 SMB y Streptococcus oralisson 89a es segura y bien tolerada y puede reducir el riesgo de otitis media aguda. El objetivo de esta investigación es evaluar su capacidad de interferir con la biopelícula de los patógenos típicos del tracto respiratorio superior. El estudio concluye que ambos actúan como probióticos para el tratamiento y prevención de las vías respiratorias superiores.

RESULTADOS: De 2014 a 2016, se registraron 166 casos de enfermedad meningocócica en personas de 18 a 24 años, con una incidencia anual promedio de 0,17 casos por 100 000 habitantes. Se identificaron seis brotes de serogrupo B en los campus universitarios, lo que representa el 31.7% de los casos del serogrupo B en estudiantes universitarios durante este período. El RR de la enfermedad meningocócica (MenB) del serogrupo B en estudiantes universitarios versus estudiantes no colegiados fue de 3.54 (95% intervalo de confianza: 2.21-5.41), y el RR de los serogrupos C, W e Y combinados fue 0.56 (95% intervalo de confianza: 0.27 –1.14). Los complejos clonales de serogrupo B más comunes identificados fueron CC32 / ET-5 y CC41 / 44 linaje 3.


CONCLUSIONES: Aunque la incidencia es baja, entre los jóvenes de 18 a 24 años, los estudiantes universitarios tienen un mayor riesgo de contraer la enfermedad de MenB esporádica y asociada a brotes. Los proveedores, estudiantes universitarios y padres deben estar conscientes de la disponibilidad de vacunas MenB.
 

Aunque los factores anteriores deben considerarse al hacer recomendaciones de salud pública, a nivel individual, la decisión de vacunar a un adolescente con la vacuna MenB es mucho más sencilla. Las infecciones meningocócicas son potencialmente mortales. Tenemos evidencia de otros países de que las vacunas MenB son efectivas. Las vacunas de MenB están cubiertas por las compañías de seguros y el Programa de vacunas para niños, incluso bajo la recomendación de la Categoría B. Y ahora podemos decir que los estudiantes universitarios tienen un mayor riesgo de contraer la enfermedad de MenB. Los pediatras y los proveedores de atención primaria tienen una razón más convincente para recomendar la vacuna MenB para sus pacientes que anticipan asistir a la universidad. Como mínimo, los pediatras deben educar a los estudiantes y las familias sobre el mayor riesgo de infecciones de MenB en estudiantes universitarios en los Estados Unidos e informarles que hay 2 vacunas disponibles que pueden proteger a los estudiantes universitarios de esta infección. Los efectos secundarios relacionados con la vacunación con MenB son relativamente mínimos. Los estudiantes y los padres pueden tomar una decisión informada acerca de recibir MenB.