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Bibliografía de 2019

Actualidad bibliográfica diciembre 2019

Top ten

  • Comprehensive Detection of Respiratory Bacterial and Viral Pathogens in the Middle Ear Fluid and Nasopharynx of Pediatric Patients With Acute Otitis MediaSawada, Shoichi; Okutani, Fumino; Kobayashi, Taisuke Less . The Pediatric Infectious Disease Journal. 38(12):1199-1203, December 2019

Background: Acute otitis media (AOM) is a common ear infection caused by respiratory viruses and bacteria of the nasopharynx. The present study aimed to detect various respiratory viruses and bacteria in middle ear fluid (MEF) and nasopharyngeal aspirates (NPA) using polymerase chain reaction (PCR).

Methods: We collected MEF and NPA samples from 122 pediatric patients with AOM. Real-time PCR detected 11 types of respiratory viruses (respiratory syncytial virus A/B, parainfluenza virus 1/2/3, human metapneumovirus, influenza virus A/B, adenovirus, human bocavirus and rhino virus) and 7 types of bacteria (Streptococcus pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, Chlamydia pneumoniae, Streptococcus pyogenes, Legionella pneumophila and Moraxella catarrhalis). MEF specimens were also examined using bacterial culture.

Results: At least 1 respiratory viral or bacterial pathogen was detected in MEF of 120 cases (98%) by viral and bacterial PCR and of 93 cases (76%) by viral PCR and bacterial culture. Respiratory viruses were detected in NPA of 84 cases (69%) and MEF of 67 cases (55%). The most common virus detected in MEF was respiratory syncytial virus (21%), followed by parainfluenza virus (15%). All the viruses present in MEF were also detected in NPA specimens. Bacteria were detected by PCR in MEF of 109 cases (89%); H. influenzae was the most frequently detected (65%).

Conclusions: In many cases, pediatric AOM was found to constitute a respiratory polymicrobial infection. Multiplex PCR was useful to detect multiple respiratory viruses and bacteria in AOM. To understand intractable AOM, further studies regarding the clinical features of each viral and bacterial coinfection are required.

  • Enfermedad invasiva por Streptococcus pyogenes: cambios en la incidencia y factorespronósticos. An Pediatr (Barc). 2019;91:286-95
    IntroducciónLa enfermedad invasiva por Streptococcus del grupo A (EISGA) es una infección grave en niños, habiéndose comunicado un aumento de incidencia en los últimos años.
    Objetivo; Evaluar las características y evolución de la EISGA en niños y determinar cambios en la incidencia o gravedad.
    Material y métodos
    Estudio retrospectivo de niños≤16 años evaluados en un hospital terciario de Madrid y diagnosticados de EISGA (junio 2005-julio 2013). Se analizó la epidemiología, clínica, microbiología y tratamiento, evaluándose cambios a lo largo del periodo estudiado y parámetros asociados a gravedad.
    Resultados
    Se incluyeron 55 niños con EISGA; 33 (60%) mujeres, con una mediana de 48,5 (20,5-88,9) meses. Los síndromes clínicos más frecuentes fueron celulitis/absceso subcutáneo (21,8%), absceso ORL (20%), neumonía (16,4%), infección osteoarticular (16,4%) y mastoiditis (12,7%). La incidencia de EISGA (casos/105 urgencias/año) aumentó de 5,6 (4,2-7,2) entre junio 2005-mayo 2009 a 18,9 (15,1-26) entre junio 2009-mayo 2013; p=0,057. El 63,6% (n=35) y el 18,2% (n=10) de los pacientes precisaron cirugía e ingreso en UCIP, respectivamente. Los niños en UCIP fueron más pequeños (26,5 vs. 52,6 meses; p=0,116), presentaron proteína C reactiva más elevada (24,5 vs. 10,7mg/dl; p<0,001) y mayor frecuencia de neumonía (60 vs. 7%; p<0,001). En el análisis multivariante solo la proteína C reactiva fue factor de riesgo de ingreso en UCIP (OR: 1,14 [1,004-1,286]; p=0,04). No hubo secuelas.
    Conclusiones
    Se objetivó un aumento de la incidencia de EISGA en niños en nuestro medio, siendo la menor edad, la presencia de neumonía y la proteína C reactiva elevada los parámetros asociados a gravedad en esta serie.

  • Infecciones invasivas por estreptococo del grupo A y por meningococo: incertidumbres y certezas. An Pediatr (Barc). 2019;91:283-5.

  • Documento de posicionamiento de la Asociación Española de Pediatría-Sociedad Española de Infectología Pediátrica (AEP-SEIP) sobre el tratamiento de las infecciones por bacterias multirresistentes An Pediatr (Barc). 2019;91:351.e1-351.e13

En los últimos años se ha evidenciado un incremento en la incidencia de infecciones por bacterias multirresistentes. Las principales amenazas son los bacilos gramnegativos productores de β-lactamasas de espectro extendido, AmpC o carbapenemasas, Staphylococcus aureus resistente a meticilina y Enterococcus faecium resistente a vancomicina. Para hacer frente a este problema, es fundamental establecer programas de optimización en el uso de antimicrobianos específicos para pediatría, realizar una vigilancia epidemiológica activa y desarrollar una adecuada política de control de infecciones. Su abordaje terapéutico es, a menudo, complejo y multidisciplinar, y precisa frecuentemente del uso de antibióticos menos empleados. En este documento de posicionamiento, elaborado por la Asociación Española de Pediatría y la Sociedad Española de Infectología Pediátrica, se revisa la epidemiología y el tratamiento de estas infecciones siguiendo la mejor evidencia disponible.

A few years ago we were all confronted by an increase in cases of scarlet fever and a number of cases of more invasive and severe Streptococcal infections. It was interesting to read that due to a very well established global surveillance system, this raise in Streptococcal pyogenes (S pyogenes) infections has been described in detail by Lynsky NN et al . [Lancet Infect Dis 2019; 19: 1209–18 http://dx.doi.org/10.1016/S1473-3099(19)30446-3] First, this is a great paper on scarlet fever and is a very interesting historical review. Up until the beginning of the 20th century it was associated a significant mortality. Long before the use of antibiotics, the incidence and severity of scarlet fever started to fall, the reason for this remains unexplained. Scarlet fever notifications in England in the period 2014–18 have been the highest seen since 1960. It is possible that the streptococcal bacteria causing the disease might have undergone a pathogenetic change and this led to a reduction in the invasive and more severe sequelae of the illness.

The Archivist discovered that S pyogenes can be serotyped or genotyped on the basis of the M antigen, which is encoded by the emm gene. Changes in disease incidence can be characterised by expansion of specific emm genotypes. This study provided a molecular explanation for the association between increased incidence of scarlet fever and increased incidence of invasive S pyogenes infections. The team identified an emergent lineage of M1T1 S pyogenes (M1UK) that expanded rapidly to become the largest single contributor to both non-invasive and invasive infections in 2016. When you review the historical epidemics, it is interesting to speculate that this molecular explanation was the cause of the epidemic waves . Variations in strain pathogenicity as well as the general population susceptibility both have an influence. I found it valuable to realise that genomic analysis confirmed that the strains that cause scarlet fever are no different to those that cause streptococcal pharyngitis and rarer invasive infections. The data highlight that group A streptococcal lineages can differ in pathogenicity.

This group analysed changes in S pyogenes emm genotypes, and notifications of scarlet fever and invasive disease in 2014–16 using regional and national data. Genomes of 135 non-invasive and 552 invasive emm1 isolates from 2009 to 2016 were analysed and compared with 2800 global emm1 sequences. Coincident with national increases in scarlet fever and invasive disease notifications, emm1 S pyogenes upper respiratory tract isolates increased significantly. Sequences of emm1 isolates from 2009 to 2016 showed emergence of a new emm1 lineage (designated M1UK)—with overlap of pharyngitis, scarlet fever, and invasive M1UK strains—which could be genotypically distinguished from pandemic emm1 isolates (M1global) by 27 single-nucleotide polymorphisms. Phylogenetic analysis of published datasets identified single M1UK isolates in Denmark and the USA. The expanded reservoir of M1UK and recognised invasive potential of emm1 S pyogenes provide plausible explanation for the increased incidence of invasive disease, and rationale for global surveillance.

Many more patients are labeled as penicillin-allergic than actually are allergic. The label should be analyzed with skin testing and test exposure. Patients with true penicillin allergy can be desensitized with a slow-escalation protocol under physician observation.

Review question(s)

How effective or harmful are different HPV vaccine schedules (i.e. number and timing of doses) and different HPV vaccines in females and males?

Main results

These results are based on research evidence to 27 September 2018. We analysed 20 studies involving 31,940 people.

Studies comparing two doses of HPV vaccine to three doses, or comparing the time interval between doses, focus on immune system responses rather than infection or disease outcomes. Two doses of HPV vaccine result in similar immune system responses to three doses, and a longer interval (up to 12 months) between doses gives a stronger immune system response than a shorter interval. There is insufficient evidence to determine whether there was a difference between the vaccine schedules for serious adverse events and death.

In 16- to 26-year-old men, one study showed evidence of moderate certainty that a quadrivalent HPV vaccine provides better protection against external genital lesions and genital warts than a dummy treatment (control). In 16- to 26-year-old women, one study showed that the nonavalent and quadrivalent vaccines provide the same levels of protection against cervical, vaginal, and vulval precancer lesions and cancer (high-certainty evidence).

There was evidence that the quadrivalent vaccine resulted in more local adverse events (such as pain, swelling, and redness at the injection site) than a control treatment in males, and that the nonavalent vaccine resulted in more local adverse events than the quadrivalent vaccine in males and females. Evidence about serious adverse events and deaths from studies comparing different HPV vaccine types or dose schedules was of low or very low-certainty.

In people living with HIV, HPV vaccines result in reasonable levels of immune system response, but evidence about their effects on persistent HPV infection or HPV-related disease outcomes and harms is limited.

Resumen: revisión sistemática que incluye datos de 8 años de seguimiento y más de 80 millones de personas vacunadas frente al VPH. Los resultados muestran una evidencia contundente del impacto de la vacunación en la infección genital por VPH, en las lesiones CIN2 en mujeres y en la verruga genital en hombres y mujeres. Además, los programas con más amplia cobertura vacunal tienen mayor efecto directo en la prevención, así como mejor inmunidad de grupo.

Review question

We reviewed the evidence about the effect of treatments aimed at reducing S. aureus on the skin in people with atopic eczema. Eligible comparisons were similar treatments without anti-S. aureus actions. We included 41 studies involving 1753 participants (evidence is current to October 2018).

Study characteristics

Included studies assessed a range of treatments, which they compared with placebos (an identical but inactive treatment), no treatment, other treatment, vehicle (inactive ingredient(s) which help deliver an active treatment), or textile without the anti-S.aureus component.

Studies were conducted worldwide, and included males and females. Twelve studies recruited children; four, adults; 19, both; and six were unclear; where reported, the average participant age ranged from 1.1 to 34.6 years. Eczema severity varied from mild to severe. Treatment durations ranged from 10 minutes to 3 months; total study durations, from 15 weeks to 27 months.

Key results

Outcomes were measured from treatment start. We classed outcomes as short-term when treatment duration was less than four weeks, and long-term when treatment was given for more than four weeks.

People may be more likely to experience slightly increased short-term improvement with topical steroid/antibiotic combinations than with steroid only (low-quality evidence, one study of infected eczema and two studies with unspecified infection). There is probably little or no difference between the combination group and the steroid only groups in short-term impact on quality of life (QoL) (moderate-quality evidence, one study of infected children). Antibiotic resistance was similar between groups in the long term, but we are uncertain of this result due to very low-quality evidence (one study of infected children).

When compared to placebo, oral antibiotics may make no difference to short-term improvement (low-quality evidence, two studies: one in uninfected infants and children; the other in mainly infected infants and children). For short-term QoL, there is probably little or no difference between the groups (moderate-quality evidence, one study of infected infants and children). Short-term antibiotic resistance was similar in both groups, but we are uncertain if there is a true difference as the quality of evidence was very low (two studies of infants and children, infected in one study and uninfected in the other).

Bleach baths may make no difference to short-term improvement when compared to placebo (low-quality evidence, one study of uninfected participants). There is also probably little or no difference in short-term QoL in children of unspecified infective status (one study; moderate-quality evidence); based on the same study, we are uncertain if short-term antibiotic resistance was different between groups (very low-quality evidence).

Side effects bad enough to stop treatment were rare in all studies; however, evidence was very low quality in all three comparisons, so we are uncertain whether there is a difference between groups. Assessment ranged from six days to two months, participants included children and adults with mixed infective status, and causes of withdrawal included worsening of eczema or itch and loose stools.

Participants in the topical steroid/antibiotic combination group experienced fewer minor side effects than those given steroids alone. Comparing oral antibiotics to placebo, participants experienced equally low numbers of minor side effects. However, we are uncertain if their are true differences between groups due to very low-quality evidence. Based on short-term assessment of mixed participants (children and adults, with mixed infective status), reported side effects included sickness, diarrhoea, stomach/joint pains, and itching. For bleach baths versus placebo, some long-term minor side effects (burning/stinging, dry skin) were reported in both groups, so there may be no difference between treatment groups (low-quality evidence, uninfected participants (2 to 30 years).

In this review we included randomized controlled trials in infants and young children that evaluated a monovalent rotavirus vaccine (RV1; Rotarix, GlaxoSmithKline) or a pentavalent rotavirus vaccine (RV5; RotaTeq, Merck).

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. OK

The Pediatric Infectious Disease Journal. 38(12):e332-e335, December 2019.

Urinary tract infections (UTIs) are usually caused by Gram-negative Enterobacteriaceae, the most common pathogens being Escherichia coli and Klebsiella pneumoniae.1,2 Antimicrobial resistance is increasing among uropathogens and the production of β-lactamases is a major resistance mechanism.3 Extended spectrum β lactamases (ESBLs) producing pathogens exhibit resistance not only to newer β-lactams, including third generation cephalosporins and monobactams, but also to other classes of antibiotics.3,4 ESBL resistance genes are located on plasmids which are transferrable to other strains, thus posing considerable infection control issues.3,4 UTIs caused by ESBL-producing E. coli and K. pneumoniae are the most common ESBL infections in childhood.5 Herein, we summarize available data on these pathogens with a focus on treatment choices.

Casos clínicos

  • Rhabdomyolysis Associated With Primary Human Herpesvirus-6 InfectionMurakami, Ryunosuke; Adachi, Shunichi; Koga, Hiroshi Less . The Pediatric Infectious Disease Journal. 38(12):e341, December 2019.

  • Congenital Syphilis N Engl J Med 2019; 381:2157 DOI: 10.1056/NEJMicm1904420

A 6-month-old girl whose parents had recently received a diagnosis of syphilis was referred for evaluation after testing suggested that she also had syphilis. Physical examination revealed frontal bossing and a soft-tissue perirectal mass. A biopsy specimen was positive for spirochetes on immunostaining.

We were interested to read the report by So et al 1 describing an infant who was unwell prior to receiving their first set of primary immunisations (including the four-component meningococcal B vaccine 4CMenB; Bexsero; GSK Biologicals) and was subsequently diagnosed with meningococcal group W meningitis shortly after vaccination. The authors highlight factors that would not have been consistent with an adverse event following immunisation (AEFI), namely the onset of fever prior to immunisation and the presentation with focal seizures, which is rare following 4CMenB vaccination, even when administered concurrently with routine immunisations.2 Such a severe clinical presentation should warrant additional investigations and the very high blood C reactive protein (CRP) level and very abnormal cerebrospinal fluid (CSF) findings (1000 white blood cells (WBC), protein 1750 mg/dL and glucose <0.3 mmol/L) would also have been inconsistent with an AEFI.

We would however, like to report our experience of three cases of aseptic meningitis following primary immunisation (including 4CMenB) in infants. All three presented with fever and irritability within 24 hours of vaccination, had a full septic screen including lumbar puncture and received empiric intravenous antibiotics (table 1). Subsequent bacterial cultures were all negative as was PCR testing of CSF for meningococcus, pneumococcus and common viral causes of meningitis (enterovirus, parechovirus, herpes simplex and varicella zoster). Antibiotics were stopped after 36–48 hours, when bacterial cultures were reported negative.

Para profundizar

To characterize the incidence of adverse events (AEs) associated with antibiotics used to treat acute otitis media in children.

We searched MEDLINE for studies conducted between January 1, 1966, and August 25, 2018. Two authors independently assessed potential studies and extracted the data. We included published randomized controlled trials, cross-sectional studies, and cohort studies that evaluated the incidence of diarrhea, generalized rash, diaper rash, and candidal diaper dermatitis associated with the use of amoxicillin, amoxicillin/clavulanate, azithromycin, cefdinir, and placebo in children with acute otitis media.

RESULTS: We included 82 studies in the meta-analysis. The incidence of diarrhea, listed from lowest to highest, was azithromycin (2.2%), placebo (6.9%), low-dose amoxicillin (8.7%), cefdinir (13.0%), high-dose amoxicillin (13.8%), and high-dose amoxicillin/clavulanate (18.9%). The incidence of generalized rash, listed from lowest to highest, was azithromycin (1.4%), placebo (2.3%), low-dose amoxicillin (2.9%), high-dose amoxicillin/clavulanate (4.9%), and high-dose amoxicillin (6.5%). In studies of low-dose amoxicillin, we found a higher incidence of diarrhea in studies that used daily diaries to collect information about diarrhea and a lower incidence of generalized rash in studies that reported only rashes judged to be secondary to antibiotic use.

CONCLUSIONS: The incidence of AEs varies widely depending on which antibiotic is used and how the information on AEs was collected or reported. The AEs rates reported here may be helpful to clinicians when choosing an antibiotic to treat acute otitis media.

De los 196 niño/as de <12 meses estudiados: en el primer mes, el 20% (5 de 25) de los bebés tenían anticuerpos por debajo del umbral de protección, que aumentó al 92% (22 de 24) en 3 meses. A los 6 meses, todos los bebés tenían títulos por debajo del umbral de protección. En un análisis multivariable, la edad del lactante fue el predictor más fuerte de susceptibilidad (odds ratio = 2.13 por cada aumento adicional de mes; intervalo de confianza del 95%: 1.52-2.97).

CONCLUSIONES: La mayoría de los lactantes eran susceptibles al sarampión a los 3 meses de edad en este entorno. Nuestros hallazgos informan sobre la importancia del debate de política vacunal relacionada con el momento ideal de la primera dosis de la vacuna de sarampión y las recomendaciones de profilaxis posexposición infantil.

Las recomendaciones actuales del Comité Asesor sobre Prácticas de Inmunización permiten la vacunación contra el sarampión a los 6 meses para los bebés que planean viajar internacionalmente, los bebés con riesgo continuo de exposición durante los brotes de sarampión y como profilaxis postexposición.

Resumen: revisión sistemática y metanálisis de estudios que incluyen vacunas que contienen virus atenuado del sarampión y su eficacia. Obtienen 56 estudios de cuyo análisis concluyen que la administración de vacuna de virus atenuado del sarampión por debajo de los 9 meses, induce una buena respuesta inmunitaria, si bien, la seroconversión es más probable a más meses tenga el niño. Además la vacuna se muestra segura. Plantea que se cambie la recomendación de vacunar solo por encima de esa edad y proponen que se recomiende la vacunación, independientemente de la edad, en situaciones de alto riesgo.

Resumen: A partir de 13 estudios recuperados en una revisión sistemática analizan la respuesta serológica al sarampión tras la vacuna triple vírica (2 dosis) en pacientes que habían recibido una dosis de vacuna frente antes de los 9 meses de edad. Los resultados muestran alta seropositividad, alta efectividad vacunal y alta respuesta de células T, independientemente de la edad a la que se puso la vacuna anterior a los 9 meses. No obstante, en uno de los estudios la media geométrica de los títulos de anticuerpos fue significativamente más baja en los que habían recibido una dosis previa a los 9 meses de edad. Pero para los autores (y es un estudio financiado por la OMS) los resultados refuerzan la recomendación de utilizar la vacuna frente al sarampión en menores de 9 meses en situaciones de riesgo.

Se analizan las reacciones adversas del VAERS (Vaccine Adverse Event Reporting System) de 7244 reports

CONCLUSIONES:

No se detectaron problemas de seguridad nuevos o inesperados o patrones de notificación de 9vHPV con efectos adversos clínicamente importantes. El perfil de seguridad de 9vHPV es consistente con los datos de los ensayos previos a la licencia y de los datos de seguridad posteriores a la comercialización de su predecesor, la vacuna contra el virus del papiloma humano tetravalente.

Human papillomavirus (HPV) vaccination coverage (48.6% in 2017) in the United States remains far below the Healthy People 2020 goal of 80%, and a 10% difference in coverage between boys (44.3%) and girls (53.1%) has been reported.1 Knowledge of HPV among vaccine-eligible individuals and their parents is critical to vaccine uptake. Furthermore, the recommendation to receive an HPV vaccine from health care professionals can help parents in their decision-making to vaccinate children.2 Therefore, we evaluated the national-level estimates of (1) HPV knowledge and (2) receipt of HPV vaccine recommendation from a health care professional.

Resumen: La eficacia de la vacuna contra el rotavirus es menor y disminuye más rápidamente en entornos de alta mortalidad que en entornos de baja mortalidad, pero la edad más precoz de las formas graves de la enfermedad en entornos de alta mortalidad significa que las vacunas vivas contra el rotavirus oral aún pueden proporcionar beneficios sustanciales.

Introducción
Objetivo principal: describir las características clínicas y epidemiológicas de los pacientes con EMI. Objetivos secundarios: describir las diferencias entre niños y adultos, factores pronósticos y cambios epidemiológicos en los últimos 14 años.

Métodos: Estudio retrospectivo realizado en un hospital terciario. Se incluyeron los pacientes diagnosticados de EMI entre 2004 y 2017, recogiéndose datos epidemiológicos, clínicos y microbiológicos.

ResultadosFueron diagnosticados 84 pacientes con EMI, 50 (59,5%) niños. Edad mediana en niños 2 años (RIC: 0,7-7,5) y adultos 41,2 años (RIC: 26,4-69,3). Bacteriemia en 47 casos (56%), meningitis en 24 (28,6%) y ambas en 13 (15,5%). Predominio del serogrupo B (MenB), en el 40,5%, seguido del serogrupo C (MenC), en el 15,5%, con mayor proporción de MenC en adultos (26,5 vs. 8%; p=0,022). Disminución en la incidencia de 2004-2010 a 2011-2017, pasando de 3,14 a 1,33 casos/100.000 urgencias en el centro de estudio (p<0,001). El 84% de los niños había recibido≥1 dosis de vacuna frente a MenC, ninguno frente a MenB. Mayor proporción de ingreso en UCI en niños (78 vs. 44,1%; p=0,001). Tendencia a mayor letalidad en adultos (11,8 vs. 2%; p=0,153). La intubación y la trombocitopenia fueron factores de riesgo independientes de desenlace adverso, y la leucopenia y el exantema purpúrico de gravedad.

Conclusiones Se objetivó un descenso en la incidencia de EMI, siendo MenB el mayoritario. El mayor porcentaje de MenC en adultos probablemente esté relacionado con una menor cobertura vacunal. La trombocitopenia, la leucopenia y el exantema purpúrico fueron factores de riesgo relacionados con peor pronóstico.

Kingella kingae fue el patógeno aislado con mayor frecuencia, responsable del 51% de las infecciones osteoarticulares (IOA), mientras que otros patógenos clásicos fueron responsables del 39,7% de los casos en la cohorte molecular. Se observó un aumento estadísticamente significativo en la incidencia media de IOA, así como una disminución en la edad media en el momento del diagnóstico después de 2007.

  • The Volume of Pediatric Blood CultureKusama, Yoshiki; Shime, Nobuaki; Ito, Kenta; Ito, Yusuke; Kasai, Masashi Less . The Pediatric Infectious Disease Journal. 38(12):e340-e341, December 2019.

Background

Bloodstream infections (BSIs) are a major cause of morbidity and mortality in paediatric patients. For fast and accurate diagnosis, blood culture (BC) is the reference standard. However, the procedure for blood sampling in paediatric patients, particularly the optimal blood volume, is the subject of controversy stemming from a lack of knowledge of the bacterial load and because of several obstacles such as low intravascular volume and the risk of causing anaemia.

The Pediatric Infectious Disease Journal. 38(12):1163-1167

BACKGROUND: The objective is to compare the prevalence of serious bacterial infection (SBI) and invasive bacterial infection (IBI) in febrile infants <60 days of age and in those between 61 and 90 days.

METHODS: Prospective registry-based cohort study including all the infants ≤90 days with fever without a source evaluated in a pediatric emergency department between 2003 and 2017. We compared the prevalence of SBI and IBI in febrile infants <60 days of age and those between 61 and 90 days.

RESULTS: We included 3,301 infants. Overall, 605 (18.3%) had a SBI (mainly urinary tract infection), of these 81 (2.5%) had an IBI (bacteremia 60, meningitis 12, sepsis 9). The prevalence of SBI in infants >60 days old was 18.5% (95% CI: 16.4-20.7) versus 16.6% (95% CI: 14.7-18.7; n.s.) in those between 29 and 60 days and versus 21.5% (95% CI: 18.6-24.7; n.s.) in those <28 days of age. The prevalence of IBI among infants >60 days old was 1.1% (95% CI: 0.6-2.2) versus 2.3% (95% CI: 1.6-3.3; P < 0.05) in those between 29 and 60 days and 5.1% (95% CI: 3.7-7.0; P < 0.05) in those <28 days of age. The prevalence of IBI in well appearing >60 days was 1.0% (versus 4.5% in those <28 days old, P < 0.01; and 2.0% in those between 29 and 60 days, P = 0.06). All bacterial meningitis, except one, were diagnosed in infants <28 days.

CONCLUSIONS: The prevalence of IBI in febrile infants between 61 and 90 days of age is high enough to support the recommendation for obtaining urine and blood tests in this population.

IMPORTANCE: The neonatal early-onset sepsis (EOS) calculator is a clinical risk stratification tool increasingly used to guide the use of empirical antibiotics for newborns. Evidence on the effectiveness and safety of the EOS calculator is essential to inform clinicians considering implementation.

OBJECTIVE: To assess the association between management of neonatal EOS guided by the neonatal EOS calculator (compared with conventional management strategies) and reduction in antibiotic therapy for newborns.

DATA SOURCES: Electronic searches in MEDLINE, Embase, Web of Science, and Google Scholar were conducted from 2011 (introduction of the EOS calculator model) through January 31, 2019.

STUDY SELECTION: All studies with original data that compared management guided by the EOS calculator with conventional management strategies for allocating antibiotic therapy to newborns suspected to have EOS were included.

DATA EXTRACTION AND SYNTHESIS: Following PRISMA-P guidelines, relevant data were extracted from full-text articles and supplements. CHARMS (Checklist for Critical Appraisal and Data Extraction for Systematic Reviews of Prediction Modeling Studies) and GRADE (Grades of Recommendation, Assessment, Development and Evaluation) tools were used to assess the risk of bias and quality of evidence. Meta-analysis using a random-effects model was conducted for studies with separate cohorts for EOS calculator and conventional management strategies.

MAIN OUTCOMES AND MEASURES: The difference in percentage of newborns treated with empirical antibiotics for suspected or proven EOS between management guided by the EOS calculator and conventional management strategies. Safety-related outcomes involved missed cases of EOS, readmissions, treatment delay, morbidity, and mortality.

RESULTS: Thirteen relevant studies analyzing a total of 175 752 newborns were included. All studies found a substantially lower relative risk (range, 3%-60%) for empirical antibiotic therapy, favoring the EOS calculator. Meta-analysis revealed a relative risk of antibiotic use of 56% (95% CI, 53%-59%) in before-after studies including newborns regardless of exposure to chorioamnionitis. Evidence on safety was limited, but proportions of missed cases of EOS were comparable between management guided by the EOS calculator (5 of 18 [28%]) and conventional management strategies (8 of 28 [29%]) (pooled odds ratio, 0.96; 95% CI, 0.26-3.52; P = .95).

CONCLUSIONS AND RELEVANCE: Use of the neonatal EOS calculator is associated with a substantial reduction in the use of empirical antibiotics for suspected EOS. Available evidence regarding safety of the use of the EOS calculator is limited, but shows no indication of inferiority compared with conventional management strategies.

It has been almost 20 years since the first conjugated pneumococcal vaccine (PCV) was introduced into childhood immunization schedules in the United States. Dramatic reductions in invasive pneumococcal disease (IPD) burden have been reported not only among children targeted for vaccination but also among unvaccinated children and adults in all settings following widespread use of the vaccine. These reductions are associated with reductions in nasopharyngeal colonization by vaccine serotypes and reduced transmission from vaccinated children.1 However, disease is not evenly distributed, and children with underlying clinical conditions are disproportionately represented among cases of IPD, especially among children older than 5 years.

Este articulo muestra los resultados de un Ensayo clínico en Fase III de la vacuna tetravalente contra el dengue ( TAK-003) realizado en regiones de Asia y Sudamérica donde la enfermedad es endémica. Concluye que la vacuna se ha mostrado eficaz en esas circunstancias.

Las infecciones fúngicas invasoras (IFI) constituyen un problema creciente en adultos y niños inmunodeprimidos, acompañándose de una elevada morbimortalidad. El número de niños inmunodeprimidos va en aumento. Los grupos de riesgo de IFI en pediatría incluyen a los grandes prematuros, que se benefician de profilaxis con fluconazol, pacientes hemato-oncológicos sometidos a quimioterapia o trasplante de precursores hematopoyéticos con neutropenias prolongadas, en quienes la profilaxis frente a hongos filamentosos suele recomendarse en situaciones de alto riesgo. En niños sometidos a trasplante de órgano sólido, la profilaxis depende del tipo de trasplante y factores de riesgo asociados. En pacientes con inmunodeficiencias primarias o adquiridas como la infección VIH o tratamiento inmunosupresor prolongado, la profilaxis antifúngica dependerá del tipo de inmunodeficiencia primaria y del grado de inmunosupresión. La enfermedad granulomatosa crónica tiene riesgo particularmente elevado de IFI y requiere siempre profilaxis frente a hongos filamentosos. En cambio, en niños con ingresos prolongados en cuidados intensivos la profilaxis frente a IFI habitualmente no está indicada. El tipo de profilaxis está limitado por la diferente aprobación de antifúngicos a distintas edades. Este documento pretende revisar la información actual disponible respecto a profilaxis antifúngica en niños, con propuesta para la estrategia más apropiada en cada tipo de paciente.

Question What is the frequency of primary immunodeficiency in children with invasive pneumococcal disease since the availability of pneumococcal vaccine?

Findings In this systematic review of 17 studies that included 6022 unique patients with primary invasive pneumococcal disease, children older than 2 years without a known predisposing condition presenting with their first episode of Streptococcus pneumoniae meningitis or pneumonia or recurrent invasive pneumococcal disease had rates of primary immunodeficiency as high as 26%.

Meaning This study’s findings suggest that immune evaluation may need to be considered in all children older than 2 years presenting with invasive pneumococcal disease, including assessment for immunoglobulin deficiency, specific antibody deficiency, complement disorders, and asplenia.

Abstract Importance Despite increasing access to vaccination, invasive pneumococcal disease (IPD) is responsible for approximately 826 000 deaths worldwide in children younger than 5 years each year. To allow early identification and prevention, an improved understanding of risk factors for IPD is needed.

Objectives To review the literature on the prevalence of primary immunodeficiency (PID) in children younger than 18 years presenting with IPD without another predisposing condition and to inform guidelines for immunologic evaluation after the first episode of IPD based on published evidence.

Findings In 6022 unique children with primary IPD, 5 of 393 (1.3%) to 17 of 162 (10.5%) of all children and 14 of 53 (26.4%) of those older than 2 years had a PID identified. Higher rates of PID, up to 10 of 15 (66.7%), were found in children with recurrent IPD. Antibody deficiency was the most common immunodeficiency, followed by complement deficiency, asplenia, and rarer defects in T-cell signaling. The site of infection was a key indicator for the risk of underlying PID, with the greatest risk of PID in children with meningitis or complicated pneumonia.

Conclusions and Relevance Results of this study suggest that invasive pneumococcal disease, and particularly recurrent IPD, is an important marker of underlying PID in children without other risk factors. The findings also suggest that children older than 2 years with pneumococcal meningitis or complicated pneumonia and all children with recurrent IPD should be referred for an immune evaluation.

The Pediatric Infectious Disease Journal. 38(12):1168-1172, December 2019.

OBJECTIVES: To perform a comprehensive description of the epidemiology of Streptococcus pyogenes invasive disease in the pediatric population in 2 regions of Spain (Catalonia and Gipuzkoa) through 12 years.

METHODS: All S. pyogenes isolates causing invasive disease in pediatric patients between 2005 and 2016 were included. The emm-type and the presence of 13 exotoxin genes (speA, speB, speC, speF, speG, speH, speI, speJ, speK, speL, speM, smeZ, ssa and slo) were determined in all 93 available isolates and the Multi Locus Sequece Typing in 10% of isolates of each different emm-type.

RESULTS: Overall, 103 cases of S. pyogenes invasive infections were detected: 77 in Catalonia and 26 in Gipuzkoa, being 50.5% females. The incidence rate per 100,000 children was 2.5 for Gipuzkoa and 2.6 for Catalonia, with no significant temporal trends. The median age was 30 months. The most frequent clinical presentations were: pneumonia (26.2%), bacteremia/sepsis (23.3%), septic arthritis/osteomyelitis (22.3%), cellulitis/mastoiditis (12.6%) and meningitis (6.8%). Eight children developed streptococcal toxic shock syndrome. Nine cases were preceded by varicella infection. The associated mortality rate was 3.9%. Three isolates were resistant to erythromycin, being one of them also resistant to clindamycin and 4 isolates were resistant to levofloxacine. Forteen different emm-types were detected being emm1/ST28 (40.9%) the most frequent clone in both regions followed by emm12/ST36-ST242, emm6/ST382, emm3/ST15, emm75/ST150 and emm4/ST38-39. speA gene was only detected in emm1 and emm3 isolates. Eight exotoxins were enough to assign an emm-type with a very high degree of accuracy (95%). The 30-valent vaccine would include 96.8% of isolates.

To describe the rate and risk factors of deep neck space involvement of Kawasaki disease. Study design We performed a retrospective analysis using the Kids' Inpatient Database from 2006, 2009, 2012, and 2016. Kawasaki disease and deep neck space involvement cases were identified using International Classification of Diseases codes among children aged <12 years. Demographic and outcome data of Kawasaki disease cases with and without deep neck space involvement were compared.

Results Of 20 787 patients with Kawasaki disease, 0.6% (130 cases) had deep neck space involvement. On multivariable analysis, children aged ≥4 years (OR 8.41; 95% CI 3.79-18.7 in those aged 6-11 years), Asian or Pacific Islanders (OR 3.72; 95% CI 1.90-7.27), non-Hispanic black children (OR 2.39; 95% CI 1.34-4.28), and Northeast hospital region (OR 2.32; 95% CI 1.21-4.46) were associated with deep neck space involvement. Surgical drainage was performed in 21.7% of patients with deep neck space involvement. Deep neck space involvement was associated with longer hospital stay and greater costs.

Conclusions. Approximately 0.6% of patients with Kawasaki disease present with deep neck space involvement in the US. Deep neck space involvement of Kawasaki disease occurs primarily in older (≥4 years old), non-white, non-Hispanic children. Deep neck space involvement is associated with operative procedures for presumed abscess, longer hospital stay, and greater costs. In caring for children with suspected deep neck space abscess, particularly when they are not responding to antibiotics, clinicians should evaluate them for the possibility of Kawasaki disease.

Resumen: la introducción en calendario de la vacuna decavalente neumocócica conjugada en Kenia, acompañada de una campaña de recuperación, dio como resultado una sustancial reducción de enfermedad neumocócica invasiva en niños y adultos sin que se haya detectado remplazamiento significativo de otros neumococos productores de enfermedad invasiva.

Resumen: la disminución rápida de la inmunidad durante los primeros años después de la vacunación por encima de los 9 meses de edad da soporte a una revisión de la recomendación de dosis única para esta población objetivo en países endémicos. La corta duración de la inmunidad en muchos vacunados sugiere que la vacuna de refuerzo es necesaria para alcanzar el umbral de inmunidad de la población del 80% para la prevención de brotes de fiebre amarilla.

The Pediatric Infectious Disease Journal. 38(12):e320-e325, December 2019.

BACKGROUND: The impact of universal 13-valent pneumococcal conjugate vaccine immunization on pediatric empyema rates and pathogens in Australia is not known. We aimed to describe empyema epidemiology, clinical characteristics and treatment during an 8-year period.

METHODS: A retrospective study between 2011 and 2018 of empyema cases admitted to a large pediatric referral hospital, for management with either pleural drainage and fibrinolytics or surgical intervention.

RESULTS: There were 195 cases in 8 years. Empyema incidence and ICU admission rates significantly increased during the study with a peak incidence of 7.1/1000 medical admissions in 2016 (χ for trend of incidence 37.8, P < 0.001 and for ICU admissions 15.3, P < 0.001). S. pneumoniae was the most common pathogen (75/195, 39%) with serotype 3 the most detected (27/75: 27%). S. pyogenes compared with S. pneumoniae had significantly fewer days of fever before admission (3.9 vs. 6.4, mean difference 2.4, 95% CI: 0.84-4.08, P = 0.003) and higher proportion requiring direct ICU admission (6/75; 8% vs. 7/15; 47%, P < 0.001). Compared with S. pneumoniae, cases with no pathogen detected by culture or PCR had fewer days of fever post intervention (4.4 vs. 7.4 days, mean difference 2.7 days, P = 0.002). S. aureus occurred more commonly in infants (10/25; 40% vs. 1/75; 1%, P < 0.001) and children of indigenous background (5/25; 20% vs. 1/75; 1%, P < 0.001) compared with S. pneumoniae.

CONCLUSIONS: We report increasing rates of pediatric empyema with higher proportions requiring ICU treatment. The most common pathogens detected were S. pneumoniae, S. aureus and S. pyogenes. Despite high 13-valent pneumococcal conjugate vaccine coverage, serotype 3 was the most common S. pneumoniae serotype identified.

The Pediatric Infectious Disease Journal. 38(12):1208-1213, Abstract

BACKGROUND: Several studies have shown an increasing trend in pediatric Clostridium difficile infection (CDI). However, the Public Health Agency in Sweden reports a decreasing incidence of CDI in the Swedish population since 2007. The main aim of this study is to analyze the epidemiology of CDI in children.

METHODS: Retrospective chart-review of patients 1 to <19 years old, positive for Clostridium difficile toxin B, tested at Karolinska University Hospital Units, over the time period from July 1, 2010 to June 30, 2018. Episodes were classified as recurrences (≥2 weeks, ≤8 weeks from previous episode) or new episodes (>8 weeks from previous episode). New episodes were classified as hospital- (HA-CDI) or community-associated (CA-CDI). Annual infection rates/100,000 children in the catchment area were calculated.

RESULTS: Three hundred twenty-eight positive tests in 206 patients were included of which 259 (79.0%) tests were new episodes and 69 (21.0%) recurrences. In 63/206 (30.6%) children, >1 episode of CDI was recorded. The mean infection rate was 8.5/100,000 children. There was an overall increasing trend in CDI-rate July 2010-June 2018, however not statistically significant (P = 0.061) nor for the incidence in HA-CDI (P = 0.720) or CA-CDI (P = 0.179). Underlying medical conditions were present in 226/259 (87.3%) new episodes of which the most common was malignancy. Of the new episodes, 188/259 (72.6%) were HA-CDI and 46/259 (17.8%) were CA-CDI.

 

CONCLUSIONS: There was an increasing trend in CDI in children in Sweden from 2010 to 2018, although not statistically significant. CDI was associated with comorbid conditions and repeated episodes were common.

Actualidad bibliográfica octubre 2019

TOP TEN

Streptococcus pneumoniae is the leading cause of bacterial infections in children, including meningitis, bacteremia, bacteremic pneumonia, empyema, and mucosal infections such as otitis media and non-bacteremic pneumonia. After the implementation of pneumococcal conjugate vaccines (PCVs), worldwide, the burden of invasive pneumococcal diseases (IPDs) and non-invasive pneumococcal diseases due to vaccine serotypes (VTs) greatly decreased in children.1 However, since 2015, several European countries have reported an increased incidence of IPDs due to non-vaccine serotypes (NVTs), which seemed variable across countries in terms of magnitude, serotypes involved, and clinical entities.1, 2, 3, 4 This led to questions regarding the long-term benefit of PCVs.

This commentary presents an overview of serotype replacement in pneumococcal carriage and diseases in Europe, with a focus on IPDs. The aim is to raise awareness among pediatricians and healthcare professionals of the potential factors involved in the phenomenon of serotype replacement diversity after PCV implementation. In addition, we analyze the potential factors involved in this phenomenon. We selected European observational studies assessing the impact of PCV10 and PCV13 beyond 5 years after their implementation at the population level in children. We reviewed the literature in MEDLINE via PubMed, with no time or language restriction (last search June 30, 2019). The search algorithm was based on a combination of terms related to “13-or 10-valent PCV,” “pneumococcal diseases or pneumococcal carriage,” and “impact/effect/change.” We completed this search by screening the reference lists of the selected articles.

In the 2017 annual report of the European Centre for Disease Prevention and Control,8 based on data from 29 European countries, when summarizing serotypes implicated in IPD in children <5 years old, serotype 24F ranked first (10.6% of cases), followed by serotypes 3 (8.5%), 12F (7.8%), 19A (7.2%), and 10A (6.9%).8

The frequency of pneumonia greatly decreased but not that of meningitis or bacteremia without source.9 Finally, the incidence of noninvasive pneumonia and otitis media seems not affected by the serotype replacement.19,20

Estudio aleatorizado controlado de no inferioridad, en 17 centros de atención primaria de salud en Suecia, entre septiembre de 2015 y febrero de 2018. Participaban pacientes de 6 o más años con faringoamigdalitis causada por SBHGA (cumplían tres o cuatro criterios de Centor y una prueba rápida de detección de antígeno positiva para el estreptococo del grupo A.). El objetivo era determinar si la exposición total a la penicilina V puede reducirse mientras se mantiene una eficacia clínica adecuada.

Intervenciones: Penicilina V 800 mg cuatro veces al día durante cinco días (total 16 g) en comparación con la dosis actual recomendada de 1000 mg tres veces al día durante 10 días (total 30 g).

Principales medidas de resultado: El resultado principal fue la curación clínica de cinco a siete días después del final del tratamiento con antibióticos. Los resultados secundarios fueron la erradicación bacteriológica, el tiempo de alivio de los síntomas, la frecuencia de recaídas un mes después del primer diagnóstico, la frecuencia de complicaciones y de faringoamigdalitis nuevas durante el período de estudio.

Conclusiones: La penicilina V cuatro veces al día durante cinco días no fue inferior en el resultado clínico a la penicilina V tres veces al día durante 10 días en pacientes con faringoamigdalitis causada por SBHGA. El número de recaídas y complicaciones no fue diferente entre los dos grupos de intervención. El tratamiento de cinco días con penicilina V cuatro veces al día podría ser una alternativa al régimen de 10 días actualmente recomendado. OK, aunque el tratamiento recomendado no son 1000 mg 3 veces al día, si no una vez al día… Me parecen dosis altísimas, tanto la que se estudia como con la que se compara… Me llama la atención que la tasa de algunos efectos secundarios, los más frecuentes, sea más baja con la tasa de 5 días. Aunque no pone si las diferencias son significativas.

CASOS CLÍNICOS

Niña de 9 años con fiebre leve durante cuatro días y erupción cutánea durante dos días. Presenta disminución de los recuentos de glóbulos blancos, plaquetas y reticulocitos. En la reacción en cadena de la polimerasa cuantitativa en suero para el ADN del parvovirus B19 mostró 10 6 copias / ml (rango de referencia: <100).

La erupción petequial localizada, como por ej. distribución en traje de baño (figura) o el síndrome purpúrico-papular en guante y calcetín, puede ocurrir durante la fase inicial de la viremia, pero es inusual.

Es prioritario descartar la enfermedad meningocócica.

La manifestación más típica del parvovirus B19 (erupción en forma de "mejilla abofeteada") generalmente aparece después de la fase inicial de viremia.

A 4-year-old previously healthy boy presented to the emergency department for evaluation of 5 days of fever and 6 days of diffuse pustular rash. Three days prior, he had been evaluated by his pediatrician and started on azithromycin for streptococcal infection, diagnosed by positive rapid streptococcal testing. Dermatology was consulted to evaluate for possible acute generalized exanthematous pustulosis (AGEP).

On examination, the patient was febrile (temperature 40.1°C). He had pustules diffusely distributed on his trunk and extremities, with confluence of lesions in the groin (Figure 1, A and B). His hands and feet were edematous, and palms and soles were erythematous. He had dry fissured lips, red strawberry tongue (Figure 2; available at www.jpeds.com), limbal-sparing nonexudative conjunctival injection, and cervical and inguinal lymphadenopathy. Laboratory results demonstrated sterile pyuria, normocytic anemia, hyponatremia, and elevated inflammatory markers. Based on the clinical and laboratory findings, Kawasaki disease was diagnosed. Echocardiogram revealed no structural abnormalities and normal coronary arteries. He was treated with intravenous immunoglobulin 2 g per kg and aspirin. Within 1 day of receiving intravenous immunoglobulin, his conjunctivitis resolved, and his rash improved with subsequent desquamation of involved areas. His fevers resolved over 48 hours, inflammatory markers trended downward, and he was discharged on hospital day 3. His rash had completely resolved at a 10-day follow-up visit. Repeat echocardiograms 10 days and 6 weeks later remained normal.

A 3-year-old boy presented to the emergency department with a 5-day history of a progressive painful swelling to his scalp. He had recently returned to Australia following a 3-month vacation in East Africa. He was systemically well, with no previous medical history of note. Just before presentation, apparent movement had been noted at the punctum of the lesion, and a single larva had been expressed and removed by the patient's mother.

Examination revealed a 10-mm-wide, nonfluctuant furuncular swelling overlying the occiput with a 5-mm-wide crusted punctum (Figure 1). There were no other cutaneous lesions, and the remainder of the examination was unremarkable. The larva (Figure 2), brought in by the patient's mother, was 18 mm long and still motile (Video; available at www.jpeds.com).

The larva was identified as that of the Tumbu fly (Cordylobia anthropophaga. C. anthropophaga is a common cause of furuncular myiasis in sub-Saharan Africa.1 .

The Pediatric Infectious Disease Journal. 38(10):e277-e278

We read the article by Gordon et al1 regarding the clinical presentation of Pediatric Mycoplasma pneumoniae infections. In their article, the authors stated that fever accompanied 33.4% of patients, and duration of symptoms was between 3 and 9 days. Different than these findings herein 4 cases of M. pneumoniae with community-associated pneumonia presenting with fever without a focus are presented.

Four cases of mycoplasma, between 4 and 17 years of age were admitted with prolonged fever and rash to our centers. The duration of fever was 8–28 days before onset of pneumonia. Signs of pneumonia (like dyspnea or retraction, rales on physical examination) and pneumonic infiltration on chest radiograph were not present at admission and all occurred after prolonged fever.

Nasopharyngeal viral multiplex polymerase chain reaction was negative but mycoplasma polymerase chain reaction was positive for all 4 patients and they all responded well to macrolide therapy. Fever was the first resolving symptom and dropped off in 24 hours of treatment.

Gordon et al also reported that children older than 6 years were more likely to have chest radiograph–confirmed pneumonia, while younger children were more likely to have other respiratory manifestations. But it should be kept in mind that radiologic or physical findings might be absent and prolonged fever could be the only symptom at admission likewise in our patients.

Signs and symptoms of M. pneumoniae infections are not unique,

From July 2009 to July 2015, Staphylococcus aureus isolated from pediatric sterile sites were selected from inpatients at the Santa Casa São Paulo Hospital, in Brazil. Polymerase chain reaction was used to detect mecA and lukS-PV/lukF-PV genes. The rate of methicillin-resistant Staphylococcus aureus was 37.7%. Ten isolates had the lukS-PV/lukF-PV genes, 2 of which were methicillin-resistant Staphylococcus aureus. Skin and soft tissues infections were significantly associated with lukS-PV/lukF-PV positive isolates, P = 0.008.

Niña, 2 años, consulta por tumoración preauricular derecha. Correctamente vacunada y sin antecedentes de interés. Los progenitores son procedentes de Ecuador; el padre tuvo tuberculosis pulmonar tratada correctamente hace 10 anos. EF :masa a nivel de parótida de 0,5 cm, blanda, dolorosa y picos febriles al inicio del cuadro. Se orienta como parotiditis vírica. Serologías negativas. Se prescriben antiinflamatorios durante una semana. Presenta empeoramiento tras 20 días de su inicio. Ecografía imagen polilobulada de 25 mm en la parótida derecha y adenopatías laterocervicales y mastoideas sugestivas de proceso inflamatorio abscesificado. Se inicia amoxicilina clavulánico sin respuesta a los 7 días ampliándose estudio. El Mantoux fue positivo (12 mm). Se realiza Quantiferon que resulta negativo. Se practica PAAF con cultivo positivo para Mycobacterium malmoense. Se inicia isoniacida, rifampicina, etambutol y claritromicina. La lesión se confirma por resonancia magnética y . Se drena. Tras 9 meses de tratamiento la lesión se mantiene estable, realizándose exéresis quirúrgica . En ninos, la adenitis cervical es la afectación más frecuente de la infección por micobacterias no tuberculosas (MNT) y afecta a menores de 5 anos sin comorbilidad. El compromiso de la glándula parótida es infrecuente. Mycobacterium avium-intracellulare complex es el patógeno más prevalente. En el norte de Europa M. malmoense es una de las MNT de mayor incidencia. El mecanismo de transmisión por MNT es aún incierto. Suelen ser lesiones unilaterales, indoloras, con evolución subaguda, tendencia a la cronicidad, aumento progresivo de tamaño y formación de fístulas, aunque pueden resolverse espontáneamente1-3,8. DX diferencial: adenitis bacteriana, tuberculosa, y en menor frecuencia con tumores parotídeos. La confirmación diagnóstica se obtiene mediante aislamiento microbiológico a partir de muestras de PAAF o exéresis quirúrgica. La ecografía es la prueba de elección; la TAC y la RMN están indicadas previas a la cirugía.m

EL Mantoux es positivo en 30 -60% de ninos, siendo poco útil para establecer el diagnóstico diferencial con Mycobacterium tuberculosis. Sin embargo, las pruebas de mediciónde interferón gamma inducido (IGRA) son típicamente negativas, La identificación de MNT mediante técnicas de diagnóstico molecular permite el aislamiento rápido del patógeno, con una sensibilidad de hasta ≥ 90%. El tratamiento es controvertido. Se recomienda farmacoterapia combinada para evitar resistencias, incluyendo un macrólido asociado a rifabutina, fluoroquinolonas o etambutol, durante un mínimo de 6 meses. La intervención quirúrgica, en algunos estudios considerada de elección, no está exenta de complicaciones: sobreinfecciones de la herida quirúrgica y lesiones neurovasculares, como parálisis del nervio facial.

Niño de 2 meses , prematuro 26 + 5 semanas (35 semanas corregidas) y 757 g. Presentaba distrés respiratorio y posible hemorragia intraventricular derecha junto con un ductus arterioso persistente, cerrado mediante cirugía. Ante un empeoramiento de su estado clínico, se enviaron al servicio de microbiología muestras de piel de pericatéter y 2 hemocultivos seriados. Los datos analíticos más importantes fueron: PCR 24,9 mg/l, Hb 8,7 g/dl, neutrófilos 9,22 × 103/l, hematocrito 29,5%, plaquetas 75 × 103/l. El primer hemocultivo extraído a través de la vena periférica fue positivo a las 23 h de incubación y el segundo a las 17 h. El microorganismo fue identificado como Herbaspirillum huttiense mediante espectrometría de masas. El aislado resultó resistente a colistina y amikacina, pero sensible a trimetoprim-sulfametoxazol , meropenem , ceftazidima, levofloxacina y minociclina.. Tras el informe se decidió cambiar el tratamiento de ceftriaxona a cefotaxima y posteriormente a meropenem. Tanto los hemocultivos de control y el cultivo de posteriores fueron estériles.

Mycoplasma pneumoniae pneumonia is prevalent in children and can be followed by upper airway carriage for months. Treatment of M pneumoniae pneumonia with macrolides is widespread and can lead to the development of macrolide resistance. The clinical consequences of chronic M pneumoniae carriage are unknown. In this article, we describe a child with acute lymphoblastic leukemia who developed macrolide-susceptible M pneumoniae pneumonia confirmed by nasopharyngeal secretions polymerase chain reaction and culture with good response to azithromycin. Five months later, the patient developed another M pneumoniae pneumonia that was diagnosed with positive macrolide-resistant M pneumoniae polymerase chain reaction and culture from the bronchoalveolar lavage.

Congenital syphilis (CS) is a preventable infection, yet the incidence has surged to the highest rates in 20 years. Because 50% of live-born infants with CS are asymptomatic at birth, there is an increasing likelihood that pediatric providers will encounter older infants whose diagnoses were missed at birth, emphasizing the importance of timely prenatal screening and treatment. We present one such case of an infant admitted twice at 3 and 4 months of age with long bone fractures and suspected nonaccidental trauma. On her second presentation, several additional symptoms prompted evaluation for and eventual diagnosis of CS. In this case, it is demonstrated that an isolated long bone fracture can be a first presentation of CS, with other classic findings possibly appearing later. Pediatric providers should be familiar with the varied presentations of CS in older children, including the radiographic findings that we describe. The rising rates of CS reveal deficiencies in our current strategy to prevent CS and, thus, we recommend reconsideration of universal syphilis screening in the third trimester and at delivery, with timely treatment to prevent CS during pregnancy.

PARA AMPLI​AR

Describir las características epidemiológicas de un importante brote de tuberculosis en el ámbito universitario y los principales factores de riesgo asociados.

Método

Se realizó un análisis descriptivo de los datos recogidos de las personas enfermas y de los contactos. Para el estudio de contactos se siguieron las pautas establecidas en el Programa de Tuberculosis de la Comunidad Autónoma del País Vasco. Seis de las cepas del brote fueron enviadas al Centro Nacional de Microbiología para su tipado molecular.

Resultados

El número total de casos del brote fue de 11. La tasa de infección tuberculosa en el aula del caso índice, incluidas las personas enfermas, fue del 88,1% (59 infectados y solo 8 no infectados). La demora diagnóstica del caso índice fue de 260 días, y en los otros 8 casos sintomáticos osciló entre 10 y 70 días. El patrón obtenido por las 2técnicas de genotipado fue idéntico en las 6 cepas estudiadas.

Conclusiones

La gran demora diagnóstica del caso índice auténtico, que se diagnosticó en el estudio de contactos, y las malas condiciones de ventilación del aula determinaron el alto número de casos secundarios asociados a este brote.

El propósito de este estudio fue evaluar las características demográficas y clínicas de los niños con neumonía adquirida en la comunidad (NAC) por Mycoplasma pneumoniae (Mp) como única bacteria (Mp mono-detección) y Mp en co-detección (virus, bacterias: Streptococcus pneumoniae, Hemophilus influenzae, Staphylococcus aureus)

Los resultados fueron: En el 38.18% presentaban una co-detección con al menos otro patógeno. La detección conjunta fue más común entre los niños de ≤3 años. No se encontraron diferencias significativas en la mayoría de los síntomas clínicos, complicaciones, afecciones subyacentes y parámetros de gravedad de la enfermedad entre los grupos etiológicos, con las siguientes excepciones. Primero, la duración prolongada de la fiebre, la falta de apetito y el goteo nasal fueron más frecuentes entre los niños con NAC y la detección conjunta de metaneumovirus. En segundo lugar, los pacientes con co-detección con virus (excluyendo rinovirus) tenían más probabilidades de presentar fiebre prolongada. En tercer lugar, los

pacientes con co-detección de MP-bacterias tenían más probabilidades de tener alteración de los gases sanguíneos. Además, los niños con NAC y co-detección Mp-rinovirus tenían significativamente más probabilidades de presentar secreción nasal severa en comparación con aquellos con monodetección por Mp

Conclusión: La detección conjunta de Mp con patógenos virales y / o bacterianos es común en la práctica clínica. Sin embargo, no hay diferencias aparentes entre la monodetección de Mp y las codetecciones de Mp en términos de características clínicas y gravedad de la enfermedad.

. Actualmente, en niños hospitalizados con neumonía adquirida en la comunidad (NAC), Staphylococcus aureus es el agente etiológico del 1% de los casos y del 15% de las NAC típicas bacterianas. Además, se ha evidenciado un incremento progresivo en la proporción de cepas de S. aureus resistentes a meticilina (SARM). Estos aislamientos se caracterizan por tener una alta virulencia, al producir con más frecuencia leucocidina de Panton-Valentine (LPV) siendo las neumonías por SARM más frecuentes en niños de menor edad, especialmente en lactantes. Se ha realizado una revisión retrospectiva de los niños menores de 2 años ingresados en nuestro hospital por NAC por SARM en los últimos 5 años (2013-2017). Se identificaron 3 casos, todos menores de 6 meses y nacidos en España de familias inmigrantes. Los 3 desarrollaron neumonías graves, asociadas a derrame pleural y necrosis parenquimatosa con empeoramiento clínico con el tratamiento antibiótico habitual. Todos los aislamientos fueron sensibles in vitro a clindamicina y trimetoprim-sulfametoxazol. Tras conocer el resultado del cultivo, se modificó la pauta antibiótica a linezolid en 2 casos, manteniendo vancomicina en el otro, pero que se tuvo que sustituir después por linezolid por mala evolución.

La resistencia a meticilina en S. aureus adquirido en la comunidad en niños suponen entre un 5 y un 10% de los aislamientos de S. aureus comunitarios en niños 5. La mayoría de los casos comunicados son infecciones de piel y partes blandas5. Las NAC por S. aureus destacan por presentar alta mortalidad (1-5%)6 y mayor riesgo de necrosis pulmonar y desarrollo de abscesos. Las neumonías por SARM presentan con frecuencia consolidación unilateral, neumatoceles y derrame pleural, y son más frecuentes en lactantes pequeños. El estado de portador de SARM incrementa hasta 6 veces el riesgo de neumonía por esta cepa3, siendo la transmisión intrafamiliar muy alta. La colonización en España es más frecuente en la población inmigrante, especialmente procedente de Sudamérica. Existe actualmente un amplio debate sobre la necesidad de descolonización en niños y sus convivientes. Parece prudente llevarlo a cabo en niños que presenten factores de riesgo, como grandes prematuros, inmunodeprimidos o pacientes ingresados en unidades de cuidados intensivos, así como en sus familiares. La Academia Americana de Pediatría recomienda el uso de vancomicina o clindamicina en el caso de neumonías con sospecha de SARM. Linezolid es una excelente alternativa, aunque el uso de linezolid en pediatría es off-label.

En conclusión, debe sospecharse SARM como agente causal de las NAC con empeoramiento clínico y radiológico progresivo (necrosis y derrame pleural) a pesar del tratamiento antibiótico empírico convencional, especialmente en lactantes hijos de familias inmigrantes. Linezolid constituye una buena alternativa a vancomicina en estos pacientes.

Background: The use of bacterial multiplex polymerase chain reaction (PCR) in children with suspected pertussis sometimes yields unexpected positive results for Mycoplasma pneumoniae. We aimed to evaluate the clinical significance of positive M. pneumoniae results in this population.

Methods: Retrospective cohort of consecutive patients with suspected pertussis tested with a bacterial multiplex PCR (including Bordetella pertussis and M. pneumoniae) between June 2015 and March 2017. Medical records were reviewed to compare demographics, clinical presentations and outcomes of patients positive for M. pneumoniae with those positive for B. pertussis and those with negative results, using multivariable logistic regression.

Results: A total of 1244 patients were included as follows: 56 (4.5%) with M. pneumoniae, 116 (9.3%) with B. pertussis and 1029 (82.7%) with negative results. Mean age was respectively 4.8 years, 6.5 years and 2.8 years (P < 0.05). Children with M. pneumoniae were less likely to present with cardinal symptoms of pertussis such as paroxysmal cough [adjusted odds ratio (OR): 0.19, 95% confidence interval (CI): 0.08–0.40) but were more likely to have fever (adjusted OR: 10.53, 95% CI: 3.54–39.49) and other nonspecific respiratory symptoms compared with children with B. pertussis. Children with M. pneumoniae had very similar clinical presentations to those with a negative PCR, but were more likely to have radiologically confirmed pneumonia (adjusted OR: 5.48, 95% CI: 2.96–9.99) and were less likely to be diagnosed with a concomitant viral infection (adjusted OR: 0.32, 95% CI: 0.07–0.99).

Conclusions: In children with suspected pertussis, the detection of M. pneumoniae is clinically relevant. However, the impact of this finding on patients’ outcome is still unclear.

Background: Intestinal parasitic infections (IPIs) represent one of the leading causes of morbidity in the world. Children involved in international adoptions constitute a special group of subjects with specific problems and specific healthcare needs. Nevertheless, in current literature there are insufficient data on IPI in this subset of children. This study aims to evaluate the prevalence of IPI in a cohort of internationally adopted children and to investigate epidemiologic factors and clinical features related to IPIs.

Methods: A retrospective study involving internationally adopted children <18 years old for which results from 3 fecal parasitologic tests were available, evaluated between September 1, 2008 and April 31, 2018 at a tertiary level university hospital in Rome. Univariate and multivariate logistic regression analyses were carried out to identify demographic factors and clinical features associated with IPIs. Two comparisons were performed, the first one according to the positivity of the parasitologic examination of the feces and the second one according to the pathogenicity of the identified strains.

Results: Of 584 children evaluated, 346 (59.3%) had a positive parasitologic examination (143 pathogenic parasites and 203 nonpathogenic parasites) and 238 (40.8%) had a negative parasitologic examination. About 28.9% of children were positive for 2 or more parasites. A statistically significant positive association was found between IPIs and age, macroarea of origin (Africa and Latin America), living in institutions before adoption and vitamin D deficiency (P < 0.05).

Conclusions: Intestinal parasites represent a widespread infection among internationally adopted children, especially in school-age children and those from Latin America and Africa. Importantly, the parasites found in adopted children were not pathogenic in most cases and did not cause significant alterations in growth, major micronutrient deficits or malnutrition.

The aim of this Cochrane Review was to assess the impact of improved disposal of child faeces on diarrhoea and soil-transmitted helminth (STH) infection. We collected and analysed all relevant studies and found 63 studies covering over 222,800 participants.

Evidence suggests that the safe disposal of child faeces may be effective in preventing diarrhoea. However, the evidence is limited and of low certainty. The limited research on STH infections provides only low and very-low certainty evidence around effects, which means there is currently no reliable evidence that interventions to improve safe disposal of child faeces are effective in preventing such STH infections.

While child faeces may represent a source of exposure to young children, interventions generally only address it as part of a broader sanitation initiative. There is a need for RCTs and other rigorous studies to assess the effectiveness and sustainability of different hardware and software interventions to improve the safe disposal of faeces of children of different age groups.

Public health programmes to regularly treat all children with deworming drugs do not appear to improve height, haemoglobin, cognition, school performance, or mortality. We do not know if there is an effect on school attendance, since the evidence is inconsistent and at risk of bias, and there is insufficient data on physical fitness. Studies conducted in two settings over 20 years ago showed large effects on weight gain, but this is not a finding in more recent, larger studies. We would caution against selecting only the evidence from these older studies as a rationale for contemporary mass treatment programmes as this ignores the recent studies that have not shown benefit.

The conclusions of the 2015 edition have not changed in this update.

BACKGROUND: Although pharyngitis is common, group A Streptococcus is an uncommon etiology, and sequelae are rare in patients <3 years old. Inappropriate testing leads to increased cost of health care and unnecessary exposure to antibiotics. Rapid streptococcal tests (RSTs) for group A Streptococcus pharyngitis are not routinely indicated in this age group. At our urban, tertiary pediatric emergency department (ED), on average, 20 RSTs were performed each month for patients <3 years of age. Our objective was to reduce RSTs in the ED in patients aged <3 years by 50% in 18 months.

METHODS: We initiated this project in October 2016 at an urban, tertiary pediatric ED. We surveyed pertinent multidisciplinary stakeholders to identify factors leading to RSTs in children <3 years of age. We conducted multiple interventions and collected weekly data on the number of RSTs in children aged <3 years (outcome measure) and the number of family complaints and return visits for complications of pharyngitis (balancing measure). We used statistical process control for analysis.

RESULTS: The mean number of RSTs ordered per month in patients aged <3 years declined by 52% in 10 months. The majority of tests during the study phase were ordered by nurse practitioners (62%) for patients aged 25 to 36 months (66%). There has been 1 family grievance and no patient complications attributable to the project.

CONCLUSIONS: Our interventions led to a successful and sustained reduction of RSTs in patients aged <3 years. A local clinical practice guideline was developed, and the project was expanded to other acute care settings.

El incremento en las infecciones de transmisión sexual por Chlamydia trachomatis, incluyendo el linfogranuloma venéreo, y Mycoplasma genitalium registrado en la última década plantea nuevos retos para mejorar su control y reforzar su prevención. El diagnóstico clínico habitual (uretritis/cervicitis) debe completarse con una búsqueda activa de la infección en varones con disuria o proctitis, mujeres con enfermedad inflamatoria pélvica y contactos asintomáticos. El diagnóstico microbiológico debe basarse en técnicas moleculares, capaces de detectar Chlamydia trachomatis (diferenciando el genotipo L para linfogranuloma venéreo) y Mycoplasma genitalium (incluyendo idealmente la detección de cepas resistentes a macrólidos). Un diagnóstico más rápido y específico permitirá un tratamiento dirigido con la pauta antibiótica idónea. El manejo de estas infecciones de transmisión sexual debe incluir un estudio de los contactos sexuales y en ocasiones un test de cura. Finalmente, deben ser valorados los cribados de infección en grupos de población con mayor prevalencia.

A bronchiectasis exacerbation is defined by the British Thoracic Society (BTS) guidelines as an acute deterioration in the nature of the cough with increased sputum volume, purulence and viscosity. There may be breathlessness, wheeze and systemic symptoms.1 It is felt important to treat exacerbations due to concerns they may contribute to overall lung function decline which is related to overall prognosis.2 In the absence of culture results broad-spectrum antibiotics are used, with amoxicillin as first-line antibiotic for bronchiectasis exacerbations.1 The National Institute for Health and Care Excellence (NICE) guidelines also suggest amoxicillin, clarithromycin and doxycycline as first-line antibiotics for treatment of an acute exacerbation, with co-amoxiclav suggested as an alternative and ciprofloxacin only on specialist …

Pediatrics, Oct 2019, 144 (4) e20190543

BACKGROUND: Children with neurologic impairment (NI) face high risk of recurrent severe pneumonia, with prevention strategies of unknown effectiveness. We evaluated the comparative effectiveness of secondary prevention strategies for severe pneumonia in children with NI.

METHODS: We included children enrolled in California Children’s Services between July 1, 2009, and June 30, 2014, with NI and 1 pneumonia hospitalization. We examined associations between subsequent pneumonia hospitalization and expert-recommended prevention strategies: dental care, oral secretion management, gastric acid suppression, gastrostomy tube placement, chest physiotherapy, outpatient antibiotics before index hospitalization, and clinic visit before or after index hospitalization. We used a 1:2 propensity score matched model to adjust for covariates, including sociodemographics, medical complexity, and severity of index hospitalization.

RESULTS: Among 3632 children with NI and index pneumonia hospitalization, 1362 (37.5%) had subsequent pneumonia hospitalization. Only dental care was associated with decreased risk of subsequent pneumonia hospitalization (adjusted odds ratio [aOR]: 0.64; 95% confidence interval [CI]: 0.49–0.85). Exposures associated with increased risk included gastrostomy tube placement (aOR: 2.15; 95% CI: 1.63–2.85), chest physiotherapy (aOR: 2.03; 95% CI: 1.29–3.20), outpatient antibiotics before hospitalization (aOR: 1.42; 95% CI: 1.06–1.92), clinic visit before (aOR: 1.30; 95% CI: 1.11–1.52), and after index hospitalization (aOR: 1.72; 95% CI: 1.35–2.20).

CONCLUSIONS: Dental care was associated with decreased recurrence of severe pneumonia. Several strategies, including gastrostomy tube placement, were associated with increased recurrence, possibly due to unresolved confounding by indication. Our results support a clinical trial of dental care to prevent severe pneumonia in children with NI.

Pediatrics, Oct 2019, 144 (4) e20190348

OBJECTIVES: We assessed racial differences in sepsis recognition in a pediatric emergency department (ED) with an established electronic sepsis alert system.

METHODS: Quality-improvement data from June 1, 2016 to May 31, 2017 was used in this retrospective cohort study. All ED visits were included for non-Hispanic black (NHB) and non-Hispanic white (NHW) patients. The sepsis pathway was activated through the alert, 2 stages and a huddle, or outside of the alert using clinician judgment alone. We evaluated racial differences in the frequency of alerts and sepsis pathway activation within and outside of the alert. Multivariable regression adjusted for high-risk condition, sex, age, and insurance.

RESULTS: There were 97 338 ED visits: 56 863 (58.4%) and 23 008 (23.6%) from NHBs and NHWs, respectively. NHWs were more likely than NHBs to have a positive second alert (adjusted odds ratio [aOR] 2.4; 95% confidence interval [CI] 2.1–2.8). NHWs were more likely than NHBs to have the sepsis pathway activated (aOR 1.4; 95% CI 1.02–2.1). Of those treated within the alert, there was no difference in pathway activation (aOR 0.93; 95% CI 0.62–1.4). Of those recognized by clinicians when the alert did not fire, NHWs were more likely than NHBs to be treated (aOR 3.4; 95% CI 1.8–6.4).

CONCLUSIONS: NHWs were more likely than NHBs to be treated for sepsis, although this difference was specifically identified in the subset of patients treated for sepsis outside of the alert. This suggests that an electronic alert reduces racial differences compared with clinician judgment alone.

Las enfermedades exantemáticas suelen tener un patrón definido típico que facilita el diagnóstico clínico, aunque ocasionalmente surgen dudas por similitud de patologías y es preciso conocer el agente etiológico. La enfermedad boca mano pie siempre ha sido una de las patologías sencillas de reconocer por su clásica afectación cutánea y mucosa; sin embargo, en los últimos años se ha visto un viraje en la distribución, extensión y morfología de las lesiones, que le otorgan gran capacidad de simulación. En los casos donde la clínica es atípica, y un erróneo etiquetado diagnóstico puede privar a un paciente de la vacunación frente a la varicela, la serología puede ser de utilidad. Presentamos un caso de enfermedad boca-mano-pie atípico en un paciente sin dermopatía previa con lesiones de gran extensión (patrón en cielo estrellado), lo que generó dudas acerca del diagnóstico.

Las infecciones por adenovirus humano se producen especialmente en niños menores de cinco años, se propagan fácilmente y, en algunos casos, son muy contagiosas. La mayoría de las infecciones son autolimitadas, de tipo respiratorio y gastrointestinal, y muchas veces son difíciles de diferenciar de las ocasionadas por otros virus. Excepcionalmente se confunden clínicamente con otros procesos graves, tal como ocurrió en los dos casos que presentamos. En los últimos años, la PCR se ha convertido en el método diagnóstico de elección, debido a su rapidez y alta sensibilidad y especificidad para la detección de AdvH Sería deseable optimizar los métodos diagnósticos para abordar con más precisión estas infecciones y que nos permitan alejarnos de la incertidumbre.

El síndrome de Lemierre es una patología poco frecuente y potencialmente letal, que se origina como complicación de una infección localizada a nivel de cabeza y cuello que se extiende al espacio carotídeo. Se asocia a tromboflebitis séptica de la vena yugular interna y con frecuencia produce embolias sépticas a distancia. Se presenta generalmente como un cuadro de fiebre y odinofagia de varios días de evolución tras el antecedente de una infección orofaríngea aparentemente resuelta. Otros focos infecciosos menos frecuentes pueden corresponder a mastoiditis, sinusitis u otitis media aguda. El diagnóstico es fundamentalmente clínico y apoyado en las pruebas de imagen, como la ecografía Doppler y la tomografía computarizada cervical con contraste. El tratamiento consiste en antibioterapia prolongada con adecuada cobertura para anaerobios, especialmente Fusobacterium necrophorum, el patógeno más frecuente. El papel de la anticoagulación en el síndrome de Lemierre es controvertido. Se presenta un caso de síndrome de Lemierre secundario a una otitis media aguda.

Archivist was reminded of acute flaccid myelitis (AFM) when he was involved with a few cases following an enterovirus D68 mini outbreak a few years ago. It is a rare diagnosis in UK. Part of the role of the general paediatrician is to be aware of these rarities and diagnose promptly. In a small case series, reported by Matesanz S et al . [J Pediatr 2019 Aug 8. pii: S0022-3476(19)30849-2. doi: 10.1016/j.jpeds.2019.07.015] the diagnostic features were highlighted. Acute flaccid myelitis (AFM) is defined as the acute onset of focal limb weakness with corresponding spinal cord grey matter-specific …

Globally, it is estimated that respiratory syncytial virus (RSV) causes 33 million new episodes of acute lower respiratory tract infection (LRTI) in children <5 years of age and ≈120,000 deaths annually. In infants, RSV represents the leading cause of hospitalization worldwide and the second commonest cause of mortality in low- and middle-income countries.1,2 RSV also causes significant disease in immunocompromised hosts and the elderly and has been associated with the development of asthma.3 The increasingly recognized burden of RSV disease has made the development of a vaccine(s) a global health priority. The World Health Organization recently released a roadmap to facilitate the development and implementation of vaccines and monoclonal antibodies (mAbs) and estimated that RSV vaccination will be available in the next 5–10 years.4 This review summarizes the strategies and challenges associated with RSV vaccine development and the vaccine candidates undergoing clinical evaluation, with a focus on those geared toward the pediatric population.

Objective: To assess the efficacy of Lactobacillus reuteri DSM 17938 (L. reuteri) for the treatment of acute gastroenteritis in children.

Study design: Children younger than 5 years with acute diarrhea, defined as a change in stool consistency to a loose or liquid form and/or an increase in the frequency of evacuations (≥3 in 24 hours), lasting for no longer than 5 days, were eligible for inclusion. Participants (n = 100) were recruited from the pediatrics department of a Polish hospital and randomly assigned to receive L. reuteri in a dose 2 × 108 colony-forming units or placebo, for 5 days, in addition to standard rehydration therapy. The primary outcome measure was duration of diarrhea.

Results: Ninety-one of the 100 children randomized were included in the intention-to-treat analysis (L. reuteri n = 44; placebo n = 47). The duration of diarrhea after randomization in both groups was similar (P = 0.6). The groups were also similar with respect to all secondary outcome measures, with one exception. Compared with the placebo group, patients in the L. reuteri group had a shorter duration of hospitalization (P = 0.048). Adverse events were similar in both groups.

Conclusions: Among children with acute gastroenteritis who were younger than 5 years of age, L. reuteri compared with placebo, as an adjunct to rehydration therapy, did not reduce the duration of diarrhea; however, it reduced the duration of hospitalization.

Objective: This cohort study, based on the design of a prior study in the United States, was conducted to elucidate the clinical features of primary human herpesvirus-6B (HHV-6B) infection.

Methods: Between June 2014 and May 2016, febrile children younger than 5 years who visited the emergency room (ER) and underwent blood examination were enrolled in this study.

Results: Fifty-nine (12%) of the 491 patients were diagnosed with primary HHV-6B infection. The rates of both simple and complex febrile seizure were significantly higher in patients with primary HHV-6B infection than in those without (P < 0.001 and P = 0.008, respectively). The median age at primary HHV-6B infection was 15 months. Forty-seven (79.7%) of the 59 patients with primary HHV-6B infection were younger than 2-year-old. Clinical features were compared between HHV-6B–infected patients older and younger than 2 years. The frequency of apparent infection (exanthema subitum) was significantly higher in the younger patients (P = 0.01). The median leukocyte (P = 0.01) and lymphocyte (P < 0.001) counts in the patients older than 2 years were significantly lower than those in the younger patients.

Conclusions: Primary HHV-6B infection accounted for 12% of ER visits. Secondary febrile seizures, in particular the complex type, were considered to be a major contributor to the disease burden of primary HHV-6B infection. The timing of primary HHV-6B infection occurred at older ages than in past reports, and the frequency of inapparent infection was higher in older patients.

Background: Kingella kingae has emerged as a significant cause of osteoarticular infections in young children. Pharyngeal colonization is considered a prerequisite for invasive K. kingae infection. We conducted a prospective study to estimate the prevalence of pharyngeal carriage of K. kingae among healthy young children in Vancouver.

Methods: From March 2016 to May 2017, children between 6 and 48 months of age visiting British Columbia Children’s Hospital outpatient clinics for noninfectious causes were included in the study. Another set of participants was enrolled from a day-care center located at British Columbia Children’s Hospital. A single-throat swab was collected after obtaining consent from parent/guardian. The samples were stored at −70°C and tested using an in-house developed real-time polymerase chain reaction assay. Epidemiologic characteristics and risk factors for K. kingae colonization were collected via a study questionnaire.

Results: A total of 179 children were enrolled in the study, but only 174 samples were eligible for testing. Of the 174 samples, 5 had indeterminate results and the remaining 169 samples were negative by K. kingae polymerase chain reaction. The median age of participants was 23 months. About 36% of children were attending day care and had another sibling <5 years of age. Previous history of cold symptoms and antibiotic use was reported in 42% and 12%, respectively.

Conclusions: The results of our study showed no prevalence of asymptomatic pharyngeal carriage of K. kingae in young children in Vancouver. Additional multicenter studies may help to understand the differences in pharyngeal carriage rate among healthy children.

Background: The major clinical dilemma managing acute rhinosinusitis (ARS) in pediatric population is distinguishing uncomplicated rhinosinusitis from a complicated bacterial ARS and orbital complications, the latter requiring antimicrobials and surgical intervention. However, factors associated with severe orbital complications and the optimum management strategy remains controversial. The objectives of this study were to characterize the clinical outcomes of children with orbital complications of ARS and to identify risk factors associated with disease severity.

Methods: This retrospective cohort analysis evaluated the clinical outcomes of 61 children admitted for orbital complications between January 1, 2002 and December 31, 2017. Descriptive statistics were performed to examine the demographics and clinical findings. We compared groups using Mann-Whitney U test for continuous variables and χ 2 for categorical variables.

Results: Although two-thirds of children had received prehospital antibiotics, half of the cohort presented with post-septal orbital complications. While 83% of isolates obtained from the same patients were susceptible to the prehospital antibiotics given, the majority of those who received prehospital antibiotics nevertheless required surgical intervention. We observed significant association between the age of presentation and disease severity. Children >5 years of age presented with more severe orbital complications despite prehospital antibiotics and were more likely to require surgical intervention (P < 0.001).

Conclusions: In this study, stage II/III orbital complications at presentation and older age were the most important determinants of medical treatment failure. Early referral to eye, nose and throat (ENT) should be considered for children >5 years with ARS due to worse orbital complications despite prehospital antibiotics.

To evaluate the relationship between detection of DNA viruses, ferritin, and outcomes in children with severe sepsis.

Study design We enrolled 75 pediatric patients with severe sepsis admitted to a tertiary care children's hospital. Plasma ferritin was measured within 48 hours of diagnosis and subsequently twice weekly. Herpes simplex type 1, human herpesvirus 6, Epstein−Barr virus, cytomegalovirus, and adenovirus DNAemia were assessed by polymerase chain reaction.

Results The incidence of DNAemia was increased significantly in patients with ferritin ≥1000 ng/mL (78% vs 28%; P < .05). Patients with ferritin ≥1000 ng/mL were more likely to have multiple DNA viruses detected in plasma (39% vs 4%; P < .001). The number of viruses detected in plasma directly correlated with the degree of hyperferritinemia and development of combined hepatobiliary and hematologic dysfunction after we controlled for bacterial and fungal coinfections (P < .05) as well as increased mortality after we controlled for severity of illness and cancer diagnosis (OR 2.6, 95% CI 1.1-6.3, P < .05).

Conclusions Viral DNAemia was associated with hyperferritinemia and adverse outcome in pediatric severe sepsis. Prospective studies are needed to determine whether hyperferritinemia may be used to identify patients at risk of occult DNAemia.

Objective The Petechiae in Children (PiC) study assesses the utility of presenting features and rapid diagnostic tests in the diagnosis of serious bacterial infection in feverish children with non-blanching rashes. An embedded qualitative study explored parents’ and clinicians’ views on the acceptability of the PiC study, including the use of research without prior consent (RWPC) in studies of diagnostic test accuracy.

Design Semistructured qualitative interviews. Analysis was thematic and broadly interpretive, informed by the constant comparative approach.

Participants Fifteen parents were interviewed 55 (median) days since their child’s hospital attendance (range 13–95). Five clinicians involved in recruitment, and consent were interviewed.

Results Parents and clinicians supported RWPC for the PiC study and future emergency paediatric diagnostic test accuracy studies as long as there is no harm to the child and emergency care is not delayed. Parents and clinicians made recommendations around the timing and conduct of a consent discussion, which were in line with RWPC guidance. Parents enrolled in the PiC study preferred a design that included consent discussions with the research team over the alternative of ‘opt-out’ consent only.

Conclusions This embedded qualitative study demonstrates that RWPC is appropriate for use in paediatric emergency studies of diagnostic test accuracy and that the approach used in PiC was appropriate. Future diagnostic studies involving additional invasive procedures or an opt-out only approach to consent would benefit from exploring parent and clinician views on acceptability at the pretrial stage.

Conclusiones:

Rotarix es altamente efectivo para prevenir el rotavirus confirmado por laboratorio en Australia, especialmente en bebés de 6 a 11 meses. La EV (eficacia vacunal) reducida en los grupos de mayor edad y con el tiempo sugiere una protección menguante, posiblemente relacionada con la ausencia de estimulación inmunológica subclínica por virus en circulación continua. Los genotipos G8 no han sido comunes en Australia, y su aparición, junto con el G3P similar a virus equino [8], puede estar relacionado con la presión selectiva inducida por la vacuna; sin embargo, se necesitan más estudios de EV específicos de la cepa.

RESULTADOS:

La tasa de respuesta fue del 65% (302 pediatras y 228 PF incluidos). Los pediatras que recomendaron encarecidamente la vacuna contra el VPH oscilaron entre el 99% para pacientes ≥15 años (mujeres) y el 83% para los de 11 a 12 años (hombres); Los PF oscilaron entre 90% para pacientes ≥15 años (mujeres) a 66% para aquellos de 11 a 12 años (hombres) (P <.0001 entre especialidades). El sesenta y cinco por ciento de los pediatras y el 42% de los PF siempre o casi siempre usaban un estilo presuntivo cuando discutían la vacuna contra el VPH (P <.0001). En general, el 40% usaba órdenes permanentes y el 42% tenía alertas electrónicas. Entre los pediatras, la proporción que informó una tasa de rechazo o aplazamiento ≥50% fue del 19% para pacientes femeninos y del 23% para pacientes masculinos de 11 a 12 años; Los FP informaron 27% y 36%, respectivamente. En la regresión multivariable (ambos sexos), el rechazo o el aplazamiento se asociaron con médicos que no recomendaron la vacuna contra el VPH a pacientes de 11 a 12 años de edad, no usaron un estilo presuntivo y percibieron menos resistencia al introducir la vacuna contra el VPH a 13 de un año de edad versus un paciente de 11 o 12 años, y anticipando una conversación incómoda al recomendar la vacuna contra el VPH a un paciente de 11 o 12 años. El ochenta y nueve por ciento de los pediatras y el 79% de los FP informaron que más adolescentes <15 años están completando la serie del VPH ahora que solo se recomiendan 2 dosis.

 

CONCLUSIONES: Aunque la mayoría de los médicos recomiendan encarecidamente la vacuna contra el VPH a pacientes de 11 a 12 años, nuestros datos revelan áreas para mejorar las recomendaciones los métodos de entrega. La mayoría de los médicos perciben que el programa de 2 dosis está resultando en un VPH más alto

Actualidad bibliográfica agosto-septiembre 2019

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Antimicrobial resistance is of global concern, and preserving the ability of many antimicrobials to kill disease-causing bacteria is likely to become more challenging over time. However, we are speeding up this process dramatically by using antibiotics too much or in the wrong way. Respecting simple key principles of optimal antibiotic prescribing together with commitment to further research in this area from the pediatric community is essential to extend the lifeline of antibiotics for the most vulnerable patients without limiting access to antibiotics for those children who require treatment.

Influenza is often misdiagnosed in children because of the low sensitivity of clinical diagnosis because of nonspecific signs and symptoms. This can be overcome by using digital immunoassays or rapid molecular diagnostic tests with adequate sensitivity and specificity. When using these tests at the patient care site, antibiotic consumption and number of healthcare consultations were reduced.

Rickettsiae are globally encountered pathogens with foci of endemicity and epidemic exacerbations under circumstances of crowding and decline of sanitation. Diagnosis is often missed due to misconceptions about epidemiology, confusing terminology and nonspecific clinical presentation. Rickettsioses should be considered in children with febrile illnesses exceeding the usual duration of a viral infection, in particular in children with rash, lymphadenopathy and nearly normal first-line laboratory tests, who reside in or return from endemic areas, recall a compatible contact history, have a constellation of symptoms starting after an arthropod bite, live under troubled social circumstances, or are part of a cluster of similar cases.

El rotavirus (RV) es la causa principal de diarrea infantil grave en todo el mundo e infecta prácticamente a todos los niños en los primeros 5años de vida, sobre todo en los primeros 2años. Existen dos vacunas atenuadas de administración oral frente al RV disponibles en nuestro medio que han demostrado ser seguras y eficaces frente a la enfermedad.

El objetivo principal de estas vacunas ha sido reproducir la historia natural de la infección y proteger frente a la enfermedad grave en los primeros meses de vida. Los recién nacidos prematuros son especialmente vulnerables a la enfermedad por RV, no solo por tener más riesgo de adquirir la infección, sino también por sus complicaciones.

La vacunación frente al RV en niños prematuros ha mostrado resultados de eficacia y seguridad similares a los comunicados en niños a término, y los datos existentes sugieren un riesgo bajo de diseminación e infección nosocomial cuando la vacunación se realiza durante la hospitalización.

Dado que un porcentaje estimable de recién nacidos prematuros permanecen ingresados en las unidades neonatales más allá de las 12semanas de vida, se considera que estos, siempre que su condición clínica lo permita, deben recibir la vacunación frente al RV sin retrasos, incluso durante la hospitalización si así fuese necesario.

The continuous increase in our knowledge of HIV medicine and antiretroviral treatment has led us to draft specific consensus documents focused on topics other than antiretroviral therapy, such as treatment of opportunistic diseases, pre- and post-exposure prophylaxis, metabolic abnormalities, treatment of HBV or HCV coinfection, treatment of patients coinfected with tuberculosis, osteoporosis, kidney disorders, and cardiovascular risk. Accordingly, the AIDS Study Group (GeSIDA) of the Spanish Society of Infectious Diseases and Clinical Microbiology has promoted the drafting of this consensus document on the control and monitoring of adult patients infected with HIV. The document provides recommendations on the initial evaluation and subsequent monitoring of HIV-infected patients that will prove useful for all professionals involved in the management of this infection.

Respiratory viral infections are associated with significant morbidity and mortality in children < 5 years of age worldwide. Among all respiratory viruses, respiratory syncytial virus (RSV) is the world’s leading cause of bronchiolitis and pneumonia in young children. There are known populations at risk for severe disease but the majority of children who require hospitalization for RSV infection are previously healthy. Viral and host factors have been associated with the pathogenesis of RSV disease; however, the mechanisms that explain the wide variability in the clinical presentation are not completely understood. Recent studies suggest that the complex interaction between the respiratory microbiome, the host’s immune response and the virus may have an impact on the pathogenesis and severity of RSV infection. In this review, we summarize the current evidence regarding the epidemiologic link, the mechanisms of viral–bacterial interactions, and the associations between the upper respiratory tract microbiome and RSV disease severity.

Rapid group A Streptococcus point-of-care testing is not currently used in the United Kingdom in the management of acute tonsillitis. This prospective, observational study describes a strong association between a molecular-based point-of-care testing result and outpatient antibiotic prescribing (odds ratio = 48; P < 0.001) in 339 children seen at our center. It highlights challenges in implementing new rapid diagnostics.

Human stool contains a myriad of microorganisms, of which the vast majority are nonpathogenic and represent an important component of the healthy microbiome. The increasing use of molecular techniques has allowed the rapid identification of bacteria, viruses and parasites in human stool. This review focuses on the 3 main classes of parasite responsible for human disease, helminths, protozoa and ectoparasites, and highlights the importance of differentiating between pathogenic and nonpathogenic parasites.

Los casos mundiales de sarampión son los más altos desde 2006, con casi el triple de casos reportados hasta la fecha en 2019 que en el mismo momento del año pasado, según el último informe preliminar de la Organización Mundial de la Salud.

Los brotes más grandes se han visto en países con baja cobertura de vacunación contra el sarampión, ya sea actualmente o en el pasado. También se producen brotes en países con altas tasas nacionales de vacunación, pero en grupos de personas no vacunadas, lo que normalmente ocurre en un área geográfica, comunidad o entre un grupo de edad.

Las razones por las cuales las personas no se vacunan varían significativamente entre comunidades y países y van desde la falta de acceso a la atención médica o las vacunas, hasta conflictos y desplazamientos, y la información errónea sobre las vacunas.

El informe comparó el período actual de 2019 con el mismo período en 2018 y descubrió que:

-La región africana de la OMS: aumento del 900% en los casos, con 177 542 en lo que va del año, muy por encima de 55 394 en todo 2018.

-La región del Pacífico occidental: aumento del 230%, con 43 175 casos, más que el número total de casos del año pasado (30 531)

-La región europea de la OMS: aumento del 120%, con cerca de 90 000 casos notificados a fecha, que supera las registradas para todo 2018 (84 462).

-La región del Mediterráneo Oriental: aumento del 50% en los casos hasta ahora (15 917 en 2019), pero aún no ha alcanzado el número total de casos en 2018 (57 960).

-La región del sudeste asiático: 35 778 casos hasta la fecha en 2019, 83 647 en todo 2018.

-La región de las Américas: 2387 casos hasta la fecha en 2019, 55 394 en todo 2018 Ambas vieron una disminución del 15% en los casos reportados, aunque los Estados Unidos están reportando su mayor recuento de casos de sarampión en 25 años.

El mayor número de casos este año provino de la República Democrática del Congo, Madagascar y Ucrania, y también se produjeron brotes importantes en Angola, Camerún, Chad, Kazajstán, Nigeria, Filipinas, Sudán del Sur, Sudán y Tailandia.

Sin embargo, el informe destacó el impacto positivo de la campaña nacional de vacuna contra el sarampión de emergencia en Madagascar, que ha visto disminuir los casos en los últimos meses.

A principios de este año, Unicef informó que alrededor de 169 millones de niños en todo el mundo no habían recibido su primera dosis de la vacuna contra el sarampión entre 2010 y 2017.

Investigadores de salud global han dicho que una barrera clave para la vacunación es ahora "incredulidad y hostilidad" en los países ricos hacia los médicos y gobiernos que promueven la importancia de la vacunación, exacerbada por la sospecha de expertos propagados por los partidos políticos populistas.

Casos clínicos

A 9-year-old girl presented to the emergency department with bilateral hip pain. Eight days before onset, she had fever and sore throat that recovered spontaneously. On physical examination, tenderness of both hip joints was observed but no heart murmur. Body temperature was 36.8°C. Blood tests showed elevated C-reactive protein (4.4 mg/dL) and antistreptolysin O titer (4540 IU/mL). Throat culture revealed Streptococcus pyogenes (M3 serotype [emm3.95 genotype] was isolated). A 12-lead standard electrocardiogram revealed a longer PR interval than that before onset (Figure 1, A and B). No significant manifestations of carditis were observed on transthoracic echocardiogram. Acute rheumatic fever (ARF) was diagnosed according to the revised Jones criteria1; amoxicillin and ibuprofen were administered. On day 11 after onset, erythema marginatum was observed on her trunk and proximal lower extremities 

A 4-month-old girl presented with a 2-week history of patchy hair loss on her scalp; parents reported that her scalp hair began shedding while bathing. The patient had received intermittent treatment with topical glucocorticoids following a clinical diagnosis of neonatal occipital alopecia, but the hair loss did not improve. Physical examination revealed patchy, irregular, “moth-eaten” patches of alopecia over the entire scalp (Figure, A ). No erythematous macules with subtle scales were present on her truck, extremities, palms, or soles.

We describe the first 2 cases from the United States, of human parechovirus infection in infants manifesting a distinct rash of the hands and feet. We propose the term “Mittens and Booties Syndrome” and provide a review of the literature of all published cases.

A previously healthy 10-year-old girl became acutely unwell with headache, nausea and vomiting, all exacerbated by movement. She also had an episode of altered consciousness with subsequent retrograde amnesia and was incontinent of urine. She presented to her local hospital and was found to be afebrile with no focal neurological signs. She was discharged with a diagnosis of first-episode absence seizure.

An immunocompetent toddler came to medication attention with gastroenteritis, complicated by encephalopathy and hepatitis. Multiplexed testing using a polymerase chain reaction meningitis panel was positive for human herpesvirus 6 (HHV-6). Clinical correlation, quantitative HHV-6 polymerase chain reaction, and metagenomic next-generation sequencing supported a likely diagnosis of primary HHV-6B infection.

A 6-year-old girl had a 3-year history of systemic juvenile idiopathic arthritis that was treated with prednisone and methotrexate. She presented with painful blisters, erosions, ulcerations with surface exudation, and crusts around mouth, oral mucosa, tongue, umbilicus, and right index finger (Figure); these had been present for 40 days. Tzanck smear revealed mutinucleated giant cells. Skin biopsy taken from umbilicus revealed numerous multinucleate giant cells and ballooning degeneration of keratinocytes. Herpes simplex virus (HSV) subtype 1 was identified using polymerase chain reaction assay. Treatment of oral acyclovir 200 mg 5 times a day was initiated, and the lesions began to improve after 3 days. Unfortunately, the patient died 8 days later because of macrophage activation syndrome and multiple infections.

Seasonal influenza infection is associated with secondary bacterial complications involving the upper and lower respiratory tract. However, the association of influenza infection with secondary severe or complicated head and neck infections is not appreciated. We report 6 cases of head and neck infections following influenza infection in pediatric patients.

Presentamos un caso de gastroenteropatía pierde proteínas (GEPP) en el curso de una infección por Mycoplasma cuyo interés radica tanto en lo inusual de dicha enfermedad en la infancia como en el hecho de no haber casos descritos en la literatura producidos por dicho agente etiológico.

Niña de 3 años acude a urgencias por vómitos repetidos desde hace 5 días, deposiciones blandas y decaimiento los últimos 3 días. Refiere pico febril (38°C) el día previo al ingreso y diuresis adecuada.

Antecedentes: perinatales sin interés clínico. Lactancia artificial. Beikost sin intolerancias. Inmunización correcta (no rotavirus). Padre con talasemia minor.

Exploración al ingreso: peso: 14,3kg, T.ª: 36,8°C. Regular estado general, algo decaída. Nutrición e hidratación adecuada. No exantemas ni petequias. Orofaringe normal. Tonos cardíacos rítmicos, sin soplos. Buena ventilación pulmonar con tos escasa. Abdomen blando, no doloroso, sin masas ni megalias. Consciente y orientada, no signos meníngeos ni focalidad neurológica…

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Some healthcare providers hold or delay vaccination because of false vaccine contraindications. This study suggests that in 21.4% of scenarios (877/4096) physicians would postpone or contraindicate the vaccination, and 24.2% (237/978) of scenarios would be vaccinated despite the existence of a true contraindication or reason for delay. Addressing false contraindications may result in increasing vaccination uptake in Europe.

Introducción En España, las vacunas frente a rotavirus (RV) están disponibles desde 2006 pero no están ni recomendadas ni financiadas por el Sistema Nacional de Salud. Sin embargo, a través de las recomendaciones de la Asociación Española de Pediatría se han alcanzado coberturas de vacunación intermedias.

Material y métodos. Se ha realizado una revisión sistemática de la literatura sobre los estudios realizados en España en los últimos 12 años (2006-2018) en relación con la infección y las vacunas frente a RV.

Resultados. Se identifican 43 estudios que cumplían los criterios de selección. La carga de enfermedad en población <5 años en atención primaria oscila entre 15 y 19 casos por 1.000 niños y en hospitalaria entre 120 y 480 casos por 100.000, lo que supone una importante repercusión económica y social. Las vacunas frente a RV han mostrado en España una efectividad de entre el 83 y el 96% y un impacto de hasta un 70% de reducción de hospitalizaciones, que es dependiente de la cobertura de vacunación alcanzada. Se identifican además nuevas líneas de investigación relacionadas con el papel de la vacuna del RV y la protección frente a convulsiones, o el papel del microbiota, entre otros.

Conclusiones. La información actualmente disponible refrenda la importante carga de enfermedad por RV en España y la elevada efectividad de las vacunas disponibles. Estas evidencias permiten una reevaluación de las recomendaciones nacionales sobre vacunación frente a RV.

Epidemiología descriptiva de la infección por Yersinia enterocolitica en un área de Castellón (España) entre 2006 y 2013 a partir de las cepas de Yersinia enterocolitica aisladas en el área y confirmadas por el laboratorio de referencia nacional.

Total 144 casos. La incidencia estimada fue de 9,7 casos 105 persona-año. El grupo de edad más afectado fue el de 0-4 años (tasa 110,3 por 105 persona-año), con una máximo en lactantes de 6 a 11 meses de edad (190,4 por 105 persona-año). La duración media de la enfermedad fue de 15,5 días. El 7% de los pacientes fueron hospitalizados. Solo se detectaron 2 brotes, de carácter familiar relacionados con el consumo de carne de cerdo. La evolución temporal refleja mayor incidencia en invierno (enero). El factor de exposición más frecuente entre los casos fue el consumo de longaniza seca de cerdo (el 50% de los casos entrevistados). Las 58 cepas tipadas fueron todas del biotipo 4, serotipo O:3, excepto una O:9. Se distinguieron 21 pulsotipos agrupados en 8 clusters con similitud del 97%. A lo largo de algunos años se observó una sustitución de unos pulsotipos por otros.

La yersiniosis tiene una incidencia alta en nuestra área, con una estacionalidad clara de predominio invernal. Afecta sobre todo a niños muy pequeños. Las cepas son del mismo serotipo, pero la variedad de pulsotipos cambió a lo largo del tiempo. Como factor de exposición para ulteriores estudios analíticos se propone el consumo de algunos productos del cerdo, sin descartar otros factores.

Biomarkers have become an integral part of the clinical decision-making process of clinicians dealing with febrile children. C-reactive protein, procalcitonin and white blood cell count are probably the most studied ones. Crucial to using biomarkers is the understanding of how a test result will alter post-test probabilities and then impact on clinical decision making. Improved analytical and computational platforms have enabled the next generation of advanced biomarker discovery studies. Promising combinations of candidate biomarkers for a diverse spectrum of febrile illnesses, such as viral and bacterial infections, have been identified using proteomics, RNA gene expression and metabolomics.

Our objective was to retrospectively describe measles hospitalizations in 52 US children’s hospitals. We identified 136 patients hospitalized for measles in 2004–2018; 17% (23/136) had complex chronic conditions, 2 of whom died or were in hospice. Among noncomplex patients only 39% received vitamin A, median length of stay was 3 days and median adjusted estimated costs were $5896.

We described nosocomially clustered cases of measles secondary to a nonvaccinated index case occurring in a teenage psychiatric unit despite optimum vaccine coverage. Surveillance of this fully vaccinated closed cohort showed a 7% attack rate. Vaccination limited the risk of complicated measles and the onset of a large outbreak.

Timely, accurate diagnosis of group A streptococci (GAS) pharyngitis prevents acute rheumatic fever and limits antibiotic overuse. The illumigene group A Streptococcus assay (Meridian Bioscience, Cincinnati, OH) is a molecular test for GAS pharyngitis with high sensitivity and specificity. We sought to determine whether the illumigene test is more likely than throat culture to be positive in patients without pharyngeal symptoms and explore the limits of detection of the test.

Methods: Patients 3–17 years of age were eligible if they had no history of pharyngitis or use of antibiotics within the previous 2 weeks; there were no upper respiratory infection symptoms, sore throat or fever and no signs of infection. Culture and illumigene were performed on duplicate throat swabs. Excess lysate from a subset of illumigene tests was evaluated by real-time polymerase chain reaction. Institutional Review Board approval was obtained.

Results: We enrolled 385 patients from February 2016 to October 2017; mean age was 10 yr; 51% were male. Most visits were for health supervision (69%). Significantly more illumigene tests (78/385, 20.3%) than throat cultures (48/385, 12.5%) were positive (χ 2 ; P =0.0035). Illumigene was “indeterminate” for 3 patients, leaving 382 pairs of swabs for analysis. Results were discordant for 32 of 382 pairs (8.4%); 31 of 32 (97%) were illumigene-positive/culture-negative (McNemar test; P < 0.000001). Real-time polymerase chain reaction was negative in 4 of 13 (31%) tested illumigene-positive lysates; the paired culture had been negative in all four. The limit of detection for the illumigene test was 55 colony forming units/mL.

Conclusions: The illumigene test is significantly more likely than throat culture to yield positive results in patients without GAS pharyngitis. Failure to appropriately select patients for testing may negatively impact antimicrobial stewardship efforts without benefit to patients.

A 13-year-old girl presents with recurrent herpes labialis (HL) on her face. She gives a history of painful episodes occurring approximately monthly since the age of 9 years. Since becoming a teenager, she has missed a lot of school due to her worry about the cosmetic appearance of recurrences. Her parents ask whether long-term antiviral medication will prevent recurrences.

Oral long-term suppressive therapy with acyclovir or valacyclovir reduces the frequency, severity and duration of episodes in adults with recurrent herpes labialis (RHL) (grade A) but has not been the subject of a trial in children.

Oral valacyclovir reduces the frequency of episodes and increases quality of life in teenagers with RHL (grade C).

The optimal indication to start, choice of antiviral, as well as dosage and duration of long-term antiviral therapy is unknown.

Maria is a 1.5-month-old healthy baby born at 39 weeks, mainly breastfed, although she has been fed artificial formula on a few occasions. In the last 2 weeks, she has been brought to the clinic with episodes of intense crying which last from 3 to 5 hours/day and occur 4–5 times a week. Her parents are finding it hard to soothe and calm her during these episodes, and find it very distressing. She undergoes a normal clinical examination and there do not seem to be any other associated conditions. As such, infantile colic seems to be the most probable cause of her current distress. Her parents have read that certain probiotics might help her, but you are very uncertain and want to know more.

Lactobacillus reuteri (DSM 17938) decreased the average crying time in predominantly breasted babies with infantile colic (grade A).

The magnitude of clinical benefit is uncertain as based on only small studies, and might be influenced by the dosage as well as the length of administration (grade D).

Maternal vaccination provides a method for protecting the pregnant woman, fetus and neonate during a period when there is increased susceptibility to infectious diseases. A dynamic state of immune tolerance during pregnancy and the need to develop adaptive memory to a new foreign antigen-rich environment lead to windows of vulnerability to infection for the mother and neonate, respectively. Passive transfer of humoral immunity through the placenta and breast milk from the mother can bridge the gap in immunity for the neonate. Studies on boosting this natural process of antibody transfer have led to the recommendation for administering inactivated influenza, diphtheria, tetanus toxoid and acellular pertussis vaccines during pregnancy. Several new maternal vaccine candidates are on the horizon.

Background: In febrile children given empiric parenteral antibiotics, guidelines advise provisional reporting of negative blood cultures and antibiotic review after 36 hours incubation for neonates and 48 hours for older children. Following improvements in culture processing and childhood vaccination, we revisited this important clinical topic, assessing time to exclude clinically significant bacteremia in well-appearing febrile children with no comorbidities or features of sepsis.

Methods: We analyzed the results of all 53,276 pediatric blood cultures taken during an 8-year period at a UK hospital.

Results: 1308 (2.5%) cultures were positive, of which 333 (25.5%) grew pathogens typically associated with clinically significant bacteremia. The remaining 975 (74.5%) grew organisms associated with contaminated culture, or with opportunistic infection only in children with relevant risk factors. Time to positivity (TTP) from incubation was significantly shorter for the 333 definite pathogens than the 975 contaminating/opportunistic organisms, with 92% of definite pathogens identified by 24 hours incubation. Only 3 of all definite pathogens were identified after 24 hours in children otherwise eligible for discharge at 24 hours. There was no significant difference in TTP for definite pathogens between neonates and older children. Median time from specimen collection to incubation was 3 hours.

Conclusions: Clinically significant bacteremia can be excluded by 24 hours incubation in well-appearing febrile children with no comorbidities or features of sepsis. This is the largest dataset of its kind, and the second to compare neonates and older children. Our findings may inform future guidelines, facilitating earlier antibiotic review and discharge.

Bacteria compete with each other for local supremacy in biologic and environmental niches. In humans, who host an array of commensal bacteria, the presence of one species or strain can sometimes prevent colonization by another, a phenomenon known as “bacterial interference.” We describe how, in the 1960s, infants (and later adults) were actively inoculated with a relatively benign strain of Staphylococcus aureus, 502A, to prevent colonization with an epidemic S. aureus strain, 80/81. This introduced bacterial interference as a clinical approach to disease prevention, but little was known about the mechanisms of interference at that time. Since then, much has been learned about how bacteria interact with each other and the host to establish carriage, compete for niches and shift from harmless commensal to invasive pathogen. We provide an overview of these findings and summarize recent studies in which the genome and function of 502A were compared with those of the current epidemic strain, USA300, providing insight into differences in their invasiveness and immunogenicity. Although staphylococcal vaccines have been developed, none has yet been approved for clinical use. Further studies of staphylococcal strains and the molecular characteristics that lead to exclusion of specific bacteria from some niches may provide an alternative path to disease prevention.

Background: The British Thoracic Society (BTS) guideline for pediatric community-acquired pneumonia (CAP) outlines severity criteria to guide clinical decision-making. Our objective was to examine the predictive performance of the criteria on the need for hospitalization (NFH) and disposition.

Methods: This was a retrospective cohort study of children 3 months–18 years of age diagnosed with CAP in an urban, pediatric emergency department (ED) in the United States from September 2014 to August 2015. Children with chronic medical conditions, recent ED visits, and ED transfers were excluded. The main outcomes were interventions or diagnoses that necessitate hospitalization (ie, NFH) and disposition (eg, admit vs. discharge). Test characteristics, stratified by age, were calculated for each outcome.

Results: Of 518 eligible children, 56.6% (n = 293) were discharged from the ED with 372 children meeting at least 1 BTS criterion. Overall BTS criteria were specific but not sensitive for NFH nor for disposition. For children <1 year of age sensitive criteria included not feeding and temperature for NFH and tachycardia, cyanosis and not feeding for disposition. For children ≥1 year of age, tachycardia had a sensitivity of >0.60 for both outcomes. The areas under the receiver operator characteristic curves for predicting any BTS criteria was 0.57 for NFH and 0.84 for disposition.

Conclusions: The BTS CAP severity criteria had fair to excellent ability to predict NFH and disposition, respectively. Although specific, the low sensitivity and poor discriminatory ability for NFH of these criteria suggest a need for improved prognostic tools for children with CAP.

The Pediatric Infectious Disease Journal. 38(8):e178-e180, August 2019.

Probiotics are increasingly used for diarrhea, but studies under the Food and Drug Administration and Investigational New Drug program are few. We conducted a phase-one placebo-controlled study of Lactobacillus reuteri DSM 17938 under Investigational New Drug program in 60 children 2–5 years of age (41 L. reuteri , 19 placebos) in a resource-constrained community in Peru. No differences in objective data on adverse events were noted, although some differences based on subjective parental reports for fever and diarrhea were seen.

The Pediatric Infectious Disease Journal. 38(6S):S39-S42

Introduction of conjugate vaccines against Haemophilus influenzae type b, Streptococcus pneumoniae , and Neisseria meningitidis has led to a substantial reduction in cases of acute bacterial meningitis in countries with high routine childhood immunization coverage. The majority of children hospitalized with meningitis in high-income countries have viral or aseptic meningitis and do not require antibiotic treatment. Cerebrospinal fluid analysis is irreplaceable in appropriately diagnosing and treating bacterial meningitis and avoiding unnecessary antibiotics and prolonged hospitalizations in children with viral meningitis. New diagnostic tests have improved detection of bacterial and viral pathogens in cerebrospinal fluid, underscoring the importance of promptly performing lumbar puncture when meningitis is suspected. This article provides an overview of acute bacterial and viral meningitis in children, focusing on the changing epidemiology, the advantages and limitations of conventional and newer diagnostic methods, and considerations for clinical practice.

The endemic mycoses are a group of infections caused by fungi with a distinct geographic distribution, defined by climatic and environmental conditions. The systemic endemic mycoses, namely histoplasmosis, blastomycosis, talaromycosis, coccidioidomycosis and paracoccidioidomycosis, occur after the inhalation of fungal spores. The cutaneous endemic mycoses, including sporotrichosis, mycetoma, entomophthoramycosis and chromoblastomycosis, enter the host via traumatic inoculation of the skin. Clinical presentation varies between these relatively heterogeneous infections, as does the susceptibility of immunosuppressed patients to disease. An understanding of the geographic range, typical manifestations, diagnostic methods, and treatment of the endemic mycoses is key in assessing patients presenting with atypical infections who may have traveled to endemic areas.

(Bacterias resistentes en las manos de trabajadores sanitarios y en el área del paciente: un estudio ambiental en un hospital del sur de Italia). Rev Esp Quimioter 2019; 32(4): 303-310.

Introducción. La OMS reconoce la resistencia a los antimicrobianos como una creciente amenaza para la salud mundial con una amplia variabilidad en toda Europa: en Italia estas tasas son más altas que en otros países. El objetivo de nuestro estudio fue detectar la resistencia a los antimicrobianos en las manos de trabajadores sanitarios y en las superficies alrededor del paciente así como evaluar la variabilidad entre los niveles de contaminación bacteriana en estas superficies y los resultados obtenidos hace seis años.
Material y métodos. El estudio se realizó entre junio de 2017 y mayo de 2018 utilizando dispositivos de contacto para superficies y muestreo activo de aire. Se empleó métodos bioquímicos automatizados para identificar microorganismos y la sensibilidad antimicrobiana fue realizada de acuerdo con las normas del EUCAST.
Resultados. Se analizaron 3.760 muestras, de las cuales el 16,17% fueron positivas y el 34% de ellas fueron resistentes a antibióticos. Al analizar los estafilococos, el 39% fueron multirresistentes y el 5% extremadamente resistentes. Un 30% de las cepas de Enterococcus faecalis fueron resistentes a gentamicina y vancomicina. Se aislaron cepas de Klebsiella pneumoniae resistentes a ceftrixona, cefoxitina, mecillinam e imipenem. Un 7% de las cepas de Acinetobacter baumannii y un 8% de las cepas de Pseudomonas aeruginosa fueron resistentes a gentamicina, imipenem y ceftazidima.
Conclusiones. Estos hallazgos están en línea con los estudios publicados en otros países, lo que confirma que la resistencia a los antibióticos también está creciendo constantemente en Italia con tasas variadas para los diferentes patógenos.

Nonpolio enterovirus (NPEV) infections are often present with herpangina (HA) and hand, foot and mouth disease (HFMD). Most countries sample NPEVs in HFMD cases, targeting enterovirus A71 (EV-A71) and coxsackievirus A16 (CV-A16) that are associated with outbreaks and severe complications. HA is also monitored in Taiwan and several other countries, but its viral characteristics are underreported.

Methods: Through Taiwan’s National Virologic Surveillance, information regarding ~100,000 child respiratory samples (2002–2015) was linked to concurrent (0–6 days before the sampling date) outpatient records from the National Health Insurance databases, including ~15,000 HA-related and ~7000 HFMD-related samples. We assessed sample representation and NPEV positive rates, and estimated total numbers of EV-A71 and CV-A16.

Results: There were more HA events (4.0 millions) than HFMD events (1.2 millions) in Taiwan. In every 1000 events with HFMD and HA, 6.0 and 4.1, respectively, respiratory samples were collected. The NPEV positive rate in HFMD-related samples was 48%, consistent across most sampling seasons, and predominantly EV-A71 or CV-A16 (74%). By comparison, the HA-related samples had a lower positive rate overall (43%), occasionally EV-A71 or CV-A16 (13%), and the positive rate depended strongly on HA incidence ( P < 10 –12 ). Compared with sampling HFMD alone, inclusion of HA-related information predicted an earlier onset of EV-A71 outbreak in 2011, and predicted 30% more EV-A71 cases.

Conclusions: This is the first representative report on viral characteristics of HA. Our findings confirm that HFMD monitoring is a reliable strategy, but there is a measurable additional benefit when HA is also monitored.

Congenital cytomegalovirus infections are among the most common of the newborn in the developed world. These infections are the most common cause of sensorineural hearing loss. Studies utilizing ganciclovir and valganciclovir demonstrate improved hearing and Bailey Developmental scores. Because of the ease of administration, valganciclovir is the recommended treatment of choice for 6 months. Therapy should be reserved for those babies with symptomatic disease; no data are available regarding the impact of treatment on those babies with asymptomatic disease.

Incidence of hearing loss in children with cCMV infection is discussed, and risk indicators for hearing loss are described.

Saffold virus (SAFV) is a novel human cardiovirus that was identified in 2007. Recently, SAFV has been isolated from nasal and stool specimens of infants presenting with respiratory and gastrointestinal symptoms and from cerebrospinal fluid (CSF) specimens of children with central nervous system infection. However, little is known regarding clinical characteristics of SAFV in children.

Methods: We reviewed 5412 specimens from the database of the infectious agents surveillance system in Niigata prefecture, Japan, between January 2006 and December 2013, and identified SAFV-infected patients. Subsequently, we retrospectively reviewed their medical records and evaluated their clinical characteristics.

Results: We identified 9 SAFV-infected patients (median age: 5 years; range: 2–16 years). Seven patients were diagnosed with pharyngitis, one with meningitis and one with fever of unknown origin. Dominant symptoms were high fever, appetite loss and headache. The median duration of the fevers was 2 days in patients with pharyngitis; however, the patient with meningitis remained febrile for 5 days. All blood tests available in this case series revealed leukocytosis with a predominance of neutrophils. CSF profiles showed mild lymphocytic pleocytosis. All patients recovered fully without complications.

Conclusions: A few clinical characteristics of SAFV infection were clarified, including high fever of short duration in patients with pharyngitis, and neutrophil-dominant leukocytosis. The clinical course and CSF profiles of a case of meningitis were similar to those of other aseptic meningitis. SAFV needs to be included in the differential diagnosis of pharyngitis or meningitis when commonly identified viruses are not identified in such patients.

The Pediatric Infectious Disease Journal. 38(9):900-905

Background: Universal vaccination with Haemophilus influenzae type b conjugate vaccines has significantly changed the epidemiology of invasive H. influenzae disease in the United States. We reviewed the epidemiology, clinical features, and outcomes in 61 patients with invasive H. influenzae disease evaluated at Texas Children’s Hospital (TCH).

Methods Cases of invasive H. influenzae disease, defined as isolation of the organism from cerebrospinal fluid, blood, synovial fluid or pleural fluid, during 2011 to 2018 among children cared for at TCH in Houston, TX, were included.

Results: We identified 61 cases of invasive H. influenzae disease in children ≤18 years of age. The overall hospitalization rate due to invasive H. influenzae disease increased between 2011 and 2018 (0 vs. 0.64/1000 hospitalizations; P = 0.019). The majority (80%) of infections occurred in children <5 years of age. Of the 61 H. influenzae infections, 24 (39.3%) infections were caused by nontypeable H. influenzae strains, 18 (29.5%) infections were caused by H. influenzae type a, 12 (19.7%) infections were caused by H. influenzae type f, 3 (4.9%) infections were caused by H. influenzae type e and 4 (6.6%) isolates were not typed. A total of 78.7% of the isolates were β-lactamase negative. The most common clinical presentations were bacteremia without a source, pneumonia and meningitis.

Conclusions: The hospitalization rate for H. influenzae invasive disease increased over an 8-year period at TCH. The overall trend was mainly driven by an increasing number of invasive infections caused by nontypeable H. influenzae and H. influenzae type a. Morbidity was substantial, especially in meningitis cases.

Broad-range polymerase chain reaction (BR-PCR) detects infectious pathogens from clinical specimens using targets for bacteria (16S rRNA), fungi (28S rDNA), and mycobacteria (fluorescence resonance energy transfer and heat shock protein 65 gene) with reported diagnostic sensitivity and specificity ranging from 43% to 100% and 100%, respectively. We describe our experience when applying BR-PCR to clinical samples submitted for conventional infectious disease testing [conventional testing (CT)] from pediatric patients with concern for infection.

Methods: Retrospective analysis of clinical samples obtained from Nationwide Children’s Hospital microbiology laboratory from January 2011 to December 2014 and sent for BR-PCR. Medical record review collected data on patient characteristics, clinical manifestations, laboratory results and antimicrobials prescribed, and a determination of clinical value of BR-PCR was assigned.

Results: There were 247 clinical samples from 163 patients identified; 71 (44%) patients were immunocompromised and 192 (78%) samples reflected pretreatment with antimicrobials. A clinically significant putative organism was identified for 59 samples (24%) between all diagnostic modalities. Conventional testing identified organisms in 41 (17%) samples, 17 of which were corroborated by BR-PCR. Broad-range polymerase chain reaction identified an organism in an additional 18 samples with negative CT results and was considered to provide additional important clinical information. Broad-range polymerase chain reaction detected a bacterial or fungal organism more frequently from tissue samples than from bronchoalveolar lavage or other fluid samples ( P = 0.0096, χ 2 ).

Conclusions: In our cohort, BR-PCR was an important adjunctive diagnostic in identifying bacteria and fungi in complex clinical situations. Additional data are needed to define the optimal clinical circumstances and specimen type in which BR-PCR can provide the highest diagnostic yield.

Background: Pneumococcal meningitis (PM) is a serious disease that can rarely recur at a later time after the initial episode.

Methods: A retrospective multicenter case–control study was conducted with data for children 18 years of age or younger obtained from the National Observatory of Bacterial Meningitis in Children between January 2001 and September 2015. Cases were all patients with RPM. Each case was matched with 2 randomized controls with a single PM episode in the year of the first episode of PM in the case and born the same year. Case and control data were compared.

Results: Among the 1634 PM episodes in children 18 years of age or younger, 24 (1.5%) children had RPM. RPM cases were significantly less frequent than single PM cases in winter (27% vs. 48%; P =0.03) and showed significantly less concomitant ear, nose and throat infections when considering the first episode (30% vs. 56%, P = 0.04) and all episodes (28% vs. 56%, P < 0.01). Cerebrospinal fluid leakage was frequent in RPM cases versus controls (83% vs. 10%, P < 0.01), including 25% discovered after the third PM episode. Immune deficiency was absent in cases and present in 15% of controls. Cases and controls did not differ in death rate or neurologic outcome.

Conclusions: RPM is rare in children. Cerebrospinal fluid leakage must be considered.

Management of suspected serious bacterial infections (SBIs) in infants less than 3 months old is challenging. Understanding the epidemiology of SBI is necessary to inform management decisions. Recent publications have challenged the previously accepted distribution of infections by specimen source and pathogen. We sought to describe the burden of SBIs in previously healthy infants less than 90 days old.

Methods: We conducted a retrospective analysis of the Military Health System database to identify SBI cases among term infants less than 90 days of age from 2005 to 2015. We defined an SBI case as any previously healthy infant with positive cultures for a likely pathogen from blood, urine or cerebrospinal fluid.

Results: Of 467,462 live births between January 2005 and September 2015, 3421 infants had positive cultures. After excluding 1781 episodes with isolates considered nonpathogenic or ICD-9 codes for chronic conditions, the overall incidence of SBI was 3.1 cases/1000 live births. The SBI rate dropped from 5.0 cases/1000 live births in 2005 to 2.0 cases/1000 live births in 2015 ( P < 0.001 for trend). The most common pathogen was Escherichia coli (51.3%).

Conclusions: In this retrospective review of 467,462 live births, the incidence of SBI decreased from 5.0/1000 to 2.0/1000 live births over time. We identified no cases of Listeria monocytogenes . These data can help inform decisions related to treatment and management of infants with suspected bacterial infections. OK

After the initial identification of the H1N1 pandemic influenza strain in Mexico in April 2009 and its subsequent global spread, several monovalent influenza vaccines were developed as part of the pandemic response. Three of these vaccines, Pandemrix, Arepanrix and Focetria were adjuvanted. One of these, the AS03-adjuvanted Pandemrix vaccine, was primarily used in Europe. Following widespread Pandemrix vaccine administration in Scandinavia, an increased risk of narcolepsy was noted in observational studies. Subsequently, this increased risk was also reported in other European countries as well. In contrast, studies from Canada of a similar AS03-adjuvanted vaccine, Arepanrix, did not demonstrate a similar increased risk of narcolepsy. No studies have identified an increased risk of narcolepsy following the MF59-adjuvanted Focetria vaccine. For many potential pandemic influenza strains, adjuvants might be required to solicit a protective immune response. Thus, it is critical that we understand the nature of the association between adjuvanted vaccine receipt and narcolepsy. Here, we present a potential hypothesis for narcolepsy seen during the 2009 H1N1 pandemic in AS03-adjuvanted influenza vaccine recipients.

We included seven randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method) that compared the effects of immunoglobulins with placebo in 486 young children hospitalised with RSV lung infections. All trials were conducted at sites in the USA; three trials included some children from South American countries (Chile and Panama); and one trial also included children from New Zealand and Australia. The trials were published between 1987 and 2014.

We found insufficient evidence of a difference between immunoglobulins and placebo for any review outcomes. We assessed the evidence for the effects of immunoglobulins when used as a treatment for RSV lower respiratory tract infection in hospitalised infants and young children as of low or very low certainty due to risk of bias and imprecision. We are uncertain of the effects of immunoglobulins on these outcomes, and the true effect may be substantially different from the effects reported in this review. All trials were conducted in high-income countries, and data from populations in which the rate of death from RSV infection is higher are lacking.

Kawasaki disease (KD) is an acute inflammation of the blood vessels that mainly affects children between six months and five years of age. Standard medical management of KD includes intravenous immunoglobulin (IVIG) with aspirin. This standard treatment is usually effective, but doesn't work for approximately 15% to 20% of children. When treatment is not effective, children may suffer from serious heart disease. Recently, researchers found that tumor necrosis factor-alpha (TNF-α) blockers may be effective for children with Kawasaki disease that has not been cured by standard treatment. However, we are still unclear about the benefits and risks of TNF-α blockers for the treatment of KD, and the potential for improved efficacy and safety is ambiguous. This review therefore assessed the benefits and harms of TNF-α blockers for the treatment of KD.

We included trials that used TNF-α blockers as a treatment for children with KD and measured treatment resistance, cardiovascular events and side effects, such as infusion reactions and infections, or other symptoms. We found five completed studies with a total of 494 participants (most recent search for studies September 2018). Four studies used TNF-α blockers as the additional treatment after IVIG treatment and one used TNF-α blockers as the first treatment for children with KD.

We found a limited number of RCTs examining the effect of TNF-α blockers for KD. In summary, low-certainty evidence indicates that TNF-α blockers have beneficial effects on treatment resistance and the adverse effect 'infusion reaction' after treatment initiation for KD when compared with no treatment or additional treatment with IVIG. Further research will add to the evidence base. Due to the small number of underpowered trials contributing to the analyses, the results presented should be

treated with caution. Further large high quality trials with timing and type of TNF-α blockers used are needed to determine the effects of TNF-α blockers for KD. OK

La nueva guía de NICE (NICE. Impetigo: antimicrobial prescribing. 2019. www.nice.org.uk/guidance/gid-ng10134/documents/draft-guideline. Google Scholar) afirma que se debe ofrecer un antiséptico tópico a las personas con impétigo localizado, no ampolloso, siempre y cuando no presente afectación sistémica o corran el riesgo de desarrollar complicaciones.

En algunas situaciones, los antibióticos seguirán siendo adecuados, por ejemplo ante un paciente con impétigo no ampolloso generalizado.

Un antibiótico oral (flucloxacilina) debe ser el tratamiento de primera línea si una persona tiene impétigo ampolloso o si presenta afectación sistémica o tiene riesgo de desarrollar complicaciones, y también es una opción para las personas con impétigo no ampolloso generalizado.

No se debe usar un tratamiento combinado con un antibiótico tópico y oral, ya que no es más efectivo que usar un solo tratamiento tópico.

 

El virus sincitial respiratorio humano (VSR) pertenece a la familia Pneumoviridae, género Orthopneumovirus. Es un virus ARN monocatenario de sentido negativo que produce epidemias de infecciones respiratorias que, típicamente, alcanzan su punto máximo en el invierno en climas templados y durante la temporada de lluvias en climas tropicales. En general, uno de los dos genotipos (A y B) predomina en una sola estación, alternando anualmente, aunque se producen variaciones regionales. El VSR es una causa de enfermedad y muerte en niños, personas mayores y pacientes inmunocomprometidos, y su efecto clínico en adultos ingresados, se detecta con el uso ampliado de ensayos moleculares multiplex. Entre los adultos, el VSR produce una amplia gama de síntomas clínicos que incluyen infecciones del tracto respiratorio superior, infecciones graves del tracto respiratorio inferior y exacerbaciones de la enfermedad subyacente. En este artículo se discute la evidencia más reciente sobre la carga de la enfermedad relacionada con el VSR en adultos, especialmente en aquellos con inmunocompromiso u otras comorbilidades. Revisamos las opciones terapéuticas y de prevención actuales, así como las que están en desarrollo.

 

Actualidad bibliográfica julio 2019

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Desde la Sociedad Española de Reumatología Pediátrica (SERPE) y la Sociedad Española de Infectología Pediátrica (SEIP) queremos comunicar nuestra preocupación por el diagnóstico erróneo de la enfermedad de Lyme que se está llevando a cabo en niños con artritis idiopática juvenil. En los últimos años se han comercializado pruebas diagnósticas no validadas científicamente, que están condicionando que niños con artritis de etiología no infecciosa estén recibiendo antibióticos durante tiempo prolongado. Esta tendencia puede condicionar la aparición de secuelas a nivel articular, y más grave si cabe, a nivel ocular por el desarrollo de uveítis crónica, que limitarán la vida futura de estos niños.

 Introducción y Objetivo: describir las características clínicas y epidemiológicas, tratamiento y evolución de los pacientes con NAC por MP (NACM) en un hospital terciario de Valencia.
Material y métodos: Se revisaron retrospectivamente las historias clínicas de los niños<14 años con NACM entre enero de 2010 y diciembre de 2015. Los pacientes con evidencia radiológica de neumonía y confirmación microbiológica de MP (PCR de exudado nasofaríngeo y/o anticuerpos IgM específicos frente a MP) se consideraron NACM.
Resultados. Un total de 162 pacientes se diagnosticaron de NACM; mediana de edad de 6 años (rango intercuartílico: 4-9 años). La proporción de pruebas positivas para MP en pacientes con NAC, así como el uso empírico de macrólidos, aumentó progresivamente con la edad. Hubo un pico de casos en 2011 y en 2015, con un máximo de casos en julio, agosto, noviembre y diciembre. El patrón radiológico más frecuente fue el infiltrado segmentario (62,3%), mientras que 22 (13,6%) presentaron derrame pleural. Los niños con NACM desarrollaron una clínica leve, con poca elevación de parámetros inflamatorios. Se inició tratamiento empírico con un macrólido en el 68,5% de los casos. La necesidad de ingreso hospitalario fue inversamente proporcional a la edad del paciente.

Conclusiones: los niños con NAC de mayor edad tuvieron la mayor proporción de infección por MP, siendo poco sintomáticos y con escasa elevación de parámetros inflamatorios, pudiéndose beneficiar del tratamiento empírico con macrólidos.

Background: Mycoplasma pneumoniae (MP) is a major cause of community-acquired upper and lower respiratory infections in school-age children; however, there is increasing recognition that younger children are also affected. Clinical manifestations vary from asymptomatic, to severe complicated pneumonia sometimes with extrapulmonary manifestations.

Methods: We reviewed the medical records of all MP positive pediatric patients admitted to the Hadassah-Hebrew University Medical Center. MP positive case was defined if MP polymerase chain reaction was positive from an oropharyngeal swab sent from 2007 to 2017.

Results: During the study period, we identified 353 MP positive pediatric cases, of which 51.3% (181 of 353) were younger than 6 years old. Full clinical data were available for 332 of 353 (94%). The median age was 5.7 years (range, 3 weeks to 18 years). Disease presentation differed between younger and older children. Children older than 6 years were more likely to have chest radiograph confirmed pneumonia (66% vs. 52%; P = 0.009), while younger children were more likely to have other respiratory manifestations (37% vs. 25%; P = 0.017). The duration of hospitalization and pediatric intensive care unit admission rate, however, did not differ between age groups. The rate of extrapulmonary manifestations were also similar.

Conclusions: MP-associated infection is a significant cause of hospitalization in the pediatric population including younger children (<6 years old). However, the clinical presentation in younger age is less typical than is thought. These findings should prompt clinicians to consider MP infections also in children younger than 6 admitted with fever even without pneumonia.

To date, the actual incidence of drug allergy in the pediatric population is not well known. Epidemiologic studies report that drug allergy affects more than 10% of children and adolescents; although when these children are fully investigated <10% are confirmed to be truly allergic to the suspected drug. Until a few years ago, penicillin allergy was the most frequently reported drug allergy with a prevalence rate of 5%–10% in adults and children. Today amoxicillin allergy is more prevalent than penicillin allergy in children. Non-β-lactam allergy is rare in children and estimated to affect 1%–3% of this population following β-lactams and nonsteroidal anti-inflammatory drugs. As regards the most frequently reported reactions to non-β-lactam drugs, sulphonamides and macrolides are among the most commonly implicated antibiotics.1

These so-called allergic reactions are rather common in children, most likely because of the frequency of rashes that occur during antibiotic treatment for a viral infection and reluctance to test to confirm allergy.

Nowadays, it is mandatory to rigorously confirm or exclude a diagnosis of antibiotic allergy to improve patient safety by using the most appropriate antibiotic depending on the infection to be treated and avoid alternative often more expensive, favoring antibiotic resistance.

Pediatric Autoimmune Neuropsychiatric Disorders Associated with Streptococcal Infection (PANDAS) as a clinical entity was advanced by investigators at the National Institute of Mental Health with 5 elements constituting diagnostic criteria: (1) presence of obsessive compulsive disorder (OCD) and/or tic disorder; (2) prepubertal onset of symptoms; (3) episodic course characterized by acute, severe onset and dramatic symptom exacerbations; (4) temporal relationship between group A beta-hemolytic streptococcal (GAS) infections and symptom onset and exacerbations and (5) association with neurologic abnormalities (eg, choreiform movements, motor hyperactivity, tics).1 In the original description of 50 patients with PANDAS approximately 40% of all presentations and exacerbations were able to be related to preceding or concurrent GAS infections and each patient had at least 1 episode in which the relationship to GAS was established.1 Pediatric Acute-onset Neuropsychiatric Syndrome (PANS) is a diagnostic entity advanced more than a decade later to broaden the scope of these disorders and allow for other instigator events besides GAS. The criteria for PANS include abrupt, dramatic overnight onset of OCD or severely restricted food intake; concurrent abrupt onset of additional severe neuropsychiatric symptoms from at least 2 of the following 7 categories: (1) anxiety; (2) emotional lability and/or depression; (3) irritability, aggression and/or severe oppositional behaviors; (4) developmental regression; (5) deterioration in school performance; (6) sensory or motor abnormalities, including heightened sensitivity to sensory stimuli, hallucinations, dysgraphia, complex motor and/or vocal tics and (7) somatic signs and symptoms, including sleep disturbances, enuresis or urinary frequency and the requirement that symptoms are not better explained by a known neurologic or medical disorder.2

In 2013, a PANS Consensus Conference was… 

Objetivo: describir la tuberculosis infantil de 2005 a 2015 en Navarra, con datos demográficos, clínicos, radiológicos, microbiológicos, tratamiento y evolución. Material y métodos: estudio descriptivo retrospectivo a partir de datos de historia clínica de los pacientes atendidos entre 2005 y 2015. Resultados: 52 pacientes, 57,7% varones, 42,3% mujeres, mediana de edad cuatro años, 38,5% inmigrantes, 61,5% hijos de inmigrantes. Distribución homogénea en los diez años, excepto un brote en 2011. Sintomáticos el 69,2%. En el 63,5% de los pacientes el caso índice es conocido. La forma clínica más frecuente es la pulmonar (82,7%). La radiología fue patológica en el 86,5%, se realizó tomografía computarizada pulmonar en el 82,7% (95,3% patológicos). El 71,2% de los cultivos fueron positivos para Mycobacterium tuberculosis (sensibles 92,3%). Tratamiento con cuatro fármacos y posteriormente dos de 6 a 12 meses. Evolución: 84,6% curación, 13,5% secuelas y un exitus. Conclusiones: la tuberculosis es un problema de salud infantil cuya forma más frecuente es pulmonar. Evoluciona favorablemente, pero presenta morbimortalidad. Es imprescindible tenerla en cuenta para diagnóstico y tratamiento precoz.

Casos clínicos

La infección por el virus de Epstein-Barr (VEB) es habitual y generalmente ocurre en la infancia o en la adultez temprana. El VEB es la etiología de la mononucleosis infecciosa, generalmente asociada con fiebre, dolor de garganta, inflamación de los ganglios linfáticos en el cuello y en ocasiones esplenomegalia. El síndrome de Alicia en el País de las Maravillas (SAPM) o síndrome de Todd es una afección rara, que principalmente afecta la integración visual y somatoestética. El SAPM sigue siendo un síndrome poco conocido y probablemente mal diagnosticado, puede ocurrir a cualquier edad, pero sobre todo en los niños en los que se asocia principalmente con la migraña y la infección por VEB. Presentamos a una paciente de diez años que acudió al servicio de urgencias con distorsión visual de la forma corporal y comportamiento extraño, sospechado inicialmente como una patología psiquiátrica pero posteriormente diagnosticado con mononucleosis infecciosa e infección por VEB confirmada serológicamente. Este caso refleja la importancia de reconocer este síndrome por parte de los médicos de urgencias y evitar derivaciones inadecuadas al servicio psiquiátrico.

La dificultad respiratoria en el periodo neonatal tardío constituye un reto pediátrico no solo diagnóstico, sino de tratamiento, ya que a las múltiples causas del cuadro se deben sumar los factores inherentes a la propia vulnerabilidad del niño. En la práctica habitual, la principal causa de estos cuadros son las infecciones (fundamentalmente víricas), aunque se deben tener en cuenta otras etiologías como cardiológicas, digestivas, metabólicas o anatómicas. Presentamos un caso clínico de tos, dificultad respiratoria e hipoxemia en un neonato de 17 días de vida en el que los datos de la anamnesis, la exploración y el cuadro clínico condujeron a la realización de pruebas complementarias específicas que llevaron al diagnóstico de neumonía por Chlamydia. Realizaremos asimismo una revisión sobre el estado actual de la cuestión basándonos en el cuadro clínico que presentaba el recién nacido.

Muchos niños manifiestan linfadenopatías en algún momento de su infancia, debidas sobre todo a enfermedades infecciosas. Es precisa una buena historia clínica, exploración física y pruebas complementarias que permitan su diagnóstico diferencial. Se describen los casos de dos niños que presentaban un cuadro clínico similar de linfadenopatías regionales, sin fiebre ni exantemas. Ambos tenían como antecedente la picadura de garrapata en el cuero cabelludo. El cuadro clínico y la serología positiva a rickettsias nos llevaron al diagnóstico de linfoadenopatía transmitida por garrapatas, TIBOLA, DEBONEL o SENLAT. El diagnóstico serológico en nuestros casos se encuentra limitado por la existencia de reacciones cruzadas con las distintas especies de rickettsias, en concreto con R. conorii (que es la habitualmente detectada en nuestro medio) e incluso con otras bacterias. La evolución de ambos casos fue favorable con tratamiento de azitromicina durante cinco días. Pese a la dificultad que supone la interpretación de los resultados serológicos, el diagnóstico de esta rickettsiosis se puede hacer a la luz de los datos clínicos y epidemiológicos. Debe plantearse la utilización simultánea de otras técnicas para aumentar la sensibilidad diagnóstica como pueden ser en la actualidad las técnicas de reacción en cadena de la polimerasa en biopsia cutánea que nos darán el diagnóstico etiológico de la infección

A 2-year-old boy was referred to our hospital with a 4-week widespread itchy skin eruption that had started 6 days after receiving measles–mumps–rubella vaccine. The rash first appeared on his face, and then spread to the arms, hands and feet. Skin examination revealed monomorphic erythematous 3–5 mm papules, some covered with crusts, in a symmetrical acral distribution over the face, hands, buttocks, feet, upper and lower limbs …

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Compared with children fully DTaP vaccinated, unvaccinated and undervaccinated children were at a greater risk of pertussis. However, most pertussis cases occurred among age-appropriately vaccinated children.

In this issue of Pediatrics, the vaccine research group at Kaiser Permanente Northern California (KPNC) contributed another important article outlining the challenges of pertussis control in a highly vaccinated population.1 Nearly one-half million children born between 1999 and 2016 and managed at KPNC from 2006 to 2017 were evaluated. Of those immunized children, all had received only diphtheria-tetanus-acellular pertussis (DTaP) vaccine. In total, 738 polymerase chain reaction–confirmed pertussis cases were diagnosed. Pertussis risk was 13 times higher among unvaccinated and nearly 2 times higher among undervaccinated children when compared with those who were fully vaccinated. However, >80% of the total pertussis cases were seen in children who had received all their recommended DTaP vaccine doses. Pertussis risk increased with increasing time since vaccination, clearly demonstrating waning immunity, which the KPNC group and others had previously reported

Pediatrics Jul 2019, 144 (1) e20191375

Clinicians caring for young febrile infants have struggled with risk stratification algorithms for invasive bacterial infections (IBIs) (bacteremia and/or bacterial meningitis) for decades1–5 because of the tension between not wanting to miss infants with IBIs yet not wanting to over-test and over-treat these vulnerable infants.6,7 Risk stratification algorithms using compete blood counts (CBCs) with or without cerebrospinal fluid (CSF) data, developed in the 1980s and 1990s, have several limitations: (1) laboratory thresholds were not derived by statistical methods, resulting in suboptimal test accuracies; (2) algorithm precision was limited by the relatively few infants with IBIs; (3) the epidemiology of IBIs has changed in the past decades8–10 with an increase in Escherichia coli and a decrease in group B Streptococcus infections due to perinatal screening; (4) algorithm specificity has been insufficient to limit the use of lumbar punctures, empirical antibiotics, and hospitalizations; and (5) newer biomarkers, including C-reactive protein (CRP) and particularly procalcitonin (PCT), are substantially more sensitive than the CBC for detecting infants with these infections.7,11,12

In a well-conducted retrospective case-control analysis from 11 emergency departments (EDs) between 2011 …

In this multicenter case-control study, we derive and internally validate a highly sensitive score that identifies non–ill-appearing febrile infants at low probability of bacteremia and/or bacterial meningitis.

Using systematic, prospective blood culture collection in children admitted with CAP, this study identifies risk factors and characterizes outcomes associated with bacteremia. .

CONCLUSIONS Blood culture results identified a causative pathogen in only 2.2% of children hospitalized with CAP, and culture results were more often positive in those with parapneumonic effusions on chest radiograph and those with severe disease requiring ICU care. Penicillin-susceptible S pneumoniae was the most common cause of bacteremic CAP in our study, supporting the existing recommendation for empirical use of narrow-spectrum aminopenicillins for most children hospitalized with suspected bacterial CAP. In an era with widespread pneumococcal vaccination and low prevalence of bacteremia in the United States, children admitted with CAP that have pleural effusion or require ICU admission may represent a high-yield population for identifying bacteremia.

Introducción: La sacroileítis piógena (SIP) es una entidad infrecuente que representa del 1 al 2% del total de las infecciones articulares en la edad pediátrica. Su diagnóstico a menudo se complica y retrasa debido a la inespecificidad de sus síntomas, signos y exploración física. Además, la identificación microbiológica puede resultar difícil debido a la alta proporción de hemocultivos negativos y los riesgos implicados en la aspiración de líquido articular en esta localización.

Pacientes y métodos: Revisión retrospectiva de las historias clínicas de todos los pacientes menores de 18 años ingresados en un hospital infantil terciario con SIP en el período 2008-2016.

Resultados: Se identificaron 6 casos de SIP en niños. Los hemocultivos fueron negativos, y la identificación del agente etiológico requirió aspiración de líquido sinovial en un paciente con infección por Aggregatibacter aphrophilus y pruebas específicas para la detección de agentes menos frecuentes en los pacientes restantes: Kingella kingae (n=2), Brucella melitensis (n=1) y Bartonella henselae (n=1). Los pacientes recibieron regímenes de antibioterapia específica, y todos presentaron una evolución favorable y libre de secuelas.

Conclusiones: A pesar del reducido tamaño muestral, nuestro estudio puso de relieve la baja efectividad del hemocultivo en el diagnóstico de la SIP pediátrica. También evidenció la necesidad de mantener un elevado índice de sospecha de los agentes atípicos y de emplear precozmente métodos diagnósticos apropiados, como las pruebas de imagen y la  (PCR) en muestras de sangre, así como la prescripción de antibioterapia efectiva.

Background: Pediatric sacroiliitis (SI) is an uncommon entity of infectious or inflammatory etiology. Recent data regarding pediatric SI are scarce. The study objective was to describe and compare the clinical features of pediatric infectious and noninfectious SI.

Methods: We reviewed files of children ≤18 years of age, admitted with SI in 2004–2017. Patients were grouped by etiology, infectious versus noninfectious. Clinical and laboratory indices, imaging, treatment protocols and outcome were compared.

Results: Study population included 40 patients with infectious SI (range: 3–192 months, median age: 15 months, 45% female) and 13 patients with noninfectious SI (range: 30–216 months, median age: 168 months, 62% females). Duration of symptoms before admission averaged 5.9 ± 7.5 days in the infectious group and 54.2 ± 96 days in the noninfectious group (P = 0.003). Symptoms observed solely in the infectious group included refusal to stand (n = 27, 77%); walk or crawl (n = 24, 65%); irritability (n = 20, 50%) and recent constipation event (n = 8, 20%). No significant differences in laboratory results were found. Infectious SI patients had uneventful medical history, rapid response to antibiotics and a higher rate of complete resolution of symptoms without recurrences.

Conclusions: An acute unilateral presentation in young patients ≤2 years of age, without chronic medical conditions, suggests an infectious etiology of SI anticipated to completely resolve with antibiotic treatment, not necessitating further workup for noninfectious etiologies.

 Introducción: El objetivo del estudio es revisar nuestra experiencia en el manejo diagnóstico y terapéutico de los abscesos cervicales profundos infantiles, y compararla con la literatura publicada.

Material y métodos: Estudio retrospectivo de todos los pacientes diagnosticados y tratados de abscesos cervicales profundos infantiles durante 15 años (2002-2016), analizando las características demográficas, clínicas, diagnósticas y terapéuticas.
Resultados: Setenta y dos casos fueron diagnosticados. Se aprecia un incremento de su incidencia en los últimos años. La localización más frecuente han sido los abscesos periamigdalinos (30,6%), seguido de las adenopatías abscesificadas (18,1%), los abscesos parafaríngeos (16,7%) y los retrofaríngeos (16,7%). Las menos frecuentes han sido los abscesos submandibulares (12,5%) y parotídeos (5,6%). La distribución fue diferente según edad (p<0,001). El síntoma clínico más frecuente ha sido la fiebre (70,8%), seguido de la odinofagia (55,56%). Las pruebas de imagen más utilizadas han sido la TAC (50,7%) y la ecografía (28,2%). El tratamiento empleado fue farmacológico en el 11,1%, todos ellos adenopatías abscesificadas menores de 1,5cm de tamaño máximo. El otro 88,9% fue intervenido quirúrgicamente. Hubo recidiva en el 12,5% de los casos.
Conclusiones; La realización de amigdalectomía y/o cervicotomía precoz en abscesos mayores de 2cm o lesiones de localización profunda disminuye el número de complicaciones graves y no presenta recidivas. Al utilizar cirugía más conservadora, se han encontrado un 12,5% de recidivas.

Objective Kawasaki disease (KD) is an increasingly common vasculitis with risk of coronary artery aneurysms (CAAs). The last UK survey was in 1990, whereas current epidemiology, treatment patterns and complication rates are unknown. The aim of this study was to address this knowledge gap.

Methods A British Paediatric Surveillance Unit survey in the UK and Ireland from 1 January 2013 to 28 February 2015 ascertained demographics, ethnicity, seasonal incidence, treatment and complication rates.

Results 553 cases were notified: 389 had complete KD, 46 had atypical KD and 116 had incomplete KD; 2 were diagnosed at postmortem with an incidence of 4.55/100 000 children under 5 years, with a male to female ratio of 1.5:1 and a median age of 2.7 years (2.5 months–15 years). Presentation was highest in January and in rural areas. Most were white (64%), and Chinese and Japanese Asians were over-represented as were black African or African mixed-race children. 94% received intravenous immunoglobulin (IVIG). The overall CAA rate was 19%, and all-cardiac complications affected 28%. Those with CAA received IVIG later than in those without (median 10 days vs 7 days). Those under 1 year had fewer symptoms, but the highest CAA rate (39%). Overall 8 of 512 cases (1.6%) had giant CAA, and 4 of 86 cases (5%) under 1 year of age developed giant CAA. Mortality from KD was 0.36%.

Conclusions The UK and Ireland incidence of KD has increased and is more frequently seen in winter and rural areas. Delayed IVIG treatment is associated with CAA, suggesting earlier and adjunctive primary treatment might reduce complications to prevent CAA, particularly in the very young.

Objective Epidemics of Kawasaki disease (KD) are well known; however, the seasonal variation in the clinical course of KD is uncertain. The aim of this study was to investigate the seasonality in the clinical course of KD.

Methods This study included 744 patients who were admitted to six hospitals in Kitakyushu City for KD from 2010 to 2014. We divided the patients into two groups according to the average monthly temperature (warm and cold periods) and compared the clinical courses of KD.

Results The clinical courses of 715 patients who were initially treated with intravenous immunoglobulin (IVIG) were investigated. The proportion of patients with resistance to the initial IVIG therapy was significantly higher during the warm period than during the cold period (p=0.016). There was no seasonality in the proportion of patients with coronary artery abnormalities.

Conclusion Seasonality was observed in the response to IVIG therapy of patients with KD.

I read with interest the article by Vadoothker et al.1 The authors present an interesting review in the pathogenesis and management of herpes simplex virus (HSV) keratitis in the pediatric population. Although the authors highlight the fact that the treatment of HSV keratitis in children is challenging, however, some comments can be added to the management section of this article. Epithelial keratitis can be treated with topical antivirals at discretion of the treating physician, with good results in most of the cases without the need of systemic medication, using either 3% acyclovir ointment when available (in Europe or Latin-American), trifluridine or more recently ganciclovir ointment.

Background Diagnosis of intrathoracic tuberculosis (ITB) is limited in children partly by their difficulty to produce sputum specimen.

Objective To systematically review the detection yields of mycobacterial culture and Xpert MTB/RIF from induced sputum (IS), nasopharyngeal aspirate (NPA) and gastric aspirate (GA) in children with presumptive ITB.

Design Pubmed, Embase and Biosis databases and grey literature were searched. Randomised controlled trials, cohort, cross-sectional or case control studies using IS, GA and NPA for diagnosis of ITB published between January 1990 and January 2018 were included. Data were extracted on study design, case definition of presumptive ITB, sample collection methods, outcome measures and results.

Results 30 studies were selected, including 11 554 children. Detection yields for culture ranged between 1% and 30% for IS, 1% and 45% for GA and 4% and 24% for NPA. For Xpert MTB/RIF, it was between 2% and 17% for IS, 5% and 51% for GA and 3% and 8% for NPA. There was a tendency of better yields with IS when the pretest probability of ITB was low to moderate and with GA when it was high. Sampling a second specimen contributed for 6%–33% of the cumulative yield and combination of different methods significantly increase the detection yields.

Conclusions Despite the important study heterogeneity, any of the specimen collection methods offers good potential to confirm childhood ITB. However, their operational challenges were poorly evaluated. In the absence of a sensitive non-sputum based test, only a minority of children with ITB can be confirmed.

La enfermedad meningocócica invasiva (EMI), causada por la bacteria Neisseria meningitidis, supone una mortalidad y morbilidad significativas. La incidencia de la enfermedad alcanza el máximo entre lactantes <1 año y niños pequeños en todo el mundo. En Europa, el serogrupo B de N. meningitidis es responsable de más del 50 % de todos los casos de EMI, mientras que en Latinoamérica la mayoría de los casos de EMI se deben a los serogrupos B o C. El desarrollo de una vacuna efectiva frente al serogrupo B ha supuesto un reto para los investigadores a lo largo de más de medio siglo. Los polisacáridos capsulares del serogrupo B no eran antígenos vacunales apropiados, y el éxito de las vacunas de vesículas de la membrana externa (OMV) se limitaba a las cepas bacterianas homólogas. La vacunología inversa permitió desarrollar una vacuna meningocócica de 4 componentes que incluía tres antígenos novedosos y las OMVs (4CMenB). Cada componente de la vacuna posee una diana distinta. La vacuna 4CMenB ha sido autorizada basándose en datos de inmunogenicidad y seguridad, debido a que la baja incidencia de la enfermedad impide la realización de estudios de eficacia clínica. El análisis de anticuerpos bactericidas en suero con complemento humano (hSBA) mide los anticuerpos funcionales del suero de los sujetos vacunados (es decir, la inmunogenicidad vacunal) y constituye un correlato de protección aceptado. La cobertura de cepas vacunales se ha evaluado tanto mediante el análisis de la hSBA, como mediante otro método más conservador denominado Sistema de Tipificación de Antígenos Meningocócicos (MATS). Desde 2013, se han recogido datos de efectividad en vida real de 4CMenB. La vacuna resultó efectiva en el control de brotes de Norteamérica y los datos recientes de introducción de la vacuna en el programa nacional de vacunación de lactantes del Reino Unido, han revelado una efectividad vacunal del 82,9 % tras las dos primeras dosis, junto a un perfil de seguridad aceptable.

  • Sífilis. Enferm Infecc Microbiol Clin.2019;37:398-404

La sífilis está causada por la espiroqueta Treponema pallidum subsp. Pallidum, que se transmite por vía sexual o vertical durante la gestación. Su incidencia se ha incrementado en los últimos años, especialmente entre los hombres que tienen sexo con hombres. Sin tratamiento, la infección progresa en distintas fases que terminan en complicaciones irreversibles neurológicas y cardiovasculares. Para su clasificación diferenciamos entre sífilis precoz (primaria, secundaria y latente de menos de un año), que es infecciosa, de la sífilis tardía (latente de más de un año y terciaria), en la que el paciente no es contagioso. El diagnóstico y el tratamiento no es sencillo debido a la gran variedad de manifestaciones clínicas y a la dificultad en la interpretación de las pruebas serológicas. El tratamiento de la sífilis se basa en la administración de penicilina o de doxiciclina en casos de alergia. Con azitromicina se han descrito fracasos terapéuticos y se han encontrado resistencias. Los pacientes que hayan sido diagnosticados y tratados deben de ser seguidos para evaluar la respuesta al tratamiento y diagnosticar posibles reinfecciones.

Introducción: las infecciones por adenovirus tienen una presentación clínica variable y son una importante causa de morbilidad en la infancia. Frecuentemente reciben tratamiento antibiótico de forma innecesaria. Este estudio busca analizar las características de los pacientes con infección por adenovirus y ver si difieren de aquellos con infección bacteriana. Pacientes y métodos: se estudiaron 174 pacientes ingresados en un hospital terciario desde enero de 2009 hasta agosto de 2017 a los que se les detectó adenovirus. Se analizaron las variables clínicas y analíticas y se compararon con las de una muestra de pacientes diagnosticados de infección bacteriana confirmada en el mismo centro en 2016.Resultados: la tasa de pacientes con infección por adenovirus fue de 1,58/100 ingresos. El 64% eran varones, siendo la edad media de 17 meses. Los que solo presentaban síntomas gastrointestinales tenían una menor edad y resultados analíticos más favorables que los que solo mostraban síntomas respiratorios. Un 24,5% presentaban coinfección por otro virus, observándose en este grupo una mayor estancia hospitalaria (7,93 frente a 6,17 días, p = 0,006). Los criterios analíticos de infección bacteriana grave no mostraron diferencias significativas al comparar entre los pacientes infectados por adenovirus y los que tenían una infección bacteriana confirmada, excepto una diferencia mínima, aunque estadísticamente significativa, al comparar las cifras de proteína C reactiva. Conclusiones: las variables analíticas y clínicas estudiadas no son suficientes para discriminar entre infección bacteriana y por adenovirus. Sería adecuado descartar infección por adenovirus sistemáticamente antes de instaurar tratamiento antibiótico.

Introducción: a pesar de los numerosos estudios publicados hasta la fecha sobre el tratamiento hospitalario de la bronquiolitis y de la prometedora eficacia del suero salino hipertónico, lo cierto es que existe controversia al respecto. Material y métodos: estudio observacional prospectivo que evalúa la eficacia del suero hipertónico al 3% frente al suero fisiológico en el tratamiento hospitalario de la bronquiolitis, en términos de reducción de estancia y de puntuación de escala clínica de gravedad; en una segunda fase se analizan factores de riesgo asociados al reingreso por broncoespasmo de los mismos pacientes. Resultados: se analizan 67 de los 73 pacientes ingresados por bronquiolitis, de los cuales 9 recibieron fisiológico y 58 hipertónico, con o sin broncodilatador asociado. La estancia hospitalaria fue de 6,07 ± 3,12 días para el grupo fisiológico, y de 6,67 ± 4,36 días para el grupo con hipertónico. La media de la puntuación (Wood-Downes modificado por Ferrés) para el grupo con fisiológico fue de 3,67 ± 1,1 y de 3,16 ± 1,1 para los que recibieron hipertónico. Para la segunda fase se obtiene una tasa de reingresos del 8,2%. Conclusiones: no encontramos diferencias significativas entre ambos grupos en tiempo de hospitalización ni en mejoría de escala clínica y días de oxigenoterapia. Pese al reducido tamaño muestral no observamos ninguna tendencia a favor de diferencias significativas en nuestra muestra. Los factores más relacionados con el reingreso han sido la edad menor a 6 meses, el sexo masculino, el tener hermanos mayores y el tabaquismo familiar.

Background: Enterovirus (EV) D68 is mainly associated with acute respiratory infection (ARI). Since 2014, when outbreaks in different countries were observed, this emerging virus was considered a potential threat to public health.

Methods: During 2015–2017, the presence of enterovirus RNA was investigated in all respiratory samples of children younger than 15 years of age with ARI, obtained for virologic studies in the Pediatric Emergency Care Units and wards of 2 hospitals in Gipuzkoa (Spain), using a commercial multiplex real-time polymerase chain reaction. When enterovirus was detected, a polymerase chain reaction to amplify a specific viral polyprotein (VP1) gene region of EV-D68 was performed.

Results: In 2016, EV-D68 circulation was associated to ARI, with the highest incidence in the spring months. EV-D68 was detected in 44 children, mean age 30.1 ± 31.7 months old, 23 (52.3%) of them females and 17 (38.6%) with underlying respiratory medical conditions. Thirty-two patients (72%) required hospital admission, receiving the discharge diagnosis of recurrent wheezing (37.5%), asthmatic crisis (37.5%) or bronchiolitis (12.5%). Seven children (15.9%) needed the support of the pediatric intensive care unit. When coinfections were excluded, children with EV-D68 infection presented with increased work of breathing, recurrent wheezing or asthmatic crisis, more frequently than those with ARI associated with EV non-D68. Moreover, clinical outcomes (hospitalization, respiratory support) were more severe. All 44 EV-D68 strains detected belonged to lineage B3.

Conclusions: EV-D68 circulated widely in Gipuzkoa during 2016 and was associated with severe ARI. In children with severe ARI of unknown etiology, the presence of EV-D68 should be considered.

Conclusiones de los autores del estudio: la profilaxis antibiótica no está indicada para la prevención de cicatrices renales tras la primera o segunda infección urinaria febril en niños sanos.

Comentario de los revisores: 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, por lo que la administración de profilaxis antibiótica no está justificada.

  • Long‐term antibiotics for preventing recurrent urinary tract infection in children. Cochrane Database of Systematic Reviews 2019, Issue 4. Art. No.: CD001534. DOI: 10.1002/14651858.CD001534.pub4.

Debido a la enfermedad aguda causada por la infección de orina (IU) y al riesgo de daño renal permanente tras sufrir una pielonefritis, a muchos niños se les administran antibióticos a largo plazo destinados a prevenir la recurrencia. Esta es la tercera actualización de una revisión publicada por primera vez en 2001 y actualizada en 2006 y 2011.

El objetivo es evaluar si la profilaxis antibiótica a largo plazo fue más efectiva que el placebo / ningún tratamiento para prevenir la recurrencia de la IU en niños, y si es así, qué antibiótico fue el más efectivo. También evaluamos los daños del tratamiento antibiótico a largo plazo.

La conclusión a la que llegan los autores es que los antibióticos a largo plazo pueden reducir el riesgo de que se repita una IU sintomática en niños que han tenido una o más IU previamente, pero el beneficio puede ser pequeño y debe considerarse junto con el mayor riesgo de resistencia microbiana.

Background: Hepatitis C virus (HCV) is the most commonly encountered blood transmittable hepatitis among cancer patients. Several studies have reported clustering of HCV infections in families or household contacts of infected cases. Data about the epidemiologic aspects of intrafamilial transmission from pediatric cancer patients are scarce and still debated. We aimed to identify the magnitude of horizontal intrafamilial transmission of HCV from infected pediatric oncology patients; its prevalence, risk factors and possible routes of transmission.

Methods: One hundred fifty-seven (86 HCV positive, 71 HCV negative) pediatric oncology patients who received treatment and follow-up at Zagazig university Hospital-Egypt and their household family contacts (751) were enrolled in this cross-sectional case-control study. Blood samples were collected from 450 relatives of HCV infected cases (group 1) and 301 household contacts of HCV-negative cases (group 2) for analysis of HCV antibodies and HCV RNA to confirm positivity. Family contacts of HCV-infected cases were interviewed, and close-ended questionnaire was completed for each participant to determine risk factors and possible routes of HCV intrafamilial transmission.

Results: Significantly higher HCV prevalence and chronicity rates were documented among relatives of HCV-infected cases as compared with contacts of HCV-negative cases (12.6% and 10.6% for group 1 vs. 7% and 5.3% for group 2, respectively). Risk factors of infection were calculated by univariate and logistic regression analysis among contacts of HCV-infected cases. Female caregivers, particularly mother (OR 5.1, 95% CI: 2–13.5), contact with index cases blood, either directly without using personal protective equipment (OR 7.8, 95% CI: 2.9–23.8) or indirectly through common use of sharps (razors, scissors) (OR 8.9, 95% CI: 3.5–20.5) and nail clippers (OR 2.1, 95% CI: 1.1–5.4) and giving care to infected cases (OR 2.9, 95% CI: 1.3–16.6) represented the real predictors of intrafamilial HCV infection.

Conclusions: Intrafamilial transmission of HCV from infected children to their relatives does occur. Parenteral route is the only documented way of transmission either directly or indirectly.

  • Measles: Public Health England urges all parents to get their children vaccinated as cases spike. BMJ 2019;365:l2335.

  • David Oliver: Vaccination sceptics are immune to debate. BMJ 2019;365:l2244

Dos artículos que analizan el aumento de casos de sarampión en Inglaterra, hecho patente en muchos otros países de nuestro entorno, así como la incredulidad y hostilidad frente a la vacuna que han contribuido a la disminución de las tasas de vacunación de la triple vírica

Salud pública inglesa revela que los casos recientes de sarampión se produjeron principalmente en comunidades no vacunadas y estaban relacionados con viajes a países con grandes brotes actuales. Aunque las coberturas vacunales son elevadas con la primera dosis, (94.9% de los de 5 años), descienden a un 87,4% en las 2ª dosis, muy por debajo del 95% recomendado por la Organización Mundial de la Salud para garantizar una inmunidad efectiva para el conseguir el efecto rebaño.

El mes pasado, un informe de Unicef ​​mostró que alrededor de 169 millones de niños en todo el mundo no habían recibido su primera dosis de la vacuna contra el sarampión entre 2010 y 2017, y la Organización Mundial de la Salud descubrió que los casos de sarampión habían aumentado en un 300% en todo el mundo entre enero y abril de 2019. , en comparación con el mismo período en 2018.

Esta disminución de las tasas de vacunación se ha atribuido a la vacilación frente a la vacunación de médicos y gobiernos, agravada por la difusión de supuestos efectos adversos no probados, propagados por grupos “pseudocientíficos” en las redes sociales. Los argumentos se centran en la libertad individual y el derecho de los padres a tomar decisiones por sus propios hijos.

La OMS ha publicado directrices sobre cómo responder en público a quienes rechazan las vacunas. Tal vez sea mejor enfocarse en métodos efectivos para elevar las tasas de vacunación y aceptar que algunos debates no se pueden ganar o si se ganan solo serán para quedar mal.

Las infecciones neumocócicas son las principales causas de morbilidad y mortalidad en todo el mundo. Utilizamos datos de ingreso hospitalarios de rutina y análisis de modelos de series de tiempo para estimar el impacto de las vacunas conjugadas antineumocócicas siete y trece valentes (PCV7 y PCV13) en los ingresos hospitalarios debido a la enfermedad neumocócica en Inglaterra.

Se redujeron sustancialmente los ingresos hospitalarios por bacteriemia, meningitis y neumonía en Inglaterra después de la introducción de la vacunación infantil.

El diagnóstico rápido y preciso de la tuberculosis (TB) infantil es difícil porque los niños a menudo no pueden producir la muestra de esputo necesaria para las pruebas convencionales. Las heces son un tipo de muestra alternativa que es fácil de recoger en los niños. Los estudios que investigan el uso de heces para la detección molecular de Mycobacterium tuberculosis (Mtb) han dado resultados prometedores. El objetivo fue evaluar las heces como una muestra alternativa al esputo para la detección de Mtb en niños.

Las muestras de heces analizadas con el método TruTip y la amplificación IS6110 produjeron estimaciones de sensibilidad y especificidad comparables a otras pruebas como el Xpert.

Due to its innately intriguing nature and recent genomic technological advances, gut microbiome research has been at the epicentre of medical research for over a decade now. Despite the degree of publicisation, a comprehensive understanding and, therefore, acceptance of the area as a whole may be somewhat lacking within the broader medical community. This paper summarises the main analytical techniques and tools currently applied to compositional microbiome research. In addition, we outline five major lessons learnt from a decade of infant microbiome research, along with the current research gaps. Finally, we aim to provide an introduction and general guidelines relating to infant gut microbiome research for the practising paediatrician.

We searched and identified 17 randomised controlled trials (studies in which participants are assigned to one of two or more treatment groups using a random method), published before October 2018. All were conducted in Europe, and collectively included 3488 children. Twelve trials included children who were not prone to acute middle ear infections, whilst five trials included children who were prone to such infections.

Key results

One-third fewer children not prone to acute middle ear infection who took probiotics experienced acute middle ear infections compared to children not taking probiotics. However, probiotics may not benefit children prone to acute middle ear infection. Taking probiotics did not impact on the number of days of school that children missed. None of the studies reported on the impact of probiotics on the severity of acute middle ear infection. There was no difference between the group taking probiotics and the group not taking probiotics in the number of children experiencing adverse events (harms).

Quality of the evidence

The quality (or certainty) of the evidence was generally moderate (meaning that further research may change our estimates) or high (further research is unlikely to change our estimates). However, the trials differed in terms of types of probiotics evaluated, how often and for how long they were taken, and how the trial results were reported.

 

 

Actualidad bibliográfica junio 2019

Top Ten

El objetivo de este estudio es conocer las características epidemiológicas, clínicas y analíticas de la primoinfección por el virus de Epstein-Barr (VEB) en niños sin diagnóstico previo de ninguna enfermedad inmune y su relación con la forma de presentación clínica.

Estudio retrospectivo de pacientes entre 0 y 15 años con IgM sérica frente a la cápside viral del VEB positiva o indeterminada, durante un período de 22 meses. Se analizaron datos epidemiológicos, clínicos y de laboratorio y se compararon según tuvieran una clínica típica (síndrome mononucleósico) o no típica.

Se incluyeron 103 niños. La mediana de la edad fue de 7 años (3-12,5 años). El 63% de los pacientes presentaron clínica típica o síndrome mononucleósico y el 37% una clínica no típica. La edad fue significativamente menor en el grupo de clínica no típica (p=0,03) y recibieron menos tratamiento antibiótico (p=0,015). En los parámetros analíticos no hubo diferencias estadísticamente significativas excepto en la PCR, discretamente más elevada en el grupo de clínica típica (p=0,04). El 33% de los pacientes tuvieron anticuerpos heterófilos positivos. El 20% tuvieron una IgM frente a la cápside viral indeterminada, la mayoría con clínica oligosintomática o atípica. El 21% tuvieron IgM positivas para otros virus y 3 de ellos fueron posibles falsos positivos para el VEB.

En nuestra población, la primoinfección por VEB es frecuente en niños de menor edad, y en ellos predominan las formas oligosintomáticas. El porcentaje de anticuerpos heterófilos positivos ha sido muy bajo en nuestra muestra. Los casos con IgM frente a la cápside viral indeterminada son más frecuentes en el grupo de clínica no típica. Es común detectar coinfección con otros virus.

  • Oseltamivir para el tratamiento de la gripe en niños y adolescentes. An Pediatr (Barc). 2019;90(5):317.e1---317.e8.

Métodos: El Grupo de Infecciones Respiratorias de la Sociedad Española de Infectología Pediátrica llevó a cabo una revisión de la bibliografía. Los hallazgos se analizaron mediante la metodología GRADE, y se elaboraron unas recomendaciones. Resultados: No se recomienda el uso sistemático de pruebas diagnósticas para la gripe en el ámbito ambulatorio y en urgencias hospitalarias en pacientes inmunocompetentes con un cuadro clínico compatible. No se recomienda el uso de antivirales a la gran mayoría de los pacientes sanos y asmáticos con gripe o sospecha de gripe estacional, si el objetivo es prevenir eventos graves. No se recomienda el uso de oseltamivir de forma sistemática en pacientes hospitalizados con gripe. Se recomienda tratar con oseltamivir a los pacientes con gripe y neumonía o enfermedad grave o a los pacientes críticos, especialmente durante las primeras 48 h de enfermedad. Se recomienda el tratamiento de los pacientes con factores de riesgo, teniendo en cuenta su enfermedad de base. La vacunación antigripal, junto a las medidas básicas de evitación, continúan siendo la principal herramienta en la prevención de la gripe.

Conclusión: En algunas situaciones hay datos suficientes para emitir recomendaciones claras. En otras situaciones los datos son incompletos y solo permiten hacer recomendaciones débiles.

La infección del tracto urinario se define como el crecimiento de microorganismos en orina recogida de forma estéril, en un paciente con síntomas clínicos compatibles. En ausencia de sintomatología el aislamiento de bacterias en urocultivo se denomina bacteriuria asintomática y no precisa tratamiento.  

La infección por Chlamydia trachomatis es un importante problema de salud pública mundial y la principal causa bacteriana de infecciones de transmisión sexual. La infección puede transmitirse a través del canal del parto, pudiendo ocasionar nasofaringitis y/o conjuntivitis neonatal (habitualmente 5-12 días tras el parto), así como neumonía en los 3 primeros meses de vida1,2. El diagnóstico etiológico de estas infecciones es importante, porque la sintomatología no se diferencia de la causada por otros microorganismos y los tratamientos que no incluyan un macrólido pueden no ser eficaces frente a C. trachomatis. El objetivo del presente trabajo fue investigar la tasa de transmisión perinatal de la infección por C. trachomatis.

Entre octubre/2010 y septiembre/2015 se estudió prospectivamente, mediante una técnica de amplificación de ácidos nucleicos (TAAN) en tiempo real (Cobas® 4800 CT/NG, Roche), la presencia de C. trachomatis en 103 hijos de madres infectadas,…

detectadas en un cribado puerperal realizado en el Hospital Universitario Donostia (HUD) 3 . Este estudio de investigación fue aprobado por el Comité de Ética del HUD (acta 9/2010). Los niños, como todos los recién nacidos en el HUD, recibieron profilaxis ocular neonatal con pomada oftálmica de tobramicina hasta octubre de 2013 o hidrocloruro de clortetraciclina con posterioridad. La transmisión vertical en el neonato se evaluó 7-10 días tras el parto mediante una exploración física y la obtención de exudado faríngeo, suplementado con exudado conjuntival en el último año del estudio y en los casos con sospecha de conjuntivitis. Los neonatos infectados fueron tratados por vía oral con eritromicina 14 días mientras estuvo la formulación disponible en el hospital o con posterioridad azitromicina 3 días. Se realizó seguimiento clínico durante 3 meses (instrucción a los padres para acudir a la consulta en caso de aparición de síntomas de conjuntivitis, neumonía o nasofaringitis, y confirmación de la ausencia de síntomas telefónicamente al finalizar el periodo).

Se constató transmisión vertical en 11 (10,7%) niños (5 varones, 6 mujeres), distribuidos uniformemente en el período de estudio. El porcentaje ascendió al 15,5% (11/71) excluyendo los nacidos por cesárea y/o de madres que recibieron tratamiento antibiótico en las 48 h preparto ( tabla 1 ). C. trachomatis se detectó en el 8,7% de las muestras faríngeas (9/103) y el 17,6% (6/34) de las conjuntivales (p = 0,15). Siete niños infectados estaban asintomáticos y 4 (3,9% del total de vigilados) presentaban conjuntivitis, en un caso asociada a cuadro catarral. Todos los casos recibieron tratamiento antibiótico (7 eritromicina, 4 azitromicina), resolviéndose la infección tempranamente en 7/8 que acudieron al control microbiológico a los 15 días; en otro caso, la detección de C. trachomatis y la sintomatología (conjuntivitis) persistió durante 2 meses, por inadecuada dispensación del tratamiento por los padres. 

Casos clínicos

La enfermedad por arañazo de gato (EAG) es una enfermedad benigna y autolimitada causada por Bartonella henselae. Clásicamente se presenta con linfadenopatía regional, pero en un 5-15% de casos se puede presentar de forma sistémica1 considerándose parte del diagnóstico diferencial de la fiebre de origen desconocido (FOD). Presentamos los casos de 2 pacientes con EAG diseminado atendidos en el hospital NCH, Columbus, Ohio, EE.UU.

Niño de 14 años sano, con fiebre de 16 días,…

A healthy 2-year-old child was referred to the paediatric emergency department for febrile torticollis with 1 cm painful cervical lymph nodes. Blood tests showed 20.8 mg/L C reactive protein and an acute Epstein-Barr virus infection. The persistence of torticollis despite a regular intake of both paracetamol and ibuprofen for 2 weeks suggested another aetiology. A CT scan associated with MRI showed an inflammatory process at the C1–C2 vertebrae (figure 1), and Kingella kingae-specific PCR was positive on biopsy. Cefamandole (150 mg/kg/day) was given intravenously for 7 days, followed by oral amoxicillin …

A 7-year-old girl developed severe neck stiffness and trismus while on treatment for a presumed throat infection. Examination findings included a fixed torticollis with restricted neck movements in all directions (figure 1); erythematous tonsils and cervical lymphadenopathy. Group A strep was cultured from her throat swab. She coincidentally had diabetes mellitus. CT neck with contrast revealed subluxation of C1/C2 (figure 2, left); and bilateral retropharyngeal, deep …

An 11-year-old girl with trisomy 21 and severe atopic dermatitis was admitted for fever of 4 days and nonitchy diffuse thick crusted scaly rash of unknown duration. Prior to the onset of the rash, she had been maintained on topical triamcinolone 1% as treatment for atopic dermatitis. Physical examination revealed elevated temperature (38.7°C), tachycardia (127 beats per minute), diffuse dry hyperkeratotic crusts (Figure, A and B), and areas of skin tenderness and erythema (Figure, B [arrow]). The rest of the examination was unremarkable. Laboratory evaluation showed leukocytosis and neutrophilia. Direct microscopy of skin scrapings revealed live scabies mites and eggs, confirming the diagnosis of Norwegian scabies. She was treated with topical permethrin 5% for 2 weeks, 7 daily doses of oral ivermectin, 200 μg/kg each (days 1, 2, 8, 9, 15, 22, and 29), and a 7-day course of clindamycin for possible superimposed bacterial infection. The rash improved within 1 week (Figure, C and D). She had negative HIV testing, normal lymphocytic subset, and B cell panel. Immunoglobulin levels showed elevated IgG and IgE and normal IgM.

A 27-month-old boy was referred to pediatric dermatology for the evaluation of crusts on his eyelashes; they had been present for 2 months and were increasing in number. The crusts had appeared after a trip to Bulgaria, where his family had been sleeping in several different hotels and places. Physical examination showed crusts on both eyelashes and a few crusts on the front part of his scalp. He had slight conjunctivitis and palpebral pruritis. The child was in good health and the physical examination was otherwise normal. His weight was 13.5 kg.

Findings of a dermoscopy examination revealed that the crusts actually consisted of agglomerates of nits on the proximal side of the eyelashes, and several parasites were visible (Figure). There were a few parasites on the front part of his scalp hair also. The hair on his father's chest had several nits. Parasitology examination revealed that the parasites were Phtirus pubis. The child and his parents were given oral ivermectin 400 μg/kg (day 1 and day 7) and topical ophthalmologic rifamycin ointment once a day for 7 days, along with manual removal of the nits and parasites. Complete remission was obtained after 3 weeks of treatment. After interrogation, we concluded that phthiriasis had been transmitted from the father's chest to the child, who used to sleep on the chest of his parents.

Para profundizar

To determine whether treatment for urinary tract infections in children could be individualized using biomarkers for acute pyelonephritis.

Study design

We enrolled 61 children with febrile urinary tract infections, collected blood and urine samples, and performed a renal scan within 2 weeks of diagnosis to identify those with pyelonephritis. Renal scans were interpreted centrally by 2 experts. We measured inflammatory proteins in blood and urine using LUMINEX or an enzyme-linked immunosorbent assay. We evaluated serum RNA expression using RNA sequencing in a subset of children. Finally, for children with Escherichia coli isolated from urine cultures, we performed a polymerase chain reaction for 4 previously identified virulence genes.

Results

Urinary markers that best differentiated pyelonephritis from cystitis included chemokine (C-X-C motif) ligand (CXCL)1, CXCL9, CXCL12, C-C motif chemokine ligand 2, INF γ, and IL-15. Serum procalcitonin was the best serum marker for pyelonephritis. Genes in the interferon-γ pathway were upregulated in serum of children with pyelonephritis. The presence of E coli virulence genes did not correlate with pyelonephritis.

Conclusions

Immune response to pyelonephritis and cystitis differs quantitatively and qualitatively; this may be useful in differentiating these 2 conditions.

Acute otitis media (AOM) is one of the most common childhood infections, generally thought to be caused by ascension of bacteria from the nasopharynx (NP) to the middle ear. Using 16S ribosomal RNA-based sequencing, we evaluated the relationship between the NP and middle ear fluid (MEF) microbiota in children with AOM with tympanostomy tubes (AOMT) as a proxy for AOM and explored whether microbiota profiling predicts natural disease course.

Microbiota profiles of paired NP and MEF samples of 94 children below 5 years of age with uncomplicated AOMT were determined.

Local diversity (P < 0.001) and overall microbiota composition (P < 0.001) of NP and MEF samples differed significantly, although paired NP and MEF samples were much more similar than unpaired samples (P < 0.001). High qualitative agreement between the presence of individual bacteria in both niches was observed. Abundances of Pseudomonas aeruginosa, Staphylococcus aureus, Streptococcus pyogenes, Turicella otitidis, Klebsiella pneumoniae and Haemophilus spp. were strongly correlated between the 2 niches. Additionally, P. aeruginosa, S. aureus, T. otitidis and Streptococcus pneumoniae abundance in NP were predictive of the presence of a range of oral types of bacteria in MEF. Interestingly, there was no association between Moraxella catarrhalis in NP and MEF samples, which was highly present in NP but virtually absent in MEF. Finally, the NP microbiota composition could predict duration of AOMT, even better than MEF microbiota.

We observed substantial correlations between paired NP and MEF microbiota in children with AOMT. Our data also suggest that NP microbiota profiling deserves further exploration as tool for future treatment decisions.

The Mantoux tuberculin test (TST) is likely the oldest widely used test in contemporary diagnostics. In the past, when its obvious weaknesses were considered, it always “received a pass” because of the lack of an alternative test. However, with the advent and improvement of interferon γ release assays (IGRAs), we feel it is past time to reconsider the widespread use of TSTs.

Existen datos limitados acerca de los abscesos perianales (AP), con respecto a su etiología y tratamiento. Este estudio retrospectivo tiene como objetivo definir las características de los niños con AP, detallar nuestra experiencia en el campo de las enfermedades infecciosas pediátricas y determinar los factores que influyen en los resultados clínicos.

Entre enero de 2005 y julio de 2015 se llevó a cabo una revisión retrospectiva de niños con AP sin enfermedad subyacente en un hospital de referencia de nivel terciario. La información incluyó características demográficas, síntomas, tamaño y localización del absceso, recurrencias de los abscesos, hallazgos de laboratorio y microbiológicos, modalidades de tratamiento, diagnóstico de enfermedades sistémicas al finalizar las investigaciones etiológicas y pronóstico.

Resultados

En el estudio se incluyeron 47 pacientes, con predominio masculino (93,6 frente a 6,4%, p<0,001). La mediana de edad fue de 7,7 meses (rango intercuartílico 1,8 a 13,7 meses) y 40 de los niños (85,1%) tenían menos de 2 años de edad. Cuatro AP drenaron espontáneamente y 7 curaron sin necesidad de drenaje (23,4%). Se aplicó drenaje mediante incisión simple a 36 pacientes (76,5%) y 6 AP requirieron de fistulotomía (12,7%). Se observaron abscesos recurrentes en 25 pacientes (53,1%). Tres pacientes con AP recurrentes fueron diagnosticados de enfermedad inflamatoria intestinal al finalizar las investigaciones.

Conclusiones

De acuerdo con los hallazgos del presente estudio, la determinación de la cifra de leucocitos, así como de los reactantes de fase aguda, parece ser útil en la primera evaluación de los niños con AP. En cuanto a las altas tasas de recurrencia en pacientes sometidos a procedimientos quirúrgicos, resulta razonable el uso de enfoques conservadores para pacientes menores de 2 años.

To develop a scale for the severity of mononucleosis.

One to 5 percent of college students develop infectious mononucleosis annually, and about 10% meet criteria for chronic fatigue syndrome (CFS) 6 months following infectious mononucleosis. We developed a severity of mononucleosis scale based on a review of the literature. College students were enrolled, generally when they were healthy. When the students developed infectious mononucleosis, an assessment was made as to the severity of their infectious mononucleosis independently by 2 physicians using the severity of mononucleosis scale. This scale was correlated with corticosteroid use and hospitalization. Six months following infectious mononucleosis, an assessment is made for recovery from infectious mononucleosis or meeting 1 or more case definitions of CFS.

In total, 126 severity of mononucleosis scales were analyzed. The concordance between the 2 physician reviewers was 95%. All 3 hospitalized subjects had severity of mononucleosis scores ≥2. Subjects with severity of mononucleosis scores of ≥1 were 1.83 times as likely to be given corticosteroids. Students with severity of mononucleosis scores of 0 or 1 were less likely to meet more than 1 case definition of CFS 6 months following infectious mononucleosis.

The severity of mononucleosis scale has interobserver, concurrent and predictive validity for hospitalization, corticosteroid use, and meeting criteria for CFS 6 months following infectious mononucleosis.

The Pediatric Infectious Disease Journal. 38(6):547-552

BACKGROUND:

There are no recent descriptions of measles hospitalizations and complications in US children despite outbreaks within the past decade-including 2 in Minnesota (2011 and 2017). The objective of our study was to describe complications, hospital management and resource utilization for children hospitalized for measles at a US children's hospital.

METHODS:

Retrospective case series of children (0-18 years of age) hospitalized for measles (observation/inpatient diagnosis code for measles) at Children's Minnesota, January 1, 2011, to September 1, 2017. Descriptive statistics were performed.

RESULTS:

Thirty-three patients were included (7 from 2011 and 21 from 2017 outbreaks). Median age was 27 months (range, 6-95 months), 94% were Black or African American (73% Somali ethnicity), 88% had medical assistance and 91% were unvaccinated to measles. Poor feeding was a primary reason for admission (97%); additional complications included otitis media (42%), pneumonia (30%), tracheitis (6%) and keratitis (3%). Additional testing was common [chest radiographs (70%), blood cultures (64%), nonmeasles viral testing (42%)]. Seventy-three percent received antibiotics, 30% required oxygen and 21% received vitamin A. Median length of stay was 3.7 days (range, 1.1-26.2 days); 1 patient was readmitted. Median direct cost in 2017 was $5291 (interquartile range : $3907-$7519), and estimated total cost to the hospital for the 2017 outbreak was $1.3 million.

CONCLUSIONS:

Clinicians should be aware of measles complications and treatment. Public and private health efforts should continue to focus on immunization, given significant implications of measles infections for patients and healthcare systems. Future studies may assess complications of measles across the United States as individual outbreaks often occur in specific populations, making generalization of results challenging.

BACKGROUND:

Pertussis continues to be a significant public health problem despite high levels of vaccination. Although hospitalizations and deaths among children greater than 12 months of age are much less frequent than among infants less than 6 months of age, only limited information is available for this age group on other measures of morbidity.

METHODS:

A cross-sectional study with a 6-week follow-up component was conducted in New South Wales, Australia in 2017 to measure morbidity among children 12-59 months of age notified to health authorities. Measures used included cough duration, cough severity, constitutional symptoms and impacts on the family. Associations between these outcomes and age group, vaccination status, asthma, treatment and family structure were explored.

RESULTS:

Three hundred and five of 472 (65%) notified cases were interviewed at baseline with approximately 20% having a severe cough with no trend in prevalence across age groups. Forty-eight percent of cases had experienced 3 or more constitutional symptoms with rates significantly higher among younger children. Children who had received an 18-month booster vaccination were significantly less likely to experience 3 or more constitutional symptoms (odds ratio: 0.46, 95% confidence interval: 0.22-0.97). Fifty-one percent of cases were still coughing at 6 weeks. One-third of carers initially reported having disrupted sleep 4 or more nights per week with substantial disruption to carers' sleep still recorded at 6 weeks.

CONCLUSIONS:

Substantial morbidity was observed in this age group with some evidence that the reintroduction of an 18-month acellular pertussis booster lessened disease severity.

Clinical scenario

A 3-year-old boy is brought into the accident and emergency department by his mother in visible respiratory distress. His mother explained that it started a few days ago with a fever and a bit of a cough and she thought that he had what all children got around this time of year. Since then, however, he has not got any better, and this morning when he woke up she noticed that he was breathing extremely quickly and making strange noises that sounded like grunts. The doctors diagnosed him with a severe community-acquired pneumonia and explained that he would have to be admitted for intravenous antibiotics and close observation. The next morning on the ward round the consultant was very worried about him as he was showing many of the features of very severe pneumonia. You have read that zinc could be useful in severe pneumonia in children and ask if it could help.

Clinical question

As an adjunct to standard treatment, does zinc (intervention) reduce mortality and/or accelerate recovery (outcome) in children under 5 years with severe pneumonia (patient)? …

Current BTS guidelines2 do not recommend zinc supplementation for children with severe pneumonia. This may reflect a presumption that their dietary intake is sufficient which may not be true in other parts of the world. Studies from low/middle-income countries have shown that while zinc does not accelerate recovery, it may reduce mortality. This effect should be assessed in children from high-income countries, and if effective, a correct dose is determined. OK, para casos clínicos

Objectives To determine the performance of procalcitonin (PCT), C reactive protein (CRP) and absolute neutrophil count (ANC) in identifying invasive bacterial infection (IBI) among well-appearing infants ≤21 days old with fever without source and no leukocyturia. To compare this performance with that in those 22–90 days old.

Design Substudy of a prospective single-centre registry performed between September 2008 and August 2017.

Setting Paediatric emergency department of a tertiary teaching hospital.

Patients 196 infants ≤21 days old and 1331 infants 22–90 days old.

Main outcome measures Sensitivity and negative likelihood ratio of blood tests for ruling out IBI (positive blood or cerebrospinal fluid culture). Abnormal blood test results: PCT ≥0.5 ng/mL, CRP >20 mg/L and ANC >10 000/µL.

Results Prevalence of IBI in infants ≤21 days old with normal or any abnormal blood test result was 3.6% and 6.8%, respectively (OR 0.52 (95% CI 0.13 to 2.01)), compared with 0.2% and 4.5% in older infants (OR 0.03 (95% CI 0 to 0.17)). Sensitivity and negative likelihood ratio of the blood tests for ruling out IBI in infants ≤21 days were 44.4% (95% CI 18.9% to 73.3%) and 0.79 (95% CI 0.43 to 1.44), respectively (vs 84.6% (95% CI 57.8% to 95.7%)%) and 0.19 (95% CI 0.05 to 0.67) in older infants). The values improved in infants with fever ≥6 hours aged 22–90 days, but not in those ≤21 days.

Conclusions PCT, CRP and ANC are not useful for ruling out IBI in febrile infants ≤21 days old. It is still recommended that these patients are admitted and given empirical antibiotic therapy, regardless of their general appearance or blood test results.

Objectives This study aimed to prospectively collect detailed clinical information for all enterovirus (EV) and human parechovirus (HPeV) meningitis cases in infants aged <90 days in the UK and Ireland.

Participants, design and setting Prospective, active national surveillance during July 2014 to July 2015 through the British Paediatric Surveillance Unit. Reporting paediatricians completed questionnaires requesting information on clinical presentation, investigations, management and outcomes at hospital discharge and after 12 months.

Main outcome measures To describe the clinical burden of EV and HPeV meningitis in infants aged <90 days.

Results During the 13-month surveillance period, 703 cases (668 EV, incidence0.79/1,000 live- births; 35 HPeV, 0.04/1,000 live-births) were identified. The most common clinical presentations were fever (EV: 570/668(85%); HPeV: 28/35(80%)), irritability (EV: 441/668(66%); HPeV: 23/35(66%)) and reduced feeding (EV: 363/668(54%); HPeV 23/35(66%)). Features of circulatory shock were present in 27% (182/668) of EV and 43% (15/35) of HPeV cases. Overall, 11% (76/668) of EV and 23% (8/35) of HPeV cases required intensive care support. Nearly all cases (678/703, 96%) were confirmed by cerebrospinal fluid (CSF) PCR, with 52% (309/600) having normal CSF white cell count for age. Two infants with EV meningitis died (2/668, 0.3%) and four survivors (4/666, 0.6%) had long-term complications at 12 months’ follow-up. Infants with HPeV meningitis survived without sequelae. Overall 189 infants had a formal hearing test and none had sensorineural hearing loss.

Conclusion The incidence of laboratory-confirmed EV/HPeV meningitis in young infants is more than twice that for bacterial meningitis. Less than 1% will develop severe neurological complications or die of their infection. Further studies are required to formally assess long-term neurodevelopmental sequelae.

  • Pneumococcal conjugate vaccines for preventing acute otitis media in children. Cochrane Database of Systematic Reviews 2019, Issue 5. Art. No.: CD001480. DOI: 10.1002/14651858.CD001480.pub5

The evidence is current up to 29 March 2019. We included 11 trials of PCVs versus control vaccines (meningococcus type C conjugate vaccine in three trials, and hepatitis A or B vaccine in eight trials) involving a total of 60,733 children. The PCVs used in the trials contained 7 to 11 different types of pneumococcus. None of the trials used the newer PCV containing 13 different types. Most trials were funded by pharmaceutical companies. Overall, risk of bias was low. In seven trials (59,415 children), children received PCVs in early infancy, and four trials included 1318 children aged one year and over who were either healthy or who had previous respiratory illness or frequent acute middle ear infections.

Administration of the licenced CRM197-PCV7 and PHiD-CV10 during early infancy is associated with large relative risk reductions in pneumococcal AOM. However, the effects of these vaccines on all-cause AOM is far more uncertain. We found no evidence of a beneficial effect on all-cause AOM of administering PCVs in high-risk infants, after early infancy (i.e. in children one year and above), and in older children with a history of respiratory illness. Compared to control vaccines, PCVs were associated with an increase in mild local reactions (redness, swelling), fever, and pain and/or tenderness. We found no evidence of a difference in more severe local reactions, fever, or serious adverse events judged causally related to vaccination.  

  • La importancia de la vigilancia epidemiológica de los enterovirus emergentes. An Pediatr (Barc). 2019;90(5):326-327

Con relación a la reciente publicación titulada «Patología neurológica aguda por enterovirus: revisión de casos clínicos en un hospital andaluz de tercer nivel tras brote epidémico de Cataluña»1 y dada la importancia y trascendencia del tema que trata desde el punto de vista neuropediátrico, nos gustaría realizar algunas reflexiones y aportar algunos comentarios.

 

 

Actualidad bibliográfica mayo 2019

Top ten

The Pediatric Infectious Disease Journal. 38(5):e107-e109

Bordetella pertussis is prevalent among infants, but its diagnosis is complicated by the fact that its signs and symptoms overlap with respiratory viruses. Indeed, when evaluating the etiology of infants less than 1 year of age suspected of having pertussis, we found that respiratory viruses frequently mimic B. pertussis and are more likely to be the causative agent.

Background: Detection of cytomegalovirus (CMV) DNA by real-time polymerase chain reaction (rt-PCR) in dried blood spots (DBSs) collected for newborn screening has been assessed for retrospective diagnosis of congenital CMV (cCMV) infection, with variable results (sensitivities ranging from 34% to 100%). We aimed to assess the accuracy of this technique in Spain in a large patient series.

Methods: Ambispective, multicenter study including patients with confirmed cCMV from the Spanish Registry of cCMV patients. cCMV was established on the presence of CMV DNA in any body fluid, by positive culture findings or by molecular techniques during the first 2 weeks of life. Children in whom cCMV had been excluded were used as negative controls. Neonatal DBS samples were collected from both groups. The presence of CMV DNA was assessed by rt-PCR (RealStar CMV, Altona, Germany) in a central laboratory.

Results: One-hundred three patients and 81 controls from 10 hospitals were included. The performance of CMV DNA determination in DBS for the diagnosis of cCMV was as follows (95% confidence interval): sensitivity 0.56 (0.47–0.65), specificity 0.98 (0.91–0.99), positive likelihood ratio 22.81 (5.74–90.58) and negative likelihood ratio 0.45 (0.36–0.56). Sensitivity increased with the birth viral load (bVL) log category. In cCMV patients, lower bVL was the single variable associated with a negative DBS rt-PCR result (P = 0.017).

Conclusions: The sensitivity of CMV rt-PCR in DBS in our series was low and correlated with the bVL. Thus, a negative DBS result would not rule out cCMV infection, especially in patients with a low viremia level at birth.

Background: Infective endocarditis (IE) remains a diagnostic and therapeutic challenge associated with high morbidity and mortality. We evaluated the microbial profile and clinical manifestation of IE in children.

Methods: A retrospective study examining pediatric IE cases treated between 2000 and 2017 at the Department of Pediatric Cardiology, KU Leuven, was conducted. Clinical presentation, treatment, complications, outcome of IE, underlying microorganisms and congenital heart defects were reviewed.

Results: Fifty-three patients were diagnosed with IE. Overall, 19 patients (36%) required cardiac surgery. Seven patients (13%) died. Eighty-seven percent of patients had an underlying congenital cardiac defect. Eighteen (34%) children presented with prosthetic graft IE. A causative organism was found in 49 (92%) cases: viridans group streptococci were identified in 17 (32%), Staphylococcus aureus in 13 (25%) and coagulase-negative staphylococci in 11 (20%) children. Community-acquired (CA) IE increased significantly from 8 (33%) cases in 2000–2007 to 20 (74%) cases in 2008–2017 (P < 0.01). Even with viridans streptococci being significantly more prevalent in the CA group (P < 0.01), we did not observe an increase of streptococcal IE from 2008 to 2017. Seventeen (32%) patients presented with hospital-acquired IE during the first year of life with 14 (82%) children after surgery and a prevalence of coagulase-negative staphylococci (53%).

Conclusions: The incidence of pediatric IE was similar over the investigated time period with a shift toward CA IE. Streptococci and staphylococci accounted for the majority of cases in both periods. Awareness of IE and its prevention is crucial in patients after implantation of prosthetic grafts.

Objective To assess the effect of the duration of fever after the initiation of treatment (FAT) of febrile urinary tract infections (UTI) on the development of permanent renal lesions based on dimercaptosuccinic acid (DMSA) scintigraphy findings. To evaluate the FAT contribution to permanent renal lesion formation in relation to fever before treatment initiation (FBT), the presence of vesicourinary reflux (VUR), age and severity of infection.

Methods The inpatient records of 148 children (median age: 2.4 months (11 days to 24 months)) with a first episode of UTI during a 3-year period were analysed. DMSA findings, and clinical and laboratory parameters were evaluated.

Results Among the study population, 34/148 (22.97%) children had permanent renal lesions on the DMSA scan 6 months after a single episode of UTI. Twenty-three children (15.5%) had mild, 10 (6.7%) had moderate and 1 (0.6%) child had severe lesions on the DMSA. FAT prolongation >/48 hours was associated with older age (p=0.01) and increased absolute neutrophil count (p=0.042). The likelihood of lesions was significantly increased when FAT was ≥48 hours (R2=0.043, p=0.021). On multiple regression analysis, with the addition of FBT>/72 hours (0.022), the presence of VUR (p<0.001), C-reactive protein (p=0.027) and age (p=0.031), the effect of FAT on lesion development disappeared (p=0.15).

Conclusions Prolongation of FAT≥48 hours of febrile UTI in children <2 years significantly contributes to the development of permanent renal lesions. However, delay in treatment initiation >/72 hours, the presence of VUR, older age and infection severity seem to be more significant predictors of the development of renal lesions.

El Erythrovirus B19 (anteriormente denominado parvovirus B19) es el agente etiológico del eritema infeccioso que afecta mayoritariamente durante la infancia y la adolescencia, pero también está relacionado con artropatías, crisis aplásicas y abortos en adultos. El propósito de esta revisión es estudiar las características de las infecciones causadas por Erythrovirus B19 diagnosticadas en nuestro hospital en los últimos 6 años y las diferencias entre la población adulta y la pediátrica.

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

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

En pediatría la clínica más frecuente es el exantema y la fiebre, y en adultos las artralgias. También es frecuente la anemia, los casos más graves en presencia de enfermedad hematológica previa. Hay que destacar la grave afectación que pueden sufrir los fetos en las gestantes.

Introducción

La gripe es una enfermedad generalmente benigna, pero en ocasiones puede ocasionar complicaciones graves. Existe controversia sobre los beneficios del tratamiento con antivirales.

Proporcionar unas recomendaciones sobre el tratamiento con oseltamivir en pacientes pediátricos con gripe, basadas en los mejores datos disponibles y válidas en nuestro medio.

El Grupo de Infecciones Respiratorias de la Sociedad Española de Infectología Pediátrica llevó a cabo una revisión de la bibliografía. Los hallazgos se analizaron mediante la metodología GRADE, y se elaboraron unas recomendaciones.

No se recomienda el uso sistemático de pruebas diagnósticas para la gripe en el ámbito ambulatorio y en urgencias hospitalarias en pacientes inmunocompetentes con un cuadro clínico compatible. No se recomienda el uso de antivirales a la gran mayoría de los pacientes sanos y asmáticos con gripe o sospecha de gripe estacional, si el objetivo es prevenir eventos graves. No se recomienda el uso de oseltamivir de forma sistemática en pacientes hospitalizados con gripe. Se recomienda tratar con oseltamivir a los pacientes con gripe y neumonía o enfermedad grave o a los pacientes críticos, especialmente durante las primeras 48h de enfermedad. Se recomienda el tratamiento de los pacientes con factores de riesgo, teniendo en cuenta su enfermedad de base. La vacunación antigripal, junto a las medidas básicas de evitación, continúan siendo la principal herramienta en la prevención de la gripe.

En algunas situaciones hay datos suficientes para emitir recomendaciones claras. En otras situaciones los datos son incompletos y solo permiten hacer recomendaciones débiles.

There is a great variability in the management of the young febrile infant.1 25-30% of young infants with a history of fever are afebrile on arrival to the ED.2 Uncertainty over the prevalence of SBI in infants presenting afebrile to the ED may contribute to management variability. In the study conducted by Ramgopal et al, the prevalence of SBI was lower among infants afebrile on ED presentation compared with those who were febrile. Nevertheless, the rate of SBI remained substantial and the rate of invasive bacterial infection (bacteremia and meningitis) did not show significant differences among the infants who did and did not have fever documented in the ED. This suggests that clinical and laboratory evaluation in the ED should not be altered based solely on the infant’s temperature at ED presentation.

  • Maternal pertussis vaccination and its effects on the immune response of infants aged up to 12 months in the Netherlands: an open-label, parallel, randomised controlled trial. Lancet Infect Dis. 2019 Apr;19(4):392-401.

Resumen: los hijos de madres vacunadas contra tos ferina en el tercer trimestre de embarazo tardan más en desarrollar anticuerpos propios frente a la enfermedad en caso de haber sido vacunada su madre durante el embarazo. Las consecuencias clínicas de este dato están por establecer. No obstante, el nivel de antivcuerpos pasivos maternos en niños vacunados, soportaría perfectamente un retraso en el inicio de la vacunación a los 3 meses de edad. Queda claro la interferencia de los anticuerpos maternos sobre la respuesta inmunitaria a la vacuna puesta al niño. Las consecuencias clínicas de esta interferencia quedan por establecerse.

Thirty-three studies were reviewed and provide the best available evidence. The studies tested 6352 children (3 days to 17 years of age) who were receiving probiotics co-administered with antibiotics to prevent AAD. The participants received probiotics (Lactobacilli spp., Bifidobacterium spp., Streptococcus spp., or Saccharomyces boulardii alone or in combination), placebo (pills not including probiotics), other treatments thought to prevent AAD (i.e. diosmectite or infant formula) or no treatment. The studies were short-term, ranging in length from 5 days to 12 weeks. Analyses showed that probiotics are effective for preventing AAD. The incidence of AAD in the probiotic group was 8% (259/3232) compared to 19% (598/3120) in the control group, demonstrating a moderate reduction (11% fewer will suffer diarrhea). For every 9 children treated, probiotics will prevent one case of diarrhea. Further, evidence suggests that higher dose probiotics (≥ 5 billion CFUs per day) reduce the incidence of AAD in the probiotic group by 8% (162/2029) compared to 23% (462/2009) in the control group, demonstrating a moderate to large reduction (15% fewer suffer diarrhea). Probiotics were generally well tolerated, and minor side effects (e.g. rash, nausea, gas, flatulence, abdominal bloating, constipation) occurred infrequently. . Evidence suggested that probiotics are effective for a moderate reduction in duration of diarrhea (almost one day). Among the various probiotics evaluated, Lactobacillus rhamnosus or Saccharomyces boulardii at 5 to 40 billion colony forming units/day appear most appropriate for preventing AAD in children receiving antibiotics. It is premature to draw conclusions about the effectiveness and safety of 'other' probiotic agents for preventing AAD. Although no serious probiotic-related side effects were observed among the mostly otherwise healthy children who participated in the studies, serious side effects have been reported in observational studies not included in this review, including severely debilitated or immuno-compromised children with underlying risk factors including central venous catheter (a flexible tube used to give medicines) use and disorders associated with bacterial or fungal translocation (the passage of bacteria from the gut to other areas of the body).

In this update sixteen studies (2036 children randomised, 1977 analysed) were included. Seven studies (612 children) compared two or more types of antibiotics, six (1088 children) compared antibiotics with placebo or no treatment, one four-armed study compared circumcision with and without antibiotic treatment, one study compared dose of antibiotic, and one three-armed study compared two different antibiotics as well as no treatment. Of the sixteen included studies only one study was judged to be at low risk of bias for all domains, with the majority judged to be at unclear risk of bias due to very poorly reported methodology.

Long-term antibiotics may reduce the risk of repeat symptomatic UTI in children who have had one or more previous UTIs but the benefit may be small and must be considered together with the increased risk of microbial resistance.

 

·Risk Factors for Complications in Children with Staphylococcus aureus Bacteremia J Pediatr. 2019 May;208:214-220.e2

Objectives: To determine risk factors for complications in children with Staphylococcus aureus (S aureus) bacteremia, including methicillin resistance.

Study design: Single center, retrospective cohort study of children ≤18 years of age hospitalized with S aureus bacteremia. We compared clinical characteristics and outcomes between those with methicillin-sensitive S aureus (MSSA) and methicillin-resistant S aureus (MRSA) bacteremia. Multivariate regression models identified risk factors associated with developing complications and with longer duration of bacteremia.

Results: We identified 394 episodes of S aureus bacteremia, 279 (70.8%) with MSSA, and 115 (29.2%) with MRSA. Primary site of infection was catheter-related in 34%, musculoskeletal in 30%, skin/soft tissue in 10.2%, pneumonia in 6.4%, and endovascular in 6.6%. Eight children (2.0%) died within 30 days because of S aureus bacteremia, 15 (3.5%) had recurrence within 30 days, and 38 (9.6%) had complications including septic emboli or a metastatic focus of infection. Methicillin resistance was associated with development of a complication (aOR 3.31; 95% CI 1.60-6.85), and catheter-related infections were less likely to be associated with a complication (aOR 0.40; 95% CI 0.15-1.03). In a Poisson regression analysis on duration of bacteremia, methicillin resistance, musculoskeletal infection, endovascular infection, black race, and delayed intervention for source control were significantly associated with longer duration of bacteremia.

Conclusions: In this cohort of children with S aureus bacteremia, MRSA infections ere associated with longer duration of bacteremia and a higher likelihood of complications.

 

Casos clínicos

Para profundizar

Background: Staphylococcus aureus (SA) is a major cause of bacteremia in children. Methicillin-resistant SA (MRSA) is considered a public health threat; however, the differences in the prognosis of children with methicillin-susceptible SA (MSSA) versus MRSA bacteremia are not well defined.

Methods: Data from all SA bacteremia events in children (0–16 years) from 2002 to 2016 in a single Israeli tertiary center were collected. Positive cultures within 48 hours of hospitalization were considered community associated (CA). Those obtained afterward or from children hospitalized within the previous year were considered health-care associated (HA).

Results: We recorded 427 events, 284 (66%) were HA, 64 (15%) were MRSA and 9 (2%) were CA-MRSA. There was no increase in MRSA during the study period. In-hospital, 30-day and 1-year mortality were 3% (12 cases), 3.5% (16 cases), and 12% (50 cases), respectively. A multivariable analysis controlling for demographics, admitting department and prior morbidity showed an increased 1-year mortality in children with HA bacteremia (hazard ratio [HR] 4.1; 95% confidence interval [CI]: 1.3–12) and prior chronic disease (HR 3.4; 95% CI 1.2 to 9.0). MRSA was not independently associated with increased one-year mortality compared with MSSA: HR (95% CI: 1.4 [0.6–3.1]).

Conclusions: Short-term pediatric mortality after SA bacteremia is low. HA-SA bacteremia has an increased long-term risk for mortality, particularly in children with chronic diseases. Our data suggest mortality was not increased for MRSA compared with MSSA bacteremia. The very low rate of CA-MRSA bacteremia justifies the current practice not to include glycopeptides in the empiric treatment of CA bacteremia in Israel.

Resumen: análisis de la frecuencia y calidad de prescripción antibiótica en urgencias pediátricas hospitalarias de 28 paises de la unión europea. Hay gran variabilidad en la prescripción entre todos los hospitales y países analizados. El 32% de los paciente recibe prescripción antibiótica, pero varía entre los diferentes hospitales de los diferentes paises analizados desde un 19 a un 64%. La prescripción fue muy variable y con excesivo uso de antibióticos de segunda línea

The Pediatric Infectious Disease Journal. 38(5):464-469

Background: Candidemia is the most frequent pediatric fungal infection, but incompletely elucidated in population-based settings. We performed a nationwide cohort study including all pediatric patients with candidemia in Denmark from 2004 to 2014 to determine age, incidence, species distribution, underlying diseases, patient management and outcomes.

Methods: All candidemia episodes were identified through the active nationwide fungemia surveillance program. Susceptibility testing followed the EUCAST E.Def 7 (European Committee on Antifungal Susceptibility Testing, Edition Definitive) reference method. χ2 test, Fisher exact test and Venn diagrams were used for statistical analyses.

Results: One hundred fifty-three pediatric patients (≤ 15 years) with 158 candidemia episodes were identified. The overall annual incidence rate was 1.3/100,000 population, higher for neonates (5.7/100,000 live births) and low birth weight neonates (103.8/100,000 live births). From 2004 to 2009 to 2010 to 2014, the proportion of Candida albicans decreased from 74.4% to 64.7%, whereas fluconazole resistance increased from 7.8% to 17.7%. Virtually all patients had at least 1 underlying disease (98.6%) and multimorbidity was common (43.5%, ≥2 underlying diseases). Underlying diseases differed by age with heart malformations and gastrointestinal disease prevalent in children younger than 3 years. The overall 30-days mortality was 10.2% and highest for neonates (17.1%). Mortality increased from 2004 to 2010 to 2014, driven by an increase among older children.

Conclusion: This first nationwide epidemiologic study of pediatric candidemia confirmed a high incidence among neonates and a substantial burden of comorbidities. Moreover, an increasing proportion of fluconazole resistant nonalbicans species was observed. Our findings underline the importance of choosing correct treatment and continuous surveillance of pediatric candidemia.

Introducción: La dosis diaria definida (DDD), tiene limitaciones para la medición del consumo antimicrobiano en pediatría. Se propone un diseño aplicable en niños.

Métodos: Se incluyeron niños (<16 años) de 10 hospitales españoles durante un periodo de 12 meses. A partir de la mediana de edad de la cohorte, utilizando tablas estandarizadas de la OMS, se obtuvo el peso correspondiente al percentil P50 de esa edad. Se calculó la DDD (gr) multiplicando el peso obtenido por la dosis recomendada (mg/kg) de cada antimicrobiano para su indicación más común.

Resultados: Un total de 40575 niños fueron incluidos. La mediana de edad fue 4,17 (RIQ: 1,36–8,98) y 4,81 (RIQ: 1,42–9,60) años para niños y niñas, respectivamente. Peso medio para la edad: 17,08kg. DDD estandarizadas fueron calculadas para antimicrobianos representativos.

Conclusiones: Se ha propuesto un método útil para monitorizar consumo antimicrobiano en pediatría utilizando DDD adaptadas, que deberá validarse en futuros estudios.

·Lactobacillus administration does not affect acute gastroenteritis. J Pediatr. 2019; 208: 294–297

The lack of efficacy in the Schnadower et al study conflicts with several trials showing a reduction of diarrhea severity and duration in different settings. The use of a modified Vesikari score, onset of therapy, rotavirus immunization, and previous antibiotic courses, differ among trials. The Schnadower et al study sample size and subgroup analysis resolve most reproducibility issues. Also, it is unlikely that the North American microbiome, gastroenteritis etiology, or medical approach differ significantly from other developed parts of the world. In the same issue of the NEJM, another published negative RCT, with the same design and some authors in common, used a probiotic combination for which comparative data are not available.1 Studies like these mark a novel trend in evidence-based medicine. Large, rigorous, RCTs challenge meta-analyses and dozens of heterogeneous studies of various quality that have previously provided the basis for acute gastroenteritis guidelines. Current guidelines recommend Lactobacillus GG as an adjunct to oral rehydration.2 If the “no treat” option is applied widely, millions of children will be left without an active therapy while their parents request an effective intervention.3

Background: The epidemiology of tuberculosis (TB) is changing in the United Kingdom and globally. Childhood TB is a key indicator of recent transmission and provides a marker of wider TB control. We describe the recent epidemiology of childhood TB in the United Kingdom, how this compares to TB in adults, and document changes with time.

Methods: TB cases notified in the United Kingdom between 2000 and 2015 were categorized as children (<15 years of age) or adults (≥15 years of age). Descriptive analyses were carried out on demographic, clinical and microbiologic data. We carried out logistic regressions to identify risk factors associated with children having no microbiologic confirmation.

Results: In the study period, 6293 TB cases (5%) in the United Kingdom were notified in children. Childhood TB incidence declined from 487 cases in 2000 (3.4 per 100,000) to 232 cases (2.0 per 100,000) in 2015. The majority (68%) of children with TB were UK born, with a high proportion of Pakistani (24%) and Black-African (22%) ethnicity. Sixty-four percent of children had pulmonary disease. Culture confirmation was low (24%). Children who were younger, UK born and those with extrapulmonary disease were less likely to have microbiologically confirmed TB. A high proportion (87%) of children completed treatment at last-recorded outcome, with few deaths (39 cases; 0.7%).

Conclusions: The incidence of TB in children in the United Kingdom has decreased in the past 16 years, with the majority of children completing TB treatment. Ongoing monitoring of childhood TB will provide a measure of the effectiveness of the national TB program.

As the global epidemic of obesity and type two diabetes in children and adults continues to be a major challenge to public health, an intriguing possible ‘off-target’ effect of the rotavirus vaccine and association with a reduction in the incidence of Type 1 diabetes, has been reported in JAMA Paediatrics. An Australian study from a team in Melbourne, JAMA Pediatr 2019;173(3):280-282. doi: 10.1001/jamapediatrics.2018.4578) and is the first report of epidemiological evidence of this possible and fascinating association.

 

Rotavirus (RV) infection has been proposed to trigger type 1 diabetes mellitus (DM1) and celiac disease (CD) by molecular mimicry in genetically susceptible children. If so, a live attenuated oral RV vaccine could also trigger these autoimmune diseases, or else, prevent the effect of wild-type RV infection.

Methods: In Rotavirus Efficacy and Safety Trial, conducted between 2001 and 2003, the participant children received RotaTeq (Kenilworth, NJ) vaccine or placebo in 1:1 ratio. The surveillance was extended as Finnish Extension Study. A questionnaire was sent in 2015 to the parents of 19,133 Finnish Extension Study participants and 5764 (30%) returned the questionnaire. Diagnosis of DM1, biopsy-proven CD and other autoimmune disease over the 11–14 year period were inquired.

Results: At the time of questionnaire, the prevalence of DM1 was similar in both groups, 0.97% (25 of 2580 children) in the placebo group and 1.04% (33 of 3184 children) in the vaccine group (P = 0.810). The prevalence of CD was significantly higher in placebo recipients (1.11%; confidence interval: 0.78%–1.6%) than in vaccine recipients (0.60%; confidence interval: 0.38%–0.93%) (P = 0.027).

Conclusions: RV vaccination using RotaTeq did not alter the occurrence of DM1 but decreased the prevalence of CD in childhood and adolescence. We propose that wild-type RV may trigger CD and the triggering effect can be prevented or reduced by RV vaccination.

Background: Bell’s palsy is a peripheral paralysis of the seventh cranial nerve, whose etiology is unknown. Using polymerase chain reaction technology, it is possible to sample accessible body fluids and identify possible viral factors. The purpose of this research is to investigate its connection to the herpes virus family by testing for the presence of the virus in the saliva and tear fluid of Bell’s palsy patients.

 

Methods: Saliva and tears were collected from 42 children and adolescents suffering from idiopathic facial nerve paralysis. Polymerase chain reaction was used to test for the presence of the viruses Epstein-Barr virus, cytomegalovirus, herpes simplex virus 1 and 2, varicella zoster virus and human herpes virus 6 (HHV-6). Samples were also taken from a control group without paralysis. A second specimen was taken from patients who tested positive for HHV-6 several months after their recovery.

Results: Of the 42 patients in the study group, 71% (30 patients) tested positive for HHV-6, compared with only 37% of the control group (P = 0.001). The prevalence of the other 5 viruses tested was low—herpes simplex virus 1: 9.5%, Epstein-Barr virus: 9.5%, cytomegalovirus: 4.8%, varicella zoster virus: 2.3% and herpes simplex virus 2: 0%. Twenty-four of the 30 patients who were HHV-6-positive during their illness were reexamined following recovery. Only 13 patients (54.2%) excreted the virus after recovery from the paralysis.

Conclusions: Herpes 6 virus appears to play some role in the etiology of facial nerve paralysis. The virus was detected in the saliva of children during acute illness and decreased with resolution. Our research opens new insights linking HHV-6 to the etiology of Bell’s palsy in children.

The Pediatric Infectious Disease Journal. 38(5):533-538

Background: This longitudinal study describes the associations between respiratory viral infections, rhinitis and the prevalence and density of the common nasopharyngeal bacterial colonizers, Streptococcus pneumoniae (Sp), Moraxella catarrhalis (Mc), Haemophilus influenzae (Hi) and Staphylococcus aureus.

Methods: In an observational cohort study, 161 children attending day care centers in Bristol, United Kingdom, were recruited. Monthly nasopharyngeal swabs were taken and stored frozen in Skim-milk, tryptone, glucose and glycerin broth (STGG) broth. Quantitative polymerase chain reaction was used for detection of respiratory viruses and 4 bacterial species. t tests and logistic regression models were used for analysis.

Results: The frequent colonisers, Sp, Mc and Hi were more frequently found at high density in contrast to Staphylococcus aureus although temporally, high-density carriage was short lived. Respiratory viral infections and symptoms of rhinitis were both independently and consistently associated with higher bacterial density with an observed 2-fold increase in density for Sp, Mc and Hi (P = 0.004–0.017).

Conclusions: For Sp and Hi, the association between young age and higher bacterial DNA density was explained by more frequent viral infection and increased nasal discharge, while the associations between some viral specie’s and some bacterial species’ density appear to be stronger than others. Increased colonization density and rhinitis may promote transmission of these commonly carried organism

  • Protection against varicella with two doses of combined measles-mumps-rubella-varicella vaccine or one dose of monovalent varicella vaccine: 10-year follow-up of a phase 3 multicentre, observer-blind, randomised, controlled trial. Lancet Infect Dis. 2019;19:287-97

Resumen: se trata de una ensayo clínico controlado de fase tres, tras 10 años, en el que se compara la eficacia vacunal frente a varicela de la pauta de dos dosis de tetravírica en comparación con una dosis de triple vírica y una dosis de antivaricela con un grupo control que recibia dos dosis de triple vírica. La eficacia vacunal fue del 95,4% en el primer grupo, y del 67,2% en el segundo grupo que administra una dosis solamente. Los efectos secundarios fueron similares. Parece claro que la efectividad a10 ños vista es superior con dos dosis de varicela que con una.

Resumen: a través de un estudio de comparación de casos y controles entre más de 15.000 niños captados, se ha comprobado que la relación monocitos/linfocitos activados CD4 y un marcador sérico de RNA, podría relacionarse con una mayor predisposición a desarrollar la enfermedad tuberculosa.

Tuberculosis causes more deaths than any other infectious disease globally. Bacillus Calmette-Guérin (BCG) is the only available vaccine, but protection is incomplete and variable. The modified Vaccinia Ankara virus expressing antigen 85A (MVA85A) is a viral vector vaccine produced to prevent tuberculosis.

The search identified six studies relating to four Phase 2 randomized controlled trials enrolling 3838 participants. Funding was by government bodies, charities, and philanthropic donors. Five studies included infants, one of them infants born to HIV-positive mothers. One study included adults living with HIV. All trials included authors from Oxford University who led the laboratory development of the vaccine. Participants received intradermal MVA85A after BCG in some studies, and before selective deferred BCG in HIV-exposed infants.

MVA85A added to BCG compared to BCG alone probably has no effect on the risk of developing microbiologically confirmed tuberculosis (RR 0.97, 95% CI 0.58 to 1.62; 3439 participants, 2 trials; moderate-certainty evidence), or the risk of starting on tuberculosis treatment (RR 1.10, 95% CI 0.92 to 1.33; 3687 participants, 3 trials; moderate-certainty evidence). MVA85A probably has no effect on the risk of developing latent tuberculosis (RR 1.01, 95% CI 0.85 to 1.21; 3831 participants, 4 trials; moderate-certainty evidence). Vaccinating people with MVA85A in addition to BCG did not cause life-threatening serious adverse effects (RD 0.00, 95% CI –0.00 to 0.00; 3692 participants, 3 trials; high-certainty evidence). Vaccination with MVA85A is probably associated with an increased risk of local skin adverse effects (3187 participants, 3 trials; moderate-certainty evidence), but not systemic adverse effect related to vaccination (144 participants, 1 trial; low-certainty evidence). This safety profile is consistent with Phase 1 studies which outlined a transient, superficial reaction local to the injection site and mild short-lived symptoms such as malaise and fever.

Our searches of the medical literature revealed one relevant study, which was in infant botulism. The treatment was a single dose of a medicine made from human immune proteins (human-derived botulinum immune globulin intravenous, or BIG-IV). Fifty-nine infants received BIG-IV, and 63 infants received a placebo (inactive treatment). Each study participant was followed up for the duration of their hospitalization. This study was sponsored by the California Department of Health Services.

We found low- and moderate-certainty evidence supporting the use of BIG-IV in infant intestinal botulism. A single RCT demonstrated that BIG-IV probably decreases the duration of hospitalization; may decrease the duration of mechanical ventilation; and probably decreases the duration of tube or parenteral feeding. Adverse events were probably no more frequent with immune globulin than with placebo. Our search did not reveal any evidence examining the use of other medical treatments including serum trivalent botulism antitoxin.

The Pediatric Infectious Disease Journal. 38(5):e82-e86

Background: Infectious disease (ID) pandemics pose a considerable global threat and can disproportionately affect vulnerable populations including children. Pediatric clinical research in pandemics is essential to improve children’s healthcare and minimize risks of harm by interventions that lack an adequate evidence base for this population. The unique features of ID pandemics require consideration of special processes to facilitate clinical research. We aimed to obtain consensus on pediatric clinician-researchers’ perceptions of the priorities to feasibly conduct clinical pediatric pandemic research in Europe.

Methods: Mixed method study in 2 stages, recruiting pediatric clinician-researchers with experience of conducting pediatric ID research in clinical settings in Europe. Stage 1 was an expert stakeholder workshop and interviews. Discussions focused on participant’s experience of conducting pediatric ID research and processes to facilitate pandemic research. Information informed stage 2, an online consensus survey to identify pediatric inician-researchers priorities to enable ID pandemic research.

Results: Twenty-three pediatric clinician-researchers attended the workshop and 39 completed the survey. Priorities were primarily focused on structural and operational requirements of research design and regulation: (1) clarity within the European Clinical Trials Directive for pediatric pandemic research; (2) simplified regulatory processes for research involving clinical samples and data; and (3) improved relationships between regulatory bodies and researchers.

Conclusions: Results suggest that changes need to be made to the current regulatory environment to facilitate and improve pediatric research in the pandemic context. These findings can provide expert evidence to research policy decision-makers and regulators and to develop a strategy to lobby for change.

El uso de la telemedicina comercial directa al consumidor (DTC) fuera del hogar médico pediátrico está aumentando entre los niños, y las infecciones respiratorias agudas (IRA) son la afección más comúnmente diagnosticada en las visitas de telemedicina de DTC. Nuestro objetivo fue comparar la calidad de la prescripción de antibióticos para las IRA entre los niños en 3 entornos: telemedicina DTC, atención en urgencias y la consulta de atención primaria (PCP).

En las visitas de telemedicina (DTC), los niños con IRA tenían más probabilidades de recibir antibióticos y menos probabilidades de recibir tratamiento  antibiótico de acuerdo con las guías clínicas en comparación con los niños que van a la consulta de atención Primaria y o acuden a urgencias.

Previous studies have shown the strongest predictor of a “5-star” rating after a DTC telemedicine encounter for an ARTI is receipt of an antibiotic prescription,5 and adults with ARTIs receive more unnecessary antibiotic prescriptions at DTC telemedicine encounters than at primary care office visits. But what about children? The American Academy of Pediatrics discourages the use of DTC telemedicine outside of the medical home, and the American Telemedicine Association suggests that DTC telemedicine should not be used for children ,2 years old.

But for pediatric ARTIs, the DTC version seems to be at best a low-quality encounter and at worst a vehicle for antibiotic overuse.

Pediatrics May 2019, 143 (5) e20184064; DOI: 10.1542/peds.2018-4064

En esta revisión sistemática, se investiga el coste-eficacia de la profilaxis con palivizumab para el VRS estratificado por el marco de utilización y los subgrupos de población infantil relevantes para la toma de decisiones sobre políticas de salud.

Palivizumab prophylaxis is used as passive immunization for respiratory syncytial virus (RSV). However, because of its high cost, the value of this intervention is unclear.

To systematically review the cost-effectiveness of palivizumab prophylaxis compared with no prophylaxis in infants <24 months of age.

Medline, Embase, and Cochrane Library up to August 2018.

Two reviewers independently screened results to include economic evaluations conducted between 2000 and 2018 from Organization for Economic Cooperation and Development countries.

Two reviewers independently extracted outcomes. Quality appraisal was completed by using the Joanna Briggs Institute checklist. Costs were adjusted to 2017 US dollars.

We identified 28 economic evaluations (20 cost-utility analyses and 8 cost-effectiveness analyses); most were from the United States (n = 6) and Canada (n = 5). Study quality was high; 23 studies met >80% of the Joanna Briggs Institute criteria. Palivizumabprophylaxis ranged from a dominant strategy to having an incremental cost-effectiveness ratio of $2 526 203 per quality-adjusted life-year (QALY) depending on study perspective and targeted population. From the payer perspective, the incremental cost-effectiveness ratio for preterm infants (29-35 weeks' gestational age) was between $5188 and $791 265 per QALY, with 90% of estimates <$50 000 per QALY. Influential parameters were RSV hospitalization reduction rates, palivizumab cost, and discount rate.

Model design heterogeneity, model parameters, and study settings were barriers to definitive conclusions on palivizumab's economic value.

Palivizumab as RSV prophylaxis was considered cost-effective in prematurely born infants, infants with lung complications, and infants from remote communities

 

 

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.

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