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Tarr PI, Freedman SB. Why antibiotics should not be used to treat Shiga toxin-producing Escherichia coli infections. Curr Opin Gastroenterol 2022; 38:30-38. [PMID: 34871193 DOI: 10.1097/mog.0000000000000798] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
PURPOSE OF REVIEW There has been much debate about treating Shiga toxin-producing Escherichia coli (STEC) infections with antibiotics. No data convincingly demonstrate that antibiotics are better than no antibiotic treatment at all, and many studies suggest antibiotics increase the risk of developing the hemolytic uremic syndrome (HUS). This topic is timely, because emerging technology enables rapid identification of STEC-infected patients, and we anticipate questions about management will increase. This review is designed to familiarize readers with the series of observations that underlie our recommendations. RECENT FINDINGS The long debate over antibiotics in STEC infections appears resolved by gradually accruing information that show that antibiotics do not benefit infected patients. In fact, they are associated with an increased likelihood of developing HUS. A meta-analysis published in 2016 demonstrated that low risk of bias studies find a clear association between antibiotic use and development of HUS. Subsequent publications do not refute these findings. SUMMARY In high-income countries, antibiotics should not routinely be given to patients with acute diarrhea unless testing demonstrates a pathogen for which antibiotics are indicated, and STEC infection has been excluded. Future work to prevent HUS should focus on preventing primary infections, and mitigating extraintestinal consequences of STEC gut infections.
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Affiliation(s)
- Phillip I Tarr
- Division of Gastroenterology, Hepatology & Nutrition, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, Missouri, USA
| | - Stephen B Freedman
- Alberta Children's Hospital Foundation Professor in Child Health and Wellness, Sections of Pediatric Emergency Medicine and Gastroenterology, Alberta Children's Hospital & Research Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
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Coccia PA, Ramírez FB, Suárez ADC, Alconcher LF, Balestracci A, García Chervo LA, Principi I, Vázquez A, Ratto VM, Planells MC, Montero J, Saurit M, Gutiérrez MGPY, Puga MC, Isern EM, Bettendorff MC, Boscardin MV, Bazán M, Polischuk MA, De Sarrasqueta A, Aralde A, Ripeau DB, Leroy DC, Quijada NE, Escalante RS, Giordano MI, Sánchez C, Selva VS, Caminiti A, Ojeda JM, Bonany P, Morales SE, Allende D, Arias MA, Exeni AM, Geuna JD, Arrúa L. Acute peritoneal dialysis, complications and outcomes in 389 children with STEC-HUS: a multicenter experience. Pediatr Nephrol 2021; 36:1597-1606. [PMID: 33394193 DOI: 10.1007/s00467-020-04876-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 09/30/2020] [Accepted: 11/25/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of acute kidney injury (AKI) in children with hemolytic uremic syndrome induced by a Shiga toxin-producing Escherichia coli infection (STEC-HUS) is supportive; however, 40 to 60% of cases need kidney replacement therapy (KRT). The aim of this study was to analyze procedure complications, especially peritonitis, and clinical outcomes in children with AKI secondary to STEC-HUS treated with acute PD. METHODS This is a multicenter retrospective study conducted among thirty-seven Argentinian centers. We reviewed medical records of 389 children with STEC-HUS hospitalized between January 2015 and February 2019 that required PD. RESULTS Complications associated with PD were catheter malfunction (n = 93, 24%), peritonitis (n = 75, 19%), fluid leaks (n = 45, 11.5%), bleeding events (n = 23, 6%), and hyperglycemia (n = 8, 2%). In the multivariate analysis, the use of antibiotic prophylaxis was independently associated with a decreased risk of peritonitis (hazard ratio 0.49, IC 95% 0.29-0.81; p = 0.001), and open-surgery catheter insertion was independently associated with a higher risk (hazard ratio 2.8, IC 95% 1.21-6.82; p = 0.001). Discontinuation of PD due to peritonitis, severe leak, or mechanical complications occurred in 3.8% of patients. No patient needed to be transitioned to other modality of KRT due to inefficacy of the technique. Mortality during the acute phase occurred in 2.8% patients due to extrarenal complications (neurological and cardiac involvement), not related to PD. CONCLUSIONS Acute PD was a safe and effective method to manage AKI in children with STEC-HUS. Prophylactic antibiotics prior to insertion of the PD catheter should be considered to decrease the incidence of peritonitis.
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Affiliation(s)
- Paula A Coccia
- Division of Pediatric Nephrology, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina.
| | - Flavia B Ramírez
- Pediatric Department, Hospital Provincial Dr. Castro Rendon, Neuquen, Argentina
| | - Angela D C Suárez
- Department of Pediatric Nephrology, Hospital de Niños Sor María Ludovica, La Plata, Buenos Aires, Argentina
| | - Laura F Alconcher
- Division of Pediatric Nephrology, Hospital Dr. José Penna, Bahía Blanca, Argentina
| | - Alejandro Balestracci
- Division of Pediatric Nephrology, Hospital General de Niños Pedro de Elizalde, Buenos Aires, Argentina
| | - Laura A García Chervo
- Department of Nephrology, Hospital de Pediatría Prof. Dr. Juan P. Garrahan, Buenos Aires, Argentina
| | - Iliana Principi
- Department of Pediatric Nephrology, Hospital Pediátrico Humberto J Notti, Mendoza, Argentina
| | - Aída Vázquez
- Department of Pediatric Nephrology, Hospital Municipal del Niño, San Justo, Buenos Aires, Argentina
| | - Viviana M Ratto
- Department of Pediatric Nephrology, Hospital de Niños Dr. Ricardo Gutierrez, Buenos Aires, Argentina
| | - María Celia Planells
- Department of Pediatric Nephrology, Hospital de Niños de la Santísima Trinidad, Cordoba, Argentina
| | - Jorge Montero
- Department of Pediatric Nephrology, Hospital Materno Infantil de Mar del Plata, Buenos Aires, Argentina
| | - Mariana Saurit
- Pediatric Nephrology Department Hospital Materno Infantil, Salta, Argentina
| | | | - María Celeste Puga
- Department of Clinical Investigation, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Elsa M Isern
- Division of Pediatric Nephrology, Hospital Nacional Profesor Dr. Alejandro Posadas, Buenos Aires, Argentina
| | | | | | - Marta Bazán
- Pediatric Nephrology Unit, Hospital Pediátrico del Niño Jesús, Cordoba, Argentina
| | - Mario A Polischuk
- Pediatric Intensive Care Unit, Clínica Pediátrica San Lucas, Neuquen, Argentina
| | | | - Adriana Aralde
- Division of Pediatric Nephrology, Hospital del Niño Jesús, Tucuman, Argentina
| | - Diego B Ripeau
- Department of Pediatrics, Sanatorio de la Trinidad de Palermo, Buenos Aires, Argentina
| | - Daniela C Leroy
- Department of Pediatrics, Hospital Interzonal de Agudos, Junin, Buenos Aires, Argentina
| | - Nahir E Quijada
- Division of Pediatric Nephrology, Hospital Infantil Municipal, Cordoba, Argentina
| | - Romina S Escalante
- Pediatric Nephrology Unit, Hospital Provincial de Rosario, Santa Fe, Argentina
| | - Marta I Giordano
- Department of Pediatrics, Complejo Sanitario San Luis, San Luis, Argentina
| | - Cristian Sánchez
- Department of Pediatric Nephrology, Hospital Juan Pablo II, Corrientes, Argentina
| | - Verónica S Selva
- Department of Pediatrics Clinica, Universitaria Reina Faviola, Cordoba, Argentina
| | | | - José María Ojeda
- Department of Pediatrics, Hospital de la Madre y el Niño, La Rioja, Argentina
| | - Pablo Bonany
- Department of Pediatrics, Dr. Lucio Molas, Santa Rosa, La Pampa, Argentina
| | - Sandra E Morales
- Department of Pediatrics, Hospital Pediátrico Dr Fernando Barreyro, Posadas, Misiones, Argentina
| | - Daniel Allende
- Department of Pediatrics, Policlínico de Neuquen, Neuquen, Argentina
| | - María Andrea Arias
- Department of Pediatric Nephrology, Hospital Materno Infantil Dr. Héctor Quintana Jujuy, San Salvador de Jujuy, Argentina
| | - Andrea M Exeni
- Division of Pediatric Nephrology, Hospital Austral, Pilar, Buenos Aires, Argentina
| | - Jésica D Geuna
- Division of Pediatric Nephrology, Hospital de Niños Victor J. Vilela, Rosario, Santa Fe, Argentina
| | - Larisa Arrúa
- Department of Pediatrics, Hospital Pediátrico Dr Avelino Castellan, Resistencia, Chaco, Argentina
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Nourse P, Cullis B, Finkelstein F, Numanoglu A, Warady B, Antwi S, McCulloch M. ISPD guidelines for peritoneal dialysis in acute kidney injury: 2020 Update (paediatrics). Perit Dial Int 2021; 41:139-157. [PMID: 33523772 DOI: 10.1177/0896860820982120] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
SUMMARY OF RECOMMENDATIONS 1.1 Peritoneal dialysis is a suitable renal replacement therapy modality for treatment of acute kidney injury in children. (1C)2. Access and fluid delivery for acute PD in children.2.1 We recommend a Tenckhoff catheter inserted by a surgeon in the operating theatre as the optimal choice for PD access. (1B) (optimal)2.2 Insertion of a PD catheter with an insertion kit and using Seldinger technique is an acceptable alternative. (1C) (optimal)2.3 Interventional radiological placement of PD catheters combining ultrasound and fluoroscopy is an acceptable alternative. (1D) (optimal)2.4 Rigid catheters placed using a stylet should only be used when soft Seldinger catheters are not available, with the duration of use limited to <3 days to minimize the risk of complications. (1C) (minimum standard)2.5 Improvised PD catheters should only be used when no standard PD access is available. (practice point) (minimum standard)2.6 We recommend the use of prophylactic antibiotics prior to PD catheter insertion. (1B) (optimal)2.7 A closed delivery system with a Y connection should be used. (1A) (optimal) A system utilizing buretrols to measure fill and drainage volumes should be used when performing manual PD in small children. (practice point) (optimal)2.8 In resource limited settings, an open system with spiking of bags may be used; however, this should be designed to limit the number of potential sites for contamination and ensure precise measurement of fill and drainage volumes. (practice point) (minimum standard)2.9 Automated peritoneal dialysis is suitable for the management of paediatric AKI, except in neonates for whom fill volumes are too small for currently available machines. (1D)3. Peritoneal dialysis solutions for acute PD in children3.1 The composition of the acute peritoneal dialysis solution should include dextrose in a concentration designed to achieve the target ultrafiltration. (practice point)3.2 Once potassium levels in the serum fall below 4 mmol/l, potassium should be added to dialysate using sterile technique. (practice point) (optimal) If no facilities exist to measure the serum potassium, consideration should be given for the empiric addition of potassium to the dialysis solution after 12 h of continuous PD to achieve a dialysate concentration of 3-4 mmol/l. (practice point) (minimum standard)3.3 Serum concentrations of electrolytes should be measured 12 hourly for the first 24 h and daily once stable. (practice point) (optimal) In resource poor settings, sodium and potassium should be measured daily, if practical. (practice point) (minimum standard)3.4 In the setting of hepatic dysfunction, hemodynamic instability and persistent/worsening metabolic acidosis, it is preferable to use bicarbonate containing solutions. (1D) (optimal) Where these solutions are not available, the use of lactate containing solutions is an alternative. (2D) (minimum standard)3.5 Commercially prepared dialysis solutions should be used. (1C) (optimal) However, where resources do not permit this, locally prepared fluids may be used with careful observation of sterile preparation procedures and patient outcomes (e.g. rate of peritonitis). (1C) (minimum standard)4. Prescription of acute PD in paediatric patients4.1 The initial fill volume should be limited to 10-20 ml/kg to minimize the risk of dialysate leakage; a gradual increase in the volume to approximately 30-40 ml/kg (800-1100 ml/m2) may occur as tolerated by the patient. (practice point)4.2 The initial exchange duration, including inflow, dwell and drain times, should generally be every 60-90 min; gradual prolongation of the dwell time can occur as fluid and solute removal targets are achieved. In neonates and small infants, the cycle duration may need to be reduced to achieve adequate ultrafiltration. (practice point)4.3 Close monitoring of total fluid intake and output is mandatory with a goal to achieve and maintain normotension and euvolemia. (1B)4.4 Acute PD should be continuous throughout the full 24-h period for the initial 1-3 days of therapy. (1C)4.5 Close monitoring of drug dosages and levels, where available, should be conducted when providing acute PD. (practice point)5. Continuous flow peritoneal dialysis (CFPD)5.1 Continuous flow peritoneal dialysis can be considered as a PD treatment option when an increase in solute clearance and ultrafiltration is desired but cannot be achieved with standard acute PD. Therapy with this technique should be considered experimental since experience with the therapy is limited. (practice point) 5.2 Continuous flow peritoneal dialysis can be considered for dialysis therapy in children with AKI when the use of only very small fill volumes is preferred (e.g. children with high ventilator pressures). (practice point).
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Affiliation(s)
- Peter Nourse
- Pediatric Nephrology Red Cross War Memorial Children's Hospital, 37716University of Cape Town, South Africa
| | - Brett Cullis
- Hilton Life Hospital, Renal and Intensive Care Units, Hilton, South Africa
| | | | - Alp Numanoglu
- Department of Surgery 63731Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Bradley Warady
- Division of Nephrology, University of Missouri-Kansas City School of Medicine, MO, USA
| | - Sampson Antwi
- Department of Child Health, Kwame Nkrumah University of Science & Technology/Komfo Anokye Teaching Hospital, Kumasi, Ghana
| | - Mignon McCulloch
- Pediatric Nephrology Red Cross War Memorial Children's Hospital, 37716University of Cape Town, South Africa
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4
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McCulloch MI, Nourse P, Argent AC. Use of locally prepared peritoneal dialysis (PD) fluid for acute PD in children and infants in Africa. Perit Dial Int 2020; 40:441-445. [PMID: 32323622 DOI: 10.1177/0896860820920132] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In less well-resourced countries, the high cost of commercially available peritoneal dialysis (PD) fluid limits its use. The major concerns regarding bedside-prepared PD fluid is peritonitis as well as electrolyte disorders. The aim of this study was to review our experience with the use of PD fluids prepared at the bedside using the intravenous infusion solution Balsol (Fresenius Kabi). METHODS This was a retrospective review of all patients who received PD for acute kidney injury (AKI) using a bedside-prepared PD solution adapted from the intravenous solution Balsol in our intensive care unit. RESULTS In total, 49 cases of acute PD were performed. Of the 49 children, 21 (43%) were male. The ages of the patients ranged from newborn to 10.2 years (median 0.33 years). The weight of children ranged from 1.3 kg to 50 kg (median 4.1 kg). The type of PD catheters used: Cook catheters, 41 patients; Kimal peel-away, 10 patients; and surgical inserted Tenckhoff type of catheter, 2 patients. The duration of PD was 1-17 days (median 3 days) Complications included peritonitis in 2 of 49 patients and blocked catheter in 6 of 49 patients. There were no electrolyte disturbances as a result of the PD. Overall survival was 43% of patients. CONCLUSIONS Locally prepared PD solutions at the bedside adapted from intravenous solutions can be used safely and effectively. This has important relevance for centres in less well-resourced countries, where commercially produced PD fluid is not available for the management of AKI.
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Affiliation(s)
- Mignon I McCulloch
- Division of Paediatric Nephrology, 63731Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Peter Nourse
- Division of Paediatric Nephrology, 63731Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
| | - Andrew C Argent
- Division of Paediatric Critical Care, 63731Red Cross War Memorial Children's Hospital, University of Cape Town, South Africa
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5
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Nepfumbada M, Naicker E, Bhimma R. Peritoneal Infections in Children Undergoing Acute Peritoneal Dialysis at a Tertiary/Quaternary Central Hospital in Kwazulu-Natal, South Africa. Perit Dial Int 2018; 38:413-418. [DOI: 10.3747/pdi.2017.00284] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Accepted: 05/10/2018] [Indexed: 11/15/2022] Open
Abstract
Background In a resource-limited setting, acute peritoneal dialysis (APD) is the modality of choice as a form of renal replacement therapy in children with acute kidney injury (AKI). However, there is a high risk of peritonitis that causes significant morbidity and mortality. Data on PD and peritonitis in developing countries are scarce. The purpose of this retrospective study was to determine the prevalence of APD-related peritonitis at a central referral hospital in KwaZulu-Natal, South Africa. Methods A retrospective study from January 2010 until December 2014 was done at Inkosi Albert Luthuli Central Hospital (IALCH). All children under the age of 13 years with AKI requiring APD were included in the study. Results Forty children were included in the study. Age ranged from 0.2 years to 12.25 years; 25 (62.5%) were male and 15 (37.5%) female. Twenty-seven (67.5%) were admitted to the intensive care unit (ICU) and 13 (32.5%) to the pediatric high care ward. Septicemia with multi-organ dysfunction was the was the main cause of AKI requiring APD in 18 (45%) children followed by poststreptococcal glomerulonephritis in 8 (20%). Acute PD was complicated by culture-proven peritonitis in 19 (47.5%) children of whom 16 (84.2%) had a single organism cultured while in 3, (15.7%) there was a mixed culture. The total number of organisms cultured was 24: 8 (33.3%) were gram-positive organisms, 12 (50%) gram-negative organisms, and 4 (16.67%) fungal. The Paediatric Index of Mortality (PIM) 2 Score risk of mortality was 99.4% for patients admitted to ICU. Mortality rate was 65%, and 14 (53%) of the children who demised had peritonitis. Conclusion This study showed an inordinately high complication rate of peritonitis, mostly secondary to gram-negative organisms, of children undergoing APD in a central referral hospital. The use of surgically placed, tunneled catheters, meticulous attention to aseptic techniques and judicious use of antimicrobials is highly recommended in reducing the incidence of peritonitis in children undergoing APD.
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Affiliation(s)
- Mulalo Nepfumbada
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Elaene Naicker
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Rajendra Bhimma
- Department of Paediatrics and Child Health, Nelson R Mandela School of Medicine, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
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Balestracci A, Toledo I, Meni Battaglia L, de Lillo L, More N, Cao G, Alvarado C. Postdiarrhoeal haemolytic uraemic syndrome without thrombocytopenia. Nefrologia 2017; 37:508-514. [PMID: 28946963 DOI: 10.1016/j.nefro.2016.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 12/01/2016] [Accepted: 12/10/2016] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Thrombocytopenia is a hallmark of postdiarrhoeal haemolytic uraemic syndrome (D+ HUS), although it can be transient and therefore undetected. There is scarce information regarding the prevalence and the course of the disease in children with D+ HUS without thrombocytopenia. OBJECTIVE To determine the prevalence of D+ HUS without thrombocytopenia and to describe the clinical characteristics of a series of children with this condition. PATIENTS AND METHODS The medical records of patients with D+ HUS hospitalised between 2000 and 2016 were reviewed to identify those without thrombocytopenia (>150,000mm3). Demographic, clinical and laboratory parameters of the selected cases were collected and descriptively analysed. RESULTS Nine cases (5.6%) without thrombocytopenia were identified among 161 patients hospitalised during the study period. Median age at diagnosis was 17 months (7-32) and median prodromal symptom duration was 15 days (7-21). Eight patients maintained normal urine output while the remaining one required dialysis. No patient presented with severe extrarenal compromise and/or hypertension. CONCLUSIONS The prevalence of non-thrombocytopenic D+ HUS was 5.6% and most cases occurred with mild forms of the disease; however, the need for dialysis in one of them indicated that normalisation of platelet count is not always an accurate marker for disease remittance. Our results also confirm that the time of onset of D+ HUS in patients without thrombocytopenia is usually delayed with respect to the initial intestinal symptoms; thus, heightened diagnostic suspicion is necessary.
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Affiliation(s)
- Alejandro Balestracci
- Unidad de Nefrología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina.
| | - Ismael Toledo
- Unidad de Nefrología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Luciana Meni Battaglia
- Unidad de Nefrología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Leonardo de Lillo
- Departamento de Pediatría, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Natalia More
- Departamento de Pediatría, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Gabriel Cao
- División de Patología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
| | - Caupolican Alvarado
- Unidad de Nefrología, Hospital General de Niños Pedro de Elizalde, Ciudad Autónoma de Buenos Aires, Argentina
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Shiga Toxin/Verocytotoxin-Producing
Escherichia coli
Infections: Practical Clinical Perspectives. Microbiol Spectr 2014; 2:EHEC-0025-2014. [DOI: 10.1128/microbiolspec.ehec-0025-2014] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
ABSTRACT
Escherichia coli
strains that produce Shiga toxins/verotoxins are rare, but important, causes of human disease. They are responsible for a spectrum of illnesses that range from the asymptomatic to the life-threatening hemolytic-uremic syndrome; diseases caused by
E. coli
belonging to serotype O157:H7 are exceptionally severe. Each illness has a fairly predictable trajectory, and good clinical practice at one phase can be inappropriate at other phases. Early recognition, rapid and definitive microbiology, and strategic selection of tests increase the likelihood of good outcomes. The best management of these infections consists of avoiding antibiotics, antimotility agents, and narcotics and implementing aggressive intravenous volume expansion, especially in the early phases of illness.
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Balestracci A, Martin SM, Toledo I, Alvarado C, Wainsztein RE. Laboratory predictors of acute dialysis in hemolytic uremic syndrome. Pediatr Int 2014; 56:234-9. [PMID: 24266872 DOI: 10.1111/ped.12245] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2013] [Revised: 08/03/2013] [Accepted: 10/24/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Strict guidelines on use of dialysis in children with post-diarrheal hemolytic uremic syndrome (D + HUS) are lacking. This study investigated laboratory predictors of acute dialysis because they are more objective than clinical features. Added to this, given that urine output is also an objective parameter, its ability to predict dialysis requirements was also investigated. METHODS Out of 153 D + HUS children reviewed, 88 received dialysis and 65 did not. Initial laboratory parameters and diuresis between both groups were analyzed. RESULTS Dialyzed patients had higher creatinine, urea, alanine aminotransferase, hematocrit and leukocyte count; and lower sodium, bicarbonate, and pH compared to non-dialyzed ones. Serum creatinine was the only independent predictor (P = 0.003) of dialysis; therefore, its ability to predict dialysis was estimated on receiver operating characteristic (ROC) curve analysis and using the Acute Kidney Injury Network (AKIN) staging system. Area under the ROC curve was 0.92 (95% confidence interval [95%CI]: 0.83-1) with a creatinine cut-off of 1.25 mg/dL (sensitivity, 100%; specificity, 76.5%) for children <1 year, and 0.93 (95%CI: 0.88-0.98) with a threshold of 2 mg/dL (sensitivity, 91%; specificity, 87.5%) for older children. AKIN stage 3 at admission predicted dialysis with a sensitivity of 92% and specificity of 84.2%. Urine output had the highest accuracy for dialysis prediction (sensitivity, 100%; specificity, 95.3%). CONCLUSIONS Initial serum creatinine concentration was the best laboratory predictor of dialysis, but the first 24 h diuresis was even better for this purpose. But, given that serum creatinine is an immediate available parameter, the cut-offs identified may label D + HUS children who will probably need dialysis, prompting early referral to centers able to provide dialysis.
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Affiliation(s)
- Alejandro Balestracci
- Nephrology Unit, Pedro de Elizalde Children's Hospital, Buenos Aires City, Argentina
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Davis TK, McKee R, Schnadower D, Tarr PI. Treatment of Shiga toxin-producing Escherichia coli infections. Infect Dis Clin North Am 2013; 27:577-97. [PMID: 24011831 DOI: 10.1016/j.idc.2013.05.010] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The management of Shiga toxin-producing Escherichia coli (STEC) infections is reviewed. Certain management practices optimize the likelihood of good outcomes, such as avoidance of antibiotics during the pre-hemolytic uremic syndrome phase, admission to hospital, and vigorous intravenous volume expansion using isotonic fluids. The successful management of STEC infections is based on recognition that a patient might have an STEC infection, and appropriate use of the microbiology laboratory. The timeliness of STEC identification cannot be overemphasized, because it avoids therapies prompted by inappropriate additional testing and directs the clinician to focus on effective management strategies. The opportunities during STEC infections to avert the worst outcomes are brief, and this article emphasizes practical matters relevant to making a diagnosis, anticipating the trajectory of illness, and optimizing care.
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Affiliation(s)
- T Keefe Davis
- Division of Nephrology, Department of Pediatrics, Washington University School of Medicine, 660 South Euclid, St Louis, MO 63110, USA
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