Acute respiratory infection: a global challenge

Epidemiological characteristics of respiratory viruses in children during the COVID-19 epidemic in Chengdu, China

IMPORTANCE

During the coronavirus disease 2019 epidemic, the Chinese government launched and used a series of nonpharmaceutical interventions (NPIs), including banning social gatherings, wearing face masks, home isolation, and maintaining hand hygiene, to control the disease spread. Whether and how NPIs influence other respiratory viruses in children remain unclear. In this article, we analyzed relative data and found that the number of samples and positive proportion of respiratory viruses decreased significantly compared with that before the epidemic. Clinicians and public health policymakers should pay attention to changes in the epidemic trends and types of respiratory viruses and maintain monitoring of respiratory-related viruses to avoid possible abnormal rebounds and epidemic outbreaks of these viruses.

Clinical, biochemical and genetic characteristics of MOGS-CDG: a rare congenital disorder of glycosylation

PURPOSE

To summarise the clinical, molecular and biochemical phenotype of mannosyl-oligosaccharide glucosidase-related congenital disorders of glycosylation (MOGS-CDG), which presents with variable clinical manifestations, and to analyse which clinical biochemical assay consistently supports diagnosis in individuals with bi-allelic variants in MOGS.

METHODS

Phenotypic characterisation was performed through an international and multicentre collaboration. Genetic testing was done by exome sequencing and targeted arrays. Biochemical assays on serum and urine were performed to delineate the biochemical signature of MOGS-CDG.

RESULTS

Clinical phenotyping revealed heterogeneity in MOGS-CDG, including neurological, immunological and skeletal phenotypes. Bi-allelic variants in MOGS were identified in 12 individuals from 11 families. The severity in each organ system was variable, without definite genotype correlation. Urine oligosaccharide analysis was consistently abnormal for all affected probands, whereas other biochemical analyses such as serum transferrin analysis was not consistently abnormal.

CONCLUSION

The clinical phenotype of MOGS-CDG includes multisystemic involvement with variable severity. Molecular analysis, combined with biochemical testing, is important for diagnosis. In MOGS-CDG, urine oligosaccharide analysis via matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry can be used as a reliable biochemical test for screening and confirmation of disease.

A Prospective Study of Etiological Agents Among Febrile Patients in Sierra Leone

Introduction

Sierra Leone has one of the highest burdens of febrile illnesses in the world. As the incidence of malaria diminishes, a better understanding of the spectrum of etiological agents was important for accurate diagnosis and empirical treatment of febrile illness.

Methods

Blood, nasopharyngeal, and fecal specimens were collected from febrile patients for serological, molecular detection, and microbiologic culture to identify potential pathogens.

Results

For this prospective study, 142 febrile patients were enrolled. The prevalence of malaria was higher in children aged 5–15 years old (P = 0.185) and adults (P = 0.018). Acute respiratory infection (ARI) presented more commonly in the under 5 years old group (P = 0.009). For diarrhea, all children groups (P = 0.024) were predominant. A total of 22.5% of the febrile patients had malaria infection, 19.7% had typhoid infection, and 2.8% were coinfected with malaria and typhoid. ARI was the most common causes of fever, accounting for 31.7% of patients, influenza A virus, Mycoplasma pneumoniae, and five other respiratory pathogens were found. Diarrhea accounted for 16.2%, and seven kinds of diarrhea bacteria were isolated. Hepatitis B accounted for 8.5%, including five cases of spontaneous bacterial peritonitis, and ascites smear staining were both Gram-negative bacteria. Tuberculous encephalitis, parasitic diseases (ascaris and filariasis), and skin infection caused by Staphylococcus aureus accounted for 0.7%, 2.1%, and 0.7%, respectively.

Conclusions

Evidence of a wide spectrum of febrile etiological agents other than malaria was identified. The spread of malaria rapid diagnostic tests (RDTs) out of hospital and establishment of a national standard for Widal test will reduce the misdiagnosis of febrile diseases. Antibiotics against Gram-negative bacteria are helpful for empirical treatment.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40121-021-00474-y.

Sierra Leone has one of the highest burdens of febrile illnesses in the world. Evidence of a wide spectrum of febrile pathogens other than malaria has been proven in this study. We considered that the etiology of febrile patients was closely related to local geography, heredity, immune features, economic industry, living habits, air pollution, medical and health conditions, and this was fully analyzed and discussed. The screening process used in this study can further simplify and identify the etiological agents of fever in more than 70% of the study population. This laid the foundation for the establishment of a more simplified and efficient diagnosis and treatment process in the local area. We also found the characteristics of age distribution of different febrile diseases. Children were an important susceptible population to fever. This study indicated the importance of reliable diagnostic tests for febrile pathogens and provided the necessary information for RDT requirements. The spread of malaria RDTs out of hospital and establishment of a national standard for Widal test will reduce the misdiagnosis of febrile diseases. For empirical treatment, antimalarial treatment was still targeted at falciparum malaria in Sierra Leone. Antibiotics against Gram-negative bacteria contributed to the empirical treatment of febrile diseases. For patients with acute respiratory tract infection, Gram-positive coccal antibiotics could be candidates for treatment. In addition, systematic and professional treatment of liver diseases should be promoted to reduce infection complications.

Alterations in biochemical markers in adenovirus infection

BACKGROUND

Analyze possible relationships between HAdV and markers for inflammation, specifically the C-reactive protein (CRP) and procalcitonin (PCT) tests, along with other haematological markers.

METHODS

Retrospective study of 487 children presenting with fever and/or acute respiratory symptoms in the Paediatric Emergency Department. Analyses included viral presence/absence (both HAdV and other respiratory viruses) in respiratory exudates, CRP and PCT alterations in plasma, and haematological markers in whole blood.

RESULTS

Viral load was >500 copies/10³ cells of HAdV in 127 cases (26.1%), of which 66 (52%, P<0.0001) had alterations in PCT, and 112 (88.1%, P<0.0001) in CRP. Haematological markers were similar either HAdV was present or not, although many HAdV positive patients demonstrated leukocytosis (66%). Bacterial cultures from 141 samples showed altered PCT in 27 (60%) with HAdV infection, in 3 (18.7%) with bacterial infection, and 13 (26.5%) without either viral or bacterial infection (P<0.05). CRP was altered in 88.9% of HAdV infected children and in 87% infected with bacteria, although the percentage was greater than in cases where other respiratory viruses were present (61.3% P<0.05).

CONCLUSIONS

Results demonstrate a clear relationship between HAdV infection and alterations in PCT and CRP which should be taken into account in paediatric patient management.

Paediatric Recurrent Ear, Nose and Throat Infections and Complications: Can We Do More?

Recurrent respiratory tract infections (rRTIs), of which there are three main groups-otitis media, tonsillitis and sinusopathies-are very common in paediatric populations and are associated with significant morbidity and mortality due to complications. These infections substantially reduce quality of life for paediatric patients and their families and are a significant personal, medical and economic burden on the patients, the patients' families and the healthcare system. Most rRTIs are of viral origin; however, indiscriminate use of antibiotics in their treatment has led to development of bacterial resistance. Effective management of rRTIs to reduce the burden of disease and to avoid overuse of antibiotics has become a great therapeutic challenge. New strategies for the management of paediatric rRTIs include focus on prevention using non-specific immunomodulators to boost the body's natural defences against infection and to downregulate infection- and allergen-induced airway inflammation. The oral immunomodulator, OM-85, a bacterial lysate, acts on the innate and adaptive branches of the immune system, conferring protection against viral and bacterial infections, and controls inflammation, thereby reducing tissue damage. OM-85 has demonstrated good tolerability and clinical efficacy in reducing the number and duration of RTIs in children with recurrent airway infections. It has also been reported to reduce the use of concomitant medications, including antibiotics, time to cure and school absenteeism. OM-85 is efficacious and well tolerated when administered concomitantly with inactivated influenza vaccine (IIV) and has been shown to reduce wheezing attacks induced by RTI in young children. Clinical results show that the greater the risk of rRTIs, the greater the benefit with OM-85. OM-85 may be considered a promising tool to add to the limited armamentarium of the ear, nose and throat (ENT) physician dealing with rRTIs and their complications, such as recurrent wheeze and asthma inception.

Incidence of acute respiratory tract infections (2006-2015) and influenza (2006-2013) among French armed forces

OBJECTIVES

We aimed to assess the incidence of respiratory tract infections in military settings between 2006 and 2015.

PATIENTS AND METHODS

We performed a retrospective epidemiological study of the entire military population from 2006 to 2015. Comprehensive data was collected from all medical centers, operational medical units, naval services, and army training hospitals and provided by the epidemiological surveillance of the armies.

RESULTS

The annual average population of the study was 331,394 soldiers. For acute respiratory tract infections (2006-2015), 22,818 cases were reported in metropolitan France, 3,211 cases in French overseas territories, 1,595 cases in the French Navy, and 1,318 cases in external military operations for a total of 28,942 cases. For influenza (2006-2013), 934 cases were reported in metropolitan France, 101 cases in French overseas territories, and 23 cases in external operations, for a total of 1,058 cases. The mean incidence rate of acute respiratory tract infections expressed as case number per 1,000 person-years (PY) was 8.7 PY (95% CI [8.6-8.8]) with an exceptional increased incidence rate in 2009 (25.9 PY, 95% CI [25.4-26.4]). The mean incidence rate of influenza was 0.35 PY (95% CI [0.33-0.37]) with a peak incidence rate of 1.9 PY in 2009.

CONCLUSION

Acute respiratory tract infections are at the forefront of infectious episodes in the French armies. Although not necessarily severe, current prevention measures are not enough to reduce the incidence threshold of these infections and need to be improved.

Immunity-targeted approaches to the management of chronic and recurrent upper respiratory tract disorders in children

Background

Upper respiratory tract infections (URTIs), including rhinitis, nasopharyngitis, tonsillitis and otitis media (OM), comprise of 88% of total respiratory infections, especially in children. Therefore effective prevention and treatment of RTIs remain a high priority worldwide. Preclinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations and non‐specific immunomodulation in the prevention and management of recurrent upper RTIs.

Objective of review

The idea of this review was to summarise the current evidence and address key questions concerning the use of conservative and immunity‐targeted approaches to recurrent and chronic URTIs, with a focus on the paediatric population.

Search strategy/Evaluation method

Literature searches were conducted in March 2017 and updated in September 2017 using: Academic Search Complete; CENTRAL; Health Source: Nursing/Academic Edition; MEDLINE; clinicaltrials.gov; and Cochrane databases. In total, 84 articles were retrieved and reviewed. Two independent researchers focused on primary and secondary endpoints in systematic reviews, meta‐analyses and randomised, controlled trials, using immunity‐directed strategies as the control group or within a subpopulation of larger studies. Existing guidelines and interventional/observational studies on novel applications were also included.

Results

Children are particularly susceptible to RTIs due to the relative immaturity of their immune systems, as well as other potential predisposing factors such as day care attendance and/or toxic environmental factors (eg increased pathogenic microbial exposure and air pollutants). Recurrent URTIs can affect otherwise healthy children, leading to clinical sequelae and complications, including the development of chronic conditions or the need for surgery. Available pre‐clinical and clinical data highlight the rationale for the use and effectiveness of immunity‐targeted approaches, including targeted immunisations (flu and pneumococcal vaccines) and non‐specific immunomodulation (bacterial lysates), in the prevention and management of recurrent croup, tonsillitis, otitis media, recurrent acute rhinosinusitis and chronic rhinosinusitis.

Conclusions

In this review, we summarise the current evidence and provide data demonstrating that some immunity‐targeted strategies, including vaccination and immunomodulation, have proved effective in the treatment and prevention of recurrent and chronic URTIs in children.

Trends in the prevalence and care-seeking behaviour for acute respiratory infections among Ugandan infants

Background

Acute Respiratory Infections (ARIs) as a group of diseases/symptoms constitute a leading cause of pediatric morbidity and mortality in sub-Saharan Africa where over 10 % of all children die before reaching their fifth birthday. Although the burden of ARIs is highest in the African countries, there is little evidence in the current literature regarding their prevalence and treatment seeking. The objective of this study was therefore to assess the secular trend in the prevalence of ARIs as well as their treatment seeking-behaviour among Ugandan infants.

Methods

This cross-sectional study was based on data from Uganda Demographic and Health Surveys (conducted between 1995 and 2016) on 26,974 singleton infants aged 0–5 months. Mothers (aged 15–49 years) were interviewed to collect information on the prevalence of recent occurrences of fever, cough and dyspnea. The adjusted trend in the prevalence and predictors of ARIs and care seeking were measured by multivariate regression methods.

Results

In 2016, the prevalence of fever, cough and dyspnea was respectively 36.23, 42.55 and 19.27%. The prevalence of all three symptoms has been declining steadily since 1995, and the percentage of children receiving treatment for fever/cough has also more than doubled during the same time. In multivariable analysis, several sociodemographic factors emerged as significant predictors of ARIs including child’s age and high birth order, mother’s age, educational level, occupation, intendedness status of the child, BMI, household wealth status, and place of residency.

Conclusions

The overall prevalence common ARIs (fever, cough, dyspnea) has been declining at a slow but steady rate, however, remains noticeably high in comparison with countries with similar level of per capita GDP in Africa. Findings of this study has important implications for health policy making regarding the prevention of ARIs among infants in the country.

Short-course versus long-course intravenous therapy with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months

BACKGROUND

Pneumonia is a leading cause of childhood mortality from infectious disease, responsible for an estimated 1.3 million deaths annually in children under five years of age, many of which are in low-income countries. The World Health Organization recommends intravenous antibiotics for five days as first-line treatment for children with severe pneumonia. Although controversy exists regarding the specific clinical features used to diagnose pneumonia, the criteria for diagnosis of severe pneumonia are better defined and are widely used to triage children for referral and second-line therapy.In 2011 it was estimated that approximately 120 million new cases of pneumonia occur globally each year in children under five years of age, of which 14 million become severe episodes. Hospitalisation for severe pneumonia in children places a significant burden on both patients and their families, including substantial expense, loss of routine, and decrease in quality of life. By reducing the duration of hospital treatment, healthcare burdens could potentially be reduced and treatment compliance may improve.This is an update of a review published in 2015.

OBJECTIVES

To evaluate the efficacy of short-course (two to three days) versus long-course (five days) intravenous therapy (alone or in combination with oral antibiotics) with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 12), MEDLINE (1966 to December week 3, 2016), Embase (1974 to 22 December 2016), and four trials registers (23 August 2017), together with reference checking of all relevant trials and reviews.

SELECTION CRITERIA

Randomised controlled trials evaluating the efficacy of short-course (two to three days) versus long-course (five days) intravenous antibiotic therapy (alone or in combination with oral antibiotics) for severe pneumonia in children aged two months to 59 months. We excluded children with any other debilitating disease, including those infected with HIV. We also excluded children who had developed pneumonia during their hospital stay (i.e. with nosocomial infection). There was no restriction on the type of antibiotic used, the dose, or the frequency of dosing.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane.

MAIN RESULTS

Our searches identified 4295 records, however no studies met our predefined inclusion criteria.

AUTHORS' CONCLUSIONS

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

Recurrent and Sustained Viral Infections in Primary Immunodeficiencies

Viral infections are commonplace and often innocuous. Nevertheless, within the population of patients with primary immunodeficiencies (PIDDs), viral infections can be the feature that drives a diagnostic evaluation or can be the most significant morbidity for the patient. This review is focused on the viral complications of PIDDs. It will focus on respiratory viruses, the most common type of viral infection in the general population. Children and adults with an increased frequency or severity of respiratory viral infections are often referred for an immunologic evaluation. The classic teaching is to investigate humoral function in people with recurrent sinopulmonary infections, but this is often interpreted to mean recurrent bacterial infections. Recurrent or very severe viral infections may also be a harbinger of a primary immunodeficiency as well. This review will also cover persistent cutaneous viral infections, systemic infections, central nervous system infections, and gastrointestinal infections. In each case, the specific viral infections may drive a diagnostic evaluation that is specific for that type of virus. This review also discusses the management of these infections, which can become problematic in patients with PIDDs.

Epidemiology of acute respiratory infections in children - preliminary results of a cohort in a rural north Indian community

BACKGROUND

Despite acute respiratory infections being a major cause of death among children in developing countries including India, there is a lack of community-based studies that document its burden and aetiology.

METHODS

A dynamic cohort of children aged 0-10 years was established in four villages in a north Indian state of Haryana from August 2012 onwards. Trained health workers conducted weekly home visits to screen children for acute respiratory infection (ARI) defined as one of the following: cough, sore throat, nasal congestion, earache/discharge, or breathing difficulty. Nurses clinically assessed these children to grade disease severity based on standard age-specific guidelines into acute upper or lower respiratory infection (AURI or ALRI) and collected nasal/throat swabs for pathogen testing.

RESULTS

Our first year results show that ARI incidence in 0-10 years of age was 5.9 (5.8-6.0) per child-year with minimal gender difference, the ALRI incidence in the under-five age group was higher among boys (0.43; 0.39-0.49) as compared to girls (0.31; 0.26-0.35) per child year. Boys had 2.4 times higher ARI-related hospitalization rate as compared to girls.

CONCLUSION

ARI impose a significant burden on the children of this cohort. This study platform aims to provide better evidence for prevention and control of pneumonia in developing countries.

Short-course versus long-course intravenous therapy with the same antibiotic for severe community-acquired pneumonia in children aged two months to 59 months

BACKGROUND

Pneumonia remains the single leading cause of childhood mortality, causing an estimated 1.3 million childhood deaths each year in children under the age of five years. The greater burden of disease occurs in low-income countries, where medical resources and hospital-based management are poor. The World Health Organization (WHO) current evidence summaries recommend intravenous antibiotics for five days as first-line treatment for severe pneumonia. Although there is controversy around the specificity of clinical features in the diagnosis of pneumonia, the criteria for the diagnosis of severe pneumonia are better defined and widely used to triage children for referral and second-line therapy.Approximately 120 million new cases of pneumonia occur globally each year in children under five years of age, of which 14 million progress to severe episodes. Hospitalisation for severe pneumonia in children places a significant burden on both patients and their families, including substantial expense, loss of routine and decrease in quality of life. By reducing the duration of treatment in the hospital, this burden could potentially be lessened and possibly lead to better treatment compliance.

OBJECTIVES

To evaluate the efficacy of short-course (two to three days) versus long-course (five days) intravenous therapy with the same antibiotic for severe community-acquired pneumonia (CAP) in children aged two months to 59 months.

SEARCH METHODS

We searched CENTRAL (2015, Issue 1), MEDLINE (1966 to January week 4, 2015) and EMBASE (1974 to February 2015).

SELECTION CRITERIA

Randomised controlled trials (RCTs) evaluating the efficacy of short-course (two to three days) versus long-course (five days) intravenous antibiotic therapy for severe pneumonia in children aged two months to 59 months. We excluded children with any other debilitating disease, including those infected with HIV and we excluded children with signs and symptoms of very severe pneumonia (i.e. unable to drink or breast feed, vomiting, lethargic, unconscious, convulsing, central cyanosis, severe respiratory distress or clinically severe malnutrition). We also excluded children who had developed pneumonia during their hospital stay (i.e. with nosocomial infection). There was no restriction on the type of antibiotic used, the dose or the frequency of dosing.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

We identified 2352 studies, however none fulfilled our pre-defined inclusion criteria.

AUTHORS' CONCLUSIONS

We did not identify any RCTs comparing a short course (two to three days) of intravenous antibiotics compared to a long course (five days) for severe pneumonia in children aged two to 59 months.

Incidence, Pattern, and Severity of Acute Respiratory Infections among Infants and Toddlers of a Peri-Urban Area of Delhi: A 12-Month Prospective Study

Acute respiratory infections (ARIs) in spite of being the single most important under-five morbidity have not been studied adequately in peri-urban settings in India. We conducted this study prospectively on a cohort of 106 children in a peri-urban area of Delhi. The overall 2-week prevalence of all types of ARI was 34.3%. Annual combined incidence of all types of ARI was 7.9 episodes/100 child-weeks; while that for no pneumonia, cough, and cold, pneumonia, and otitis media was 7.1, 0.85, and 0.09 epi/100 ch-wks, respectively. Incidence of ARI was higher in infancy (9.4 epi/100 ch-wks) as compared to toddlers (7.0 epi/100 ch-wks). Pneumonia incidence was higher among boys (0.9 epi/100 ch-wks as compared to 0.6 for girls) and the highest in infants under 2 months of age (1.09 epi/100 ch-wks; P < 0.01). Incidence of severe pneumonia was roughly one-tenth that of pneumonia. Incidence of both ARI and pneumonia peaked in spring and autumn. Mothers of infants, zespecially those under 2 months of age, need to be made aware of ARI/pneumonia and IEC campaigns may be aired more intensively keeping their peak season in mind.

Detection of viral and bacterial pathogens in acute respiratory infections

OBJECTIVES

The role of bacteria in acute respiratory illnesses (ARI) of adults and interactions with viral infections is incompletely understood. This study tested the hypothesis that bacterial co-infection during ARI adds to airway inflammation and illness severity.

METHODS

Two groups of 97 specimens each were randomly selected from multiplex-PCR identified virus-positive and virus-negative nasal specimens obtained from adults with new onset ARI, and 40 control specimens were collected from healthy adults. All specimens were analyzed for Haemophilus influenzae(HI), Moraxella catarrhalis(MC) and Streptococcus pneumoniae(SP) by quantitative-PCR. General linear models tested for relationships between respiratory pathogens, biomarkers (nasal wash neutrophils and CXCL8), and ARI-severity.

RESULTS

Nasal specimens from adults with ARIs were more likely to contain bacteria (37% overall; HI = 28%, MC = 14%, SP = 7%) compared to specimens from healthy adults (5% overall; HI = 0%, MC = 2.5%, SP = 2.5%; p < 0.001). Among ARI specimens, bacteria were more likely to be detected among virus-negative specimens compared to virus-positive specimens (46% vs. 27%; p = 0.0046). The presence of bacteria was significantly associated with increased CXCL8 and neutrophils, but not increased symptoms.

CONCLUSION

Pathogenic bacteria were more often detected in virus-negative ARI, and also associated with increased inflammatory biomarkers. These findings suggest the possibility that bacteria may augment virus-induced ARI and contribute to airway inflammation.

Advantage of meditation over exercise in reducing cold and flu illness is related to improved function and quality of life

Please cite this paper as: Obasi et al. (2012) Advantage of meditation over exercise in reducing cold and flu illness is related to improved function and quality of life. Influenza and Other Respiratory Viruses 00(0), 00–00.

Purpose  To examine whether apparent advantages following training in meditation over exercise can be attributed to specific symptoms, functional impairments, or quality‐of‐life indicators assessed by the Wisconsin Upper Respiratory Symptom Survey (WURSS‐24).

Methods  Results from the randomized controlled trial “Meditation or Exercise for Preventing Acute Respiratory Illness” showed mean global severity and total days of illness were worse in control (358, 8·9) compared with exercise (248, 5·1) or meditation (144, 5·0). Global severity of illness was estimated using area under the curve from daily self‐reported severity scores on the WURSS‐24. For this project, we estimated within‐group WURSS item‐level severity and between‐group effect sizes (Cohen’s “d” statistic) relative to control. The item‐level effect sizes were grouped into (i) symptom and (ii) function and quality of life domains.

Results  Among the three groups, mediators showed the lowest severity estimates for 21 of 22 WURSS items. Item‐level Cohen’s “d” indicated most benefit was evident in WURSS items representing function and quality of life. Compared with exercise, meditation fostered larger reductions in illness severity, although due mostly to improved function and the quality of life domain (d = −0·33, P < 0·001) compared with symptom domain (d = −0·22, P < 0·001).

Conclusions  The apparent advantage of training in meditation over exercise for reducing cold and flu illness is explained more by improved function and quality of life than by a reduction in symptom severity.

Human metapneumovirus in patients with respiratory tract infection in Kuwait

Human metapneumovirus (hMPV) has been recognized as an important cause of respiratory tract infections in all age groups and in all geographical area. The role of hMPV in causing respiratory tract infections in Kuwait was not yet investigated. The aim of this study was to determine the prevalence of hMPV infection in Kuwait among patients with respiratory tract infection with respect to other respiratory viruses. During January–December 2009, 460 respiratory samples from 388 patients with respiratory tract infection were collected from different hospitals. They were tested for hMPV RNA by real‐time PCR, and for other respiratory viruses by conventional PCR. Out of 388 patients, 110 (28%) were positive for viral respiratory infections; 21 (5.4%) were positive for hMPV, 29 (7.5%) were positive for rhinovirus, 13 (4%) were positive for respiratory syncytial virus, and 10 (3%) were positive for adenovirus. Most (n = 19, 90.5%) of hMPV‐positive patients were admitted to the intensive care unit, 76% of them were of age 2 years and below, and 24% of age 59 years and above. All hMPV‐positive elderly patients had pneumonia while 50% of hMPV‐positive infants had bronchopneumonia. Children with hMPV/rhinovirus co‐infection (n = 3, 1%) had recurrent chest infection and frequent intensive care unit admission. The hMPV infection was mostly detected between December and May, and genotype B was more prevalent than genotype A. This is the first study demonstrating the prevalence of hMPV infection in Kuwait, and suggests that hMPV infection is prevalent in infants and elderly patients with lower respiratory tract infection. J. Med. Virol. 83:1811–1817, 2011. © 2011 Wiley‐Liss, Inc.

A randomized controlled trial of oral zinc in acute pneumonia in children aged between 2 months to 5 years

OBJECTIVE

To evaluate the effectiveness and safety of zinc supplementation as adjuvant in treatment of pneumonia.

METHODS

Ninety-eight children with acute bacterial pneumonia, aged between 2 months to 5 years, were studied in a randomized controlled single blind design. They received either zinc supplementation, as zinc acetate syrup, or placebo, as vitamin B-complex syrup, for 14 days, concomitantly with antimicrobial treatment (49 per group). Chest radiograph and blood tests were done for confirmation of diagnosis and severity of pneumonia was assessed by breathing rate, chest in-drawing and body temperature. Potentially immunosuppressed children or those with serious comorbidity were excluded. Follow-up was done daily while subjects were admitted (generally 7 days) and the final assessment made on the 14th day on out-patient basis.

RESULTS

Children enrolled in zinc and placebo groups were of comparable age [17 ± 10 and 10 ± 30 months (median ± interquartile range) respectively] and sex distribution [34 (69.4%) vs 31 (63.3%) males respectively]. Duration of illness at diagnosis was also comparable. Patients supplemented with zinc showed no difference in clinical cure rate at 14 days when compared with placebo. Fast breathing was present after 1 wk of treatment in 49% subjects in zinc supplemented vs 43% on placebo (p = 0.685). There was also no difference in breathing rate at study end. Regarding fever, the mean temperature was <99°F in both groups at study end. Hemoglobin, total leukocyte count, standard liver function tests and creatinine showed no difference between groups either at baseline or at study end. There were no treatment emergent adverse events attributable to zinc.

CONCLUSIONS

Though well tolerated; the addition of zinc does not improve symptom duration or cure rate in acute bacterial pneumonia in under-five children.

Respiratory syncytial virus and human rhinoviruses are the major causes of severe lower respiratory tract infections in Kuwait

Respiratory infections are very common in Kuwait, yet little is known about the cause of severe lower respiratory tract infections. This study was designed to investigate the viral cause of lower respiratory tract infections using sensitive molecular methods. PCR was applied to investigate 10 respiratory viruses in respiratory samples from 1,014 patients aged between 3 days to 76 years with acute lower respiratory tract infections. Of the 1,014 patients with lower respiratory tract infections, 288 (28.4%) had a viral infection. One hundred fifty‐five (53.8%) presented with bronchiolitis, 100 (43.7%) with pneumonia, and 33 (11.5%) with croup. One hundred six (36.8%) and 99 (34.4%) patients had evidence of respiratory syncytial virus and human rhinoviruses infections, respectively. Adenoviruses were detected in 44 (15.2%) patients, while influenza A virus in 21 (7.3%) patients. The majority of respiratory syncytial virus infections (84%) were among patients aged <1 year. Similarly, of the 99 patients infected by human rhinoviruses, 50 (50.5%) were also among this age group. In contrast, most of influenza A virus infections, 12 of 21 (57.1%), were among patients aged over 16 years. Parainfluenza virus‐2 and human coronaviruses were not detected in any of the patients' samples. Over the 3‐year period, most of the hospitalized patients were seen during the autumn and winter months from October through March. These data show that respiratory syncytial virus and human rhinoviruses may be the major causes of lower respiratory tract infections in children admitted to hospital in Kuwait. J. Med. Virol. 82:1462–1467, 2010. © 2010 Wiley‐Liss, Inc.

Short-course versus long-course antibiotic therapy for non-severe community-acquired pneumonia in children aged 2 months to 59 months

BACKGROUND

Pneumonia is the leading cause of mortality in children under five years of age. Treatment of pneumonia requires an effective antibiotic used in adequate doses for an appropriate duration. Recommended duration of treatment ranges between 7 and 14 days, but this is not based on any empirical evidence. Shorter duration of therapy, if found to be effective, could be particularly important in resource-poor settings where there is a high risk of death, poor access to medicines and health care, and limited budgets for medicines.

OBJECTIVES

To evaluate the efficacy of short-course versus long-course therapy with the same antibiotic for non-severe community-acquired pneumonia in children aged 2 to 59 months.

SEARCH STRATEGY

We searched The Cochrane Central Register of Controlled Trials (CENTRAL); the Database of Abstracts of Reviews of Effects (DARE) (The Cochrane Library, 2007, Issue 3); MEDLINE (OVID) (January 1966 to September 2007); EMBASE (Embase.com) (1974 to September 2007); and LILACS (1982 to September 2007).

SELECTION CRITERIA

All randomized controlled trials (RCTs) evaluating the efficacy of short-course versus long-course therapy using the same antibiotic for non-severe community-acquired pneumonia in children.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial quality and extracted the data.

MAIN RESULTS

Three studies (5763 children) were included. Analysis of three days versus five days of treatment with the same antibiotic for non-severe pneumonia in children showed non-significant differences in rates of clinical cure at the end of treatment (RR 0.99; 95% CI 0.97 to 1.01), treatment failure at the end of treatment (RR 1.07; 95% CI 0.92 to 1.25) and relapse rate after seven days of clinical cure (RR 1.09; 95% CI 0.83 to 1.42). Subgroup analysis evaluating the impact of different antibiotics showed non-significant differences for these outcomes with different durations of therapy.

AUTHORS' CONCLUSIONS

The evidence of this review suggests that a short course (three days) of antibiotic therapy is as effective as a longer treatment (five days) for non-severe pneumonia in children under five years of age. However, there is a need for more well-designed RCTs to support our review findings.

Immunostimulants for preventing respiratory tract infection in children

BACKGROUND

Acute respiratory tract infections (ARTIs) are a major cause of childhood morbidity and mortality. Immunostimulants (IS) may reduce the incidence of ARTIs.

OBJECTIVES

To determine the efficacy and safety of IS in preventing ARTIs in children.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 4, 2005); MEDLINE (January 1966 to January 2006); and EMBASE (January 1990 to January 2006); PASCAL (up to January 2006); SciSearch (up to January 2006); and IPA (up to January 2006) for reports of trials. Investigators in the field were also contacted. Ongoing studies were searched in the trial registration web site, metaRegister of Controlled Trials.

SELECTION CRITERIA

All comparative trials which enrolled patients less than 18 years of age were included. The intervention of interest was the use of an IS medication administered by any method for preventing ARTIs. Clinical trials using random or quasi-random allocation and comparing IS medication or medications to placebo were included.

DATA COLLECTION AND ANALYSIS

The outcome on ARTIs was analyzed both as the mean number of ARTIs by group and as a percent change in the rate of ARTIs. Meta-analysis was undertaken using a random-effects model and results were presented as weighted mean differences (WMD) with 95% confidence intervals (CI). The trials search, quality assessment and data extraction were undertaken independently by two authors. A funnel plot suggested there may be publication bias in the trials identified.

MAIN RESULTS

Thirty-four placebo controlled trials (3877 participants) provided data in a form suitable for inclusion in the meta-analysis. When compared with placebo, the use of IS was shown to reduce ARTIs measured as the total numbers of ARTIs (WMD -1.27; 95% CI -1.58 to -0.97) and the difference in ARTIs rates (WMD -39.68%; 95% CI -47.27% to -32.09%). The trial quality was generally poor and a high level of statistical heterogeneity was evident. The subgroup analysis of bacterial IS studies produced similar results, with lower heterogeneity. No difference in adverse events was evident between the placebo and IS groups

AUTHORS' CONCLUSIONS

This review showed that IS reduces the incidence of ARTIs in children, by 40% on average. However, due to significant heterogeneity and the poor quality of the trials this positive result should be interpreted with caution. The safety profile of IS appears to be good. Further high-quality trials are needed and we encourage national health authorities to conduct large, multicenter, double-blind, placebo-controlled trials on the role of IS in the prevention of ARTIs.

Oxidative stress and enzymic–non-enzymic antioxidant responses in children with acute pneumonia

In this article, oxidative stress and enzymic-non-enzymic antioxidants status were investigated in children with acute pneumonia. Our study included 28 children with acute pneumonia and 29 control subjects. The age ranged from 2 to 11 years (4.57+/-2.13 years) and 2 to 12 years (4.89+/-2.22 years) in the study and control groups, respectively. Whole blood malondialdehyde (MDA) and reduced glutathione (GSH), serum beta-carotene, retinol, vitamin C, vitamin E, catalase (CAT), ceruloplasmin (CLP), total bilirubin, erythrocyte superoxide dismutase (SOD) and glutathione peroxidase (GPx) levels were studied in all subjects. There was a statistically significant difference between the groups for all parameters except for serum CAT. Whole blood MDA, serum CLP and total bilirubin levels were higher in the study group than those of the control group. However, SOD, GPx, beta-carotene, retinol, vitamin C, vitamin E and GSH levels were lower in the study group compared with the control group. All antioxidant vitamin activities were decreased in children with acute pneumonia. Our study demonstrated that oxidative stress was increased whereas enzymic and non-enzymic antioxidant activities were significantly decreased in children with acute pneumonia.

Adherence to management guidelines in acute respiratory infections and diarrhoea in children under 5 years old in primary health care in Botswana

OBJECTIVE

To evaluate health care providers' adherence to management guidelines for acute respiratory infection and diarrhoea in children under 5 years old in Botswana primary health care.

DESIGN

Cross-sectional prospective field survey. Data collection was carried out through observation of consecutive consultations at 30 randomly assigned clinics and health posts in three purposely chosen districts.

STUDY PARTICIPANTS

This study comprises 185 cases of acute respiratory infection and 85 cases of diarrhoea.

MAIN MEASURE

Criteria for acceptable standards of history taking and physical examination for acute respiratory infection and diarrhoea were defined as well as criteria for categorizing the appropriateness of antibiotic prescription. The percentage of oral dehydration salts provided in cases of diarrhoea was calculated.

RESULTS

Acute respiratory infection and diarrhoea accounted for 270 (including 15 missing cases) of all main diagnoses (n = 539). In 262 cases (97%) health care providers were nurses or enrolled nurses; in 3% family welfare educators. Acceptable history taking, physical examination, and both combined in acute respiratory infection was found in 113 (63%), 32 (18%), and 28 (16%), and in diarrhoea in 45 (58%), 26 (34%) and 20 (26%) cases, respectively. Antibiotics were prescribed in 76 of 255 (30%) cases. Prescription was assessed as inappropriate in 56 of 76 (74%) of all cases; in 41 of 52 (79%) cases with acute respiratory infection, in none of the pneumonia cases, and in all 15 cases of diarrhoea. Oral rehydration salts were prescribed in 74 (87%) of the diarrhoea cases.

CONCLUSIONS

Health care providers' adherence to guidelines on history taking was suboptimal in acute respiratory infection and diarrhoea but poor on examination in both conditions. A high level of inappropriate antibiotic prescription was found in acute respiratory infection and diarrhoea. Overall, there is considerable scope for improving diagnostic and therapeutic management of these major childhood diseases in Botswana primary health care.

Short-Course Therapy for Community-Acquired Pneumonia in Paediatric Patients

Studies conducted over the past few years for the treatment of pneumonia have provided data on the basis of which therapeutic decisions concerning the duration of therapy can be taken. Results from a majority of the studies conducted in hospitalised patients using the conventional methods for diagnosing pneumonia have methodological problems, which make it difficult to draw definite conclusions. Despite these limitations, the overall trend of these descriptive studies show a therapy of < or =5 days being as effective as the longer course of 7-14 days for children up to the age of 12 years. Data for duration of antibacterial therapy for infants <2 months of age hardly exists. Evidence suggests that a shorter course of antibacterial therapy of 3 days is effective for treatment of community-acquired, non-severe ambulatory pneumonia in immunocompetent children aged 2-59 months old. Shorter duration of therapy offers several potential advantages that include prevention of the emergence of antimicrobial resistance, lower healthcare costs, improved adherence to therapy and fewer adverse effects. There is a need to improve the evidence base for the optimum duration of therapy for children hospitalised with severe pneumonia.

Prescribing patterns for acute respiratory infections in primary health care, aseer region, saudi arabia

OBJECTIVE

The objective of this study was to identify the patterns of prescribing for Acute respiratory infections in patients attending primary health care centers in the Aseer region, southwestern Saudi Arabia. MATERIALS #ENTITYSTARTX00026;

METHODS

This study was conducted at primary health care centers in the Aseer region during November 2003. A master sheet designed by the investigator was distributed to all the working physicians in the primary health care center in the Aseer region. The master sheet included the age, sex, complaints, signs, clinical diagnosis and the type of medications prescribed. Physicians were asked to include all patients attending on 17(th) November 2003, and send the master sheet to the Technical Supervision Unit at Primary Care Department, General Directorate of Health Affairs. Data of the master sheet was entered and analyzed by using SPSS.

RESULTS

The total number of patients attending with acute respiratory infections(ARIs) was 3000 which represented 25% of the patients attending primary health care centers that day. Children formed 60% of the total number of cases. Regarding symptoms and signs, it was found that 70% had a cough, 59% had a runny nose, and 43% had a sore throat . The common cold was the most common diagnosis (42%). Antipyretics, antihistamines, antibiotics and antitussives were prescribed for 78%, 48%, 45% and 25% respectively. Statistical analysis using logistic regression revealed that the higher the temperature, the more severe the throat congestion and the presence of exudates on pharynx, the higher the likelihood to prescribe antibiotics.

CONCLUSION

In this study, it was found that the prescription of all drugs for ARIs was still high in spite of the fact that these conditions are self-limiting. To rationalize prescribing for ARI, implementation of the national protocol for diagnosis and treatment of ARIs is mandatory. Further studies to explore the physician's knowledge, attitudes and behavior concerning prescribing for ARI is strongly recommended.

Pneumonia in HIV-infected and HIV-uninfected children in developing countries

PURPOSE OF REVIEW

Pneumonia is a leading cause of illness and death in children younger than 5 years in developing countries, accounting for approximately 20% of childhood deaths. The HIV epidemic has sharply increased the incidence, severity, and mortality of childhood pneumonia in the developing world, particularly in sub-Saharan Africa. This article reviews recent findings on the epidemiology, clinical features, and management of HIV-infected and -uninfected children with pneumonia in developing countries.

RECENT FINDINGS

Bacterial infection remains a major cause of pneumonia mortality; in HIV-infected children, a broader spectrum of pathogens including gram-negative infections and Pneumocystis jiroveci occurs. Mycobacterium tuberculosis is an important cause of acute pneumonia among children from high tuberculosis prevalence areas. Use of case management guidelines substantially reduces neonatal, infant, and under-5 mortality and pneumonia-specific mortality in developing countries. New advances in therapy include the use of short-course antibiotics and high-dose amoxicillin twice daily for ambulatory treatment of HIV-negative children with pneumonia. New preventive interventions include the development of conjugate vaccines against Streptococcus pneumoniae and Haemophilus influenzae, but these are not widely affordable nor available in developing countries. Despite a lower efficacy in HIV-infected children, these vaccines still protect against disease in a significant proportion of children. Available preventive interventions including micronutrient supplementation with zinc and vitamin A, and immunization as contained in the WHO Expanded Program of Immunization can substantially reduce the burden of childhood pneumonia.

SUMMARY

Urgent measures to implement existing available, effective interventions for prevention and treatment of childhood pneumonia and achieve high coverage rates in developing countries are needed.

Pharmacopoeial quality of drugs supplied by Nigerian pharmacies

BACKGROUND

The quality of medicines available in some less-developed countries is inadequate in terms of content of active ingredient. Reasons for the poor quality of drugs include widespread counterfeiting of medicines in less-developed countries, excessive decomposition of active ingredient as a result of high temperature and humidity, and poor quality assurance during the manufacture of medicinal products. Our aim was to investigate the quality of different drugs obtained from retail pharmacies in two urban areas of Nigeria, and, in instances of poor quality, to ascertain the reason why.

METHODS

We randomly collected 581 samples of 27 different drugs from 35 pharmacies in Lagos and Abuja in Nigeria. We analysed the medicines for drug content by validated chromatographic methods, and compared our results with pharmacopoeial requirements.

FINDINGS

279 (48%) samples did not comply with set pharmacopoeial limits, and this proportion was uniform for the various types of drugs tested. Although some preparations contained no active ingredient, most had amounts just outside the pharmacopoeial limits. We identified samples with both too much and too little active drug content.

INTERPRETATION

The most probable cause of the poor quality of drugs is absence of adequate quality assurance during manufacture. Substandard drugs sold in the pharmacies of less-developed countries could contribute to global microbial resistance and therapeutic failure of infectious diseases.

Radiologic differentiation between bacterial and viral lower respiratory infection in children: a systematic literature review

A systematic literature review was performed to quantify the accuracy of chest radiography in differentiating bacterial from viral lower respiratory infection in children. Relevant studies were identified in a systematic literature search and were included in the review according to predetermined criteria. Five of 13 relevant identified studies met the inclusion criteria. No clinically useful degree of accuracy was demonstrated, but great caution is needed in interpreting the findings because of the suboptimal nature of the reference standards, even in included studies. It is recommended that future surveys of the microbial etiology of pneumonia that employ a credible reference standard (such as lung aspiration) be used as opportunities to perform studies of diagnostic accuracy.

Primary prevention of acute respiratory tract infections in children using a bacterial immunostimulant: a double-masked, placebo-controlled clinical trial

BACKGROUND

Acute respiratory tract infections (ARTIs) are among the main causes of morbidity and mortality in children. The bacterial extract OM-85 BV has shown some protective effect for ARTIs in preschool children and a reduction in exacerbations of chronic bronchitis in adults.

OBJECTIVES

This trial reports results of a double-masked, placebo-controlled, parallel-group clinical study that assessed the efficacy and tolerability of OM-85 BV in the prevention of ARTIs in school girls living in an orphanage.

METHODS

Two hundred girls (age range, 6 to 13 years) living in an orphanage entered the trial. Participants were randomly allocated to receive either OM-85 BV or placebo for 10 consecutive days a month for 3 consecutive months. Patients were followed up for 6 months, including the administration period. The trial began in September 1996 and finished in March 1997. Primary end points were the type and number of infections. Secondary end points included when an infection occurred, time to clinical cure, severity of infection, absenteeism from school due to an ARTI, number of antibiotics or other drugs prescribed, and duration of concomitant drug treatment.

RESULTS

During the trial, patients in the OM-85 BV group experienced 143 ARTIs (135 upper ARTIs and 8 otitis episodes) and patients in the placebo group experienced 299 ARTIs (273 upper ARTIs, 1 lower ARTI, and 25 otitis episodes). The median number of ARTIs was 1.0 (0.0, 3.0; 5th percentile, 95th percentile) in the OM-85 BV group compared with 3.0 (2.0, 4.0; 5th percentile, 95th percentile) in the placebo group. This difference was statistically significant (P < 0.001). Participants who received OM-85 BV also showed significantly better results (P < 0.001) than participants who received placebo in terms of median duration of illness, median number of missed school days due to an ARTI, median number of antibiotic and drug courses, and median duration of concomitant treatment. There were significant differences (P < 0.05) in severity of ARTIs during month 4 of the trial, with patients receiving OM-85 BV showing less severe ARTIs than patients receiving placebo and shorter mean time to clinical cure from the second month to the fourth month. No adverse events related to the trial medications were reported.

CONCLUSIONS

OM-85 BV had a preventive effect on ARTIs in the school girls, with a reduction in the antibiotic requirements and the duration of ARTIs. Future studies are needed to further explore the role of OM-85 BV in the prevention of ARTIs.

Rapid detection of respiratory viruses by centrifugation enhanced cultures from children with acute lower respiratory tract infections

BACKGROUND

Acute respiratory tract infection (ARI) is the major cause of morbidity and mortality in young children in developing countries. Information on viral aetiology in ARI in India is very limited.

OBJECTIVE

The aim of the study was to define the role of viruses in acute lower respiratory tract infections (ALRTI) in children in India using centrifugation enhanced cultures followed by indirect immunofluorescence (IIF).

STUDY DESIGN

Nasopharyngeal aspirates (NPAs) were collected from children from September 1995 to April 1997, attending paediatric clinic of All India Institute of Medical Sciences (AIIMS) with symptoms of ALRTI. Virus isolation was done by centrifugation enhanced cultures using HEp-2, LLC-MK2 and MDCK cells. The viruses were identified at 24-48 h post inoculation by IIF staining using monoclonal antibodies to respiratory syncytial virus (RSV), parainfluenza virus (PIV), influenza virus and adenovirus.

RESULTS

Of 200 NPA samples, 89 (44.5%) were positive for one or more viral pathogens. RSV was detected in 34 (17%) of all ALRTI cases followed by influenza viruses in 29 (14.5%), PIVs in 23 (11.5%) and adenoviruses in three (1.5%). In 79 children with bronchiolitis, RSV was most frequently isolated (25%) pathogen, while in bronchopneumonia cases (101) the most common viral pathogen was influenza virus (17%). In eight cases (4%) of ALRTI dual infections were detected. In 100 NPA specimens IIF staining on direct cell smears was carried out and viruses were detected in only 17%. RSV and influenza virus infection peaked from September to December, where as PIV infections were more frequent from January to April.

CONCLUSION

Respiratory viruses accounted for 44.5% of cases of ALRTI in India and the results of viral aetiology could be given in 24-48 h using centrifugation enhanced cultures. RSV was the most common viral agent associated with ALRTI in children under 5 years of age with greater association with bronchiolitis.