Antimicrobial treatment of diarrhea/acute gastroenteritis in children

Acute gastroenteritis (AGE) are usually caused by viruses, especially Rotavirus and Norovirus. Among the bacterial causes, very few warrant antibiotic treatment, mainly Shigella, Vibrio cholerae, Campylobacter (only for severe cases, particularly in the initial phase) and severe cases of Salmonella infection. The antimicrobial treatments proposed in this guide follow the latest guidelines of the European Society of Pediatric Infectious Diseases and the European Society of Pediatric Gastroenterology and Nutrition. Azithromycin is the preferred antibiotic for infections due to Shigella and Campylobacter. Ceftriaxone and ciprofloxacin are recommended for salmonellosis when antibiotic treatment is indicated. In most cases, empirical treatment without bacteriological documentation should be avoided.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011-12 and 2012-13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

[Safety of oral ivermectin in children]

Ivermectin is an antiparasitic drug, a derivate of avermectins, and a product of fermentation of an actinomycete, Streptomyces avermitilis. Its structure associates two avermectins. Ivermectin acts on the chloride-dependent channels of both glutamate and γ-aminobutyric acid, interrupting neurotransmission in invertebrates. In humans, several mechanisms of brain protection exist, including P-glycoprotein, present on the apical face of endothelial cells of the blood-brain barrier and coded by the MDR1 gene. Ivermectin is presently used in mass treatment of onchocerciasis, other filariasis, some intestinal nematode infections, but also in scabies, and more rarely in resistant head lice. The side effects described are related to the release of antigen and cause an inflammatory reaction. Studies conducted in children or infants have shown good tolerance of ivermectin. However, its use in infants who weigh less than 15kg is a problem because of the absence of marketing authorization for this age group. However, the risk of excessive and uncontrolled use in head lice requires close surveillance.

Markers of a recent bocavirus infection in children with Kawasaki disease: "a year prospective study"

BACKGROUND

Retrospective studies and case-reports have suggested the possible role of various viruses in the pathogenesis of the Kawasaki disease.

OBJECTIVES

To determine prospectively the incidence of Kawasaki diseases associated with a recent bocavirus infection in the course of a year.

STUDY DESIGN

Thirty-two children with Kawasaki disease were enrolled in a 13 months prospective study to assess the frequency of human bocavirus type 1 infections. Seasonal shedding of virus, markers of recent infection such as viraemia, viral load, and serum interferon alpha were analyzed.

RESULTS

Three of 32 (9%) children had HBoV-DNA in the serum suggesting a recent infection. HBoV-DNA was detected in naso-pharyngeal aspiration of 7/32 (21.8%) children with Kawasaki Disease and six of them (18%) had an increased viral load. No common respiratory viruses were isolated from the 32 patients with the exception of one adenovirus. The seven bocaviruses were identified during the winter-spring season. In addition, 4 of 7 of Kawasaki disease patients shedding bocavirus had detectable interferon alpha in the blood, indicating a possible active or recent viral infection.

CONCLUSIONS

This study shows that a recent bocavirus infection is concomitant with the onset of some cases of Kawasaki disease. Bocavirus may be a cofactor in the pathogenesis of this disease as previously reported for other infectious agents.

[Counsel for traveling children]

Consultation of child traveler has two main objectives: to assess of health risk related to the child's health status and history and also the risk related to travel environment; to counsel and prescribe preventive measure to reduce these travel health risks. The evaluation is based on physical examination and a detailed interview including personal history and information regarding the regions of proposed travel. Up to date knowledge of the epidemiology of visited sites, preventive measures and presumptive treatment is required. Essential health recommendations include, in case of exposure, prevention of malaria, arthropod borned diseases and vaccine preventable diseases. For all destinations advice regarding prevention of diarrhea, accident risks and aggravation of preexisting chronic diseases is needed. Universal primary prevention counselling is valuable for all travellers regardless of their age. In the case of children, special attention must be given to food and water hygiene, sun and heat exposure, swimming risks and transports security measures. Evaluation of risk and health education take time and often several visits are needed to complete the immunization schedule before departure.

[Anti-meningococcal vaccines: diversity of vaccination policies and recommendations]

In European Country, Canada, Australia and Brazil immunization program with conjugate meningococcal C, including universal vaccination of infants or toddlers, with a catch-up program up to 19 y in several areas, have been successful in reducing disease incidence through direct and indirect protection. In USA, quadrivalent conjugate vaccines targeting serogroups ACYW135 are used in programs of adolescent immunization at 10 and 15 years because serotype Y is frequent. A mass immunization campaign against serogroupe A disease with a conjugate vaccine is beginning in African belt of meningitis. Polysaccharide vaccines A, C or ACYW135 are used in travelers but quadrivalent conjugate vaccine, with larger targets, gives higher titers after booster and must be preferred. Some questions are pending: immunize before or after one year of age, a booster dose in adolescence and the routine use of quadrivalent conjugate vaccine in Europe if the incidence of serotype Y is growing.

[Pneumococci isolated from vaccinated children with pneumonia]

Among 76 children fully vaccinated with 7-valent conjugate vaccine and subsequently hospitalized from 2006 to 2009 for community-acquired pneumonia, isolated or with empyema or pleuritis, 10 had confirmed pneumococcal infections. All pneumococci isolated with blood or pleural culture were non vaccine serotypes (1, 5, 7F, and 19A). The proportion of pneumococcal pneumonias was similar to that in two series from the same hospital before the vaccine era. These data show that the 13-valent conjugate vaccine could be useful in prevention of community-acquired pneumonia and that bacteriologic survey of community-acquired pneumonia remains necessary.

Epidemiology and clinical features of gastroenteritis in hospitalised children: prospective survey during a 2-year period in a Parisian hospital, France

Rotavirus is recognised as the most important agent of severe acute gastroenteritis (AGE) in young children. In a 2-year prospective survey, we investigated the epidemiology and clinical features of the viral and bacterial pathogens in children hospitalised for AGE. The study was performed in a Parisian teaching hospital from November 2001 to May 2004. Clinical data were prospectively collected to assess the gastroenteritis severity (20-point Vesikari severity score, the need for intravenous rehydration, duration of hospitalisation). Stools were systematically tested for group A rotavirus, norovirus, astrovirus and adenovirus 40/41, sapovirus and Aichi virus and enteropathogenic bacteria. A total of 457 children (mean age 15.9 months) were enrolled. Viruses were detected in 305 cases (66.7%) and bacteria in 31 cases (6.8%). Rotaviruses were the most frequent pathogen (48.8%), followed by noroviruses (8.3%) and adenoviruses, astroviruses, Aichi viruses and sapoviruses in 3.5%, 1.5%, 0.9% and 0.4%, respectively. Cases of rotavirus gastroenteritis were significantly more severe than those of norovirus with respect to the Vesikari score, duration of hospitalisation and the need for intravenous rehydration. Rotaviruses were the most frequent and most severe cause in children hospitalised for AGE, and noroviruses also account for a large number of cases in this population.

[Imported malaria: diagnostic traps and rapid tests]

Imported malaria is a disease prevalent in France: 6,000 to 8,000 cases a year, of which 15% are pediatric cases. Despite this high incidence, the diagnosis is often delayed. The patient may then evolve to a severe form. This diagnostic delay is due to non-specific clinical symptoms in children. The most common symptoms are fever and digestive disorders (diarrhea, vomiting). In the absence of thrombocytopenia, the laboratory tests are not very useful for diagnosis. Parasitological examinations are dependent on the experience of the biologist, particularly in cases of low parasitemia as those observed in children who have received partial chemoprophylaxis. The recent introduction of rapid tests based on the detection of Plasmodium proteins, allows emergency remedy to this problem. The blood smears remains the gold standard and has to be used to confirm the results of rapid tests. If rapid tests improve the detection of Plasmodium in 2009, it remains mandatory to evoke the diagnosis of malaria in any febrile child coming from an endemic area.

[Human bocavirus infections]

Le bocavirus humain (HboV) a été récemment cloné lors d’un criblage systématique de prélèvements nasopharyngés d’enfants hospitalisés pour infections respiratoires. Ce virus, du genre bocavirus, de la famille des Parvoviridae, a été détecté par son ADN, lors de différentes études, dans environ 5 % des prélèvements nasopharyngés. Il serait responsable d’infections respiratoires hautes et basses chez les jeunes enfant de moins de cinq ans avec un pic hivernal. Son rôle pathogène dans ces infections reste encore à déterminer, compte tenu d’un taux élevé de co-infections virales. Des études supplémentaires permettront de préciser le rôle de ce virus, possiblement systémique, dans d’autres affections.

Unexpected substitution of dominant rotavirus G genotypes in French hospitalized children over five consecutive seasons

The study was designed to evaluate the circulation of group A rotaviruses in French hospitalized children, and to detect unusual strains. This prospective study was conducted from 2001 to 2006 in children consulting for acute diarrhea at the pediatric emergency department in three French University Hospitals. The rotaviruses were detected by rapid test and genotyped by RT-PCR on the basis of their outer capsid proteins VP4 (P-type) and VP7 (G-type). The stools from 757 children were analyzed. G1P[8] strains were predominant (44.0%), followed by G9P[8] (17.7%), G3P[8] 13.1%, G4P[8] (9.5%), and G2P[4] (1.8%); mixed rotavirus infections occurred in 2.3%. G9 rotaviruses emerged during the 2004-2005 season (73.4%) and remained the second most prevalent strains. Few unusual strains, G6, G8, G12 and P[6]-types, were detected. The monitoring of rotavirus infections should be maintained to document strain distribution and to assess the emergence of new reassortants that may not respond to current rotavirus vaccines.

[Children arthropod bites protective measures: insecticides and repellents]

Vector transmitted diseases are often a serious threat for child health, especially for children traveller in tropical regions. Few arthropod borne diseases are preventable by immunization or chimioprophylaxis. Prevention of most of them is based on personal protection against arthropod bites. The evidence of its efficacy has been established by the use of impregnated bed nets, impregnated clothes with permethrin or mosquito repellent which reduced significantly child malaria morbidity and mortality in endemic countries. These personal protective measures are able to minimize arthropod bites and prevent Chikungunya infection, dengue fever and Lyme disease. The choice of a repellent among the commercialised products need to be efficacy and safety evidence based. This article propose to raise this issue and to give pragmatic recommendations, with a focus to children below 30 months who are at a high toxicological risk. Severity of these diseases allowed to use potentially toxic repellents if misused.

Detection of human bocavirus in children with Kawasaki disease

Human bocavirus (HboV) is an emerging virus that has been implicated as a cause of acute upper and lower respiratory tract infection in children. As no serological assay is available, PCR was used to screen nasopharyngeal, serum or stool samples from 16 patients with Kawasaki disease for HBoV nucleic acid. HBoV was identified by PCR in five (31.2%) patients, suggesting that this emerging virus may also play a pathogenic role in some cases of Kawasaki disease.

[Simultaneous outbreaks of rotavirus and respiratory syncytial virus in Paris: a 12-year survey]

OBJECTIVE

The authors had for aim to study the coincidence of RSV and rotavirus epidemic peaks in pediatric patients hospitalized in the Paris area.

METHODOLOGY

A retrospective hospital-based monocentric cohort study was made over a 12-year period (1993-2004). Clinical and laboratory findings were prospectively collected on admission.

RESULTS

Three thousand and four hundred ninety-six stool samples were positive for rotavirus; 3,507 nasopharyngeal aspirates were positive for RSV. The coincidence of epidemic peaks for both viruses in November, December, and January was observed during the 12 years of the study.

CONCLUSION

The exact coincidence of winter outbreaks of RSV and rotavirus is a characteristic of the Paris area. It contributes to increase overcrowding in pediatric units and nosocomial infections.

Pertussis in young infants: apnoea and intra-familial infection

This study investigated 41 infants, aged <4 months, who were hospitalised with symptoms compatible with pertussis. Of these, 16 had Bordetella pertussis infection confirmed by real-time PCR. For four of these 16 patients, the initial sample was PCR-negative, but samples collected 5-7 days after the onset of infection were PCR-positive. PCR was also positive with samples from 15/16 families and 20/41 household contacts. Nine of the 20 positive household contacts were asymptomatic. Among the 16 infants with proven pertussis, apnoea was more frequent than in a control group for whom PCR was negative with both children and household contacts (69% vs. 28%). It was concluded that real-time PCR performed with samples from household contacts facilitates the diagnosis of infants suspected clinically of having pertussis, thereby enabling earlier treatment.

[Distinction between bacterial and aseptic meningitis in children: refinement of a clinical decision rule]

OBJECTIVES

To refine and to re-validate the best current tool (the Nigrovic rule: ''outpatient management may be considered for children without seizure, blood neutrophil count>or=10,000/mm(3), positive cerebrospinal fluid -CSF- Gram-staining, CSF protein>or=80 mg/dl, or CSF neutrophil count>or=1,000/mm(3)'') proposed to distinguish between aseptic meningitis (AM) and bacterial meningitis (BM) in the emergency department.

METHODS

Children hospitalized for BM between 1995 and 2004, or AM between 2000 and 2004 were included, and randomly divided into derivation (111 children, 14 BM) and internal validation (57 children, 7 BM) sets. The Nigrovic rule was refined on the derivation set, introducing new variables (purpura, toxic appearance and high serum procalcitonin), changing variables thresholds (CSF protein) and withdrawing some variables (blood neutrophil count, CSF neutrophil count), according to previous results, with the aim to obtain 100% sensitivity user friendly tool. The refined rule was then applied on the internal validation set, stayed blinded during the derivation process.

RESULTS

The refined rule was: start antibiotics in case of seizure, purpura, toxic appearance, procalcitonin>or=0.5 ng/ml, positive CSF Gram-staining, or CSF protein>or=50 mg/dl. The refined rule had 100% sensitivity on the derivation and the internal validation sets (95% confidence interval 78-100, and 65-100, respectively) with 62 and 51% specificity, respectively.

CONCLUSION

The refined rule (called Meningitest) was a highly sensitive, specific and user friendly tool that could allow to safely avoid>50% a posteriori unuseful antibiotic treatments for patients with AM.

Vaccinations de l'enfant voyageur

Each year, half a million of children leave France to travel towards countries south or east of the European Union, sometimes in poor sanitary conditions. In order to propose essential or useful immunizations for these trips, the current synthesis will allow the practitioner to insure that the routine French immunization schedule has been followed, and to complete it if needed, to protect the child according to the epidemiological situation in the visited area, to try to reduce the limitations of the immunization of the traveler child. In case of emergency, or close departure, it may be useful to follow an accelerated schedule of the last minute, and, sometimes, to immunize traveler children with a chronic disease. Informations on Internet sites useful for the knowledge of current infectious risks in the destination country are also provided.

[Nosocomial rotavirus infections in a pediatric unit: surveillance during four successive winters]

The incidence of rotavirus and RSV outbreaks during winter seasons leads to overcrowding of pediatric units in the Paris area, and increases the risk of viral nosocomial infections in hospitalized young infants.

OBJECTIVE

The aim of this study was to measure the incidence of rotavirus nosocomial infections in children less than 2 years of age during 4 consecutive winters.

METHODS

All infants admitted in the pediatric unit during the winter were prospectively screened for rotavirus with a stools exam. All children with negative stools examination on admission but developing diarrhea after 2 days of hospitalization underwent a new screening test for rotavirus in stools.

RESULTS

During the 4 consecutive winters, the global incidence of nosocomial rotavirus infection was 13.9% (12.7 to 15.9%). Asymptomatic carriage of rotavirus was detected in 3% of admitted infants. The risk of nosocomial rotavirus infection increases with young age and the length of hospital stay.

CONCLUSION

The incidence of nosocomial rotavirus infections was high in this unit. It is related to overcrowding due to coincidence of diarrhea and bronchiolitis outbreaks in the Paris area and to the young age of hospitalized patients.

Tuberculose de l'enfant après contage familial : une expérience en pédiatrie générale

The heterogeneity of clinical presentations of children in contact with a tuberculous adult do not allow simple guidelines for treatment and exams. Indications of thoracic computed tomography (CT) in young children and the risk of a follow-up without antituberculous treatment are always discussed.

PATIENTS

Sixty-nine children, belonging to 50 families, living in close contact with an adult treated for tuberculosis were explored during 7 years in a General Pediatric Unit. A CT was performed in 51 patients.

RESULTS

Mantoux test was negative in 3/17 children with typical tuberculous disease on X-ray. When results of CT were compared with those of standard thoracic X-ray, a difference for the diagnosis of mediastinal adenopathies was found only in children younger than 5 years. Fifty-eight patients were given usual treatment of latent or patent tuberculosis if indicated, or a chemoprophylaxis. All of them had normal clinical and X-ray exam 2 to 4 years later. Eleven children, initially checked in an other unit, were given no treatment, but a follow-up was set up. However, after 6 to 24 months, 4/11 had a patent tuberculosis and 5/11 a latent tuberculosis, 6/9 being aged more than 3 years.

CONCLUSION

This study shows that risk of tuberculosis after familial contamination is high, and that the choice of absence of treatment with following re-evaluation, is sometimes questionable because families or doctors do not perform the prescribed follow-up. To perform systematically a thoracic CT, searching for mediastinal adenopathies, is useful only before the age of 5 years.

Clinical decision rules to distinguish between bacterial and aseptic meningitis

BACKGROUND

Clinical decision rules have been derived to distinguish between bacterial and aseptic meningitis in the emergency room to avoid unnecessary antibiotic treatments and hospitalisations.

AIMS

To evaluate the reproducibility and to compare the diagnostic performance of five clinical decision rules.

METHODS

All children hospitalised for bacterial meningitis between 1995 and 2004 or aseptic meningitis between 2000 and 2004 have been included in a retrospective cohort study. Sensitivity and specificity were calculated by applying each rule to the patients. The best rule was a priori defined as the one yielding 100% sensitivity for bacterial meningitis, the highest specificity, and the greatest simplicity for a bedside application.

RESULTS

Among the 166 patients included, 20 had bacterial meningitis and 146 had aseptic meningitis. Although three rules achieved 100% sensitivity (95% CI 84-100), one had a significantly lower specificity (13%, 95% CI 8-19) than those of the other two rules (57%, 95% CI 48-65; and 66%, 95% CI 57-73), which were not statistically different. The ease of manual computation of the rule developed by Nigrovic et al (a simple list of five items: seizure, blood neutrophil count, cerebrospinal fluid (CSF) Gram stain, CSF protein, CSF neutrophil count) was higher than the one developed by Bonsu and Harper.

CONCLUSION

On our population, the rule derived by Nigrovic et al had the best balance between accuracy and simplicity of manual computation and could help to avoid two thirds of unnecessary antibiotic treatments and hospitalisations.

Delay in diagnosis of imported Plasmodium falciparum malaria in children

The study reported here prospectively evaluated the time-to-diagnosis of imported Plasmodium falciparum malaria in children in seven French pediatric emergency departments during a 1-week period. For the 29 patients included, the mean patient, doctor and total delays were 3.1, 1.5 and 4.7 days, respectively. The late medical diagnosis for 11 patients was mainly due to the treating physician's failure to consider malaria, despite having been informed that the child had been in an endemic area, and erroneously making a diagnosis of viral infection. The five patients who were diagnosed correctly without delay had higher mean platelet counts than the others (206,000 vs 118,541/mm(3); p=0.008). The results indicate that greater awareness of the risk of malaria in returning travelers may help reduce delays in diagnosis and its consequences.

Prediction of vesicoureteral reflux after a first febrile urinary tract infection in children: validation of a clinical decision rule

AIMS

To test the reproducibility of a highly sensitive clinical decision rule proposed to predict vesicoureteral reflux (VUR) after a first febrile urinary tract infection in children. This rule combines clinical (family history of uropathology, male gender, young age), biological (raised C reactive protein), and radiological (urinary tract dilation on renal ultrasound) predictors in a score, and provides 100% sensitivity.

METHODS

A retrospective hospital based cohort study included all children, 1 month to 4 years old, with a first febrile urinary tract infection. The sensitivities and specificities of the rule at the two previously proposed score thresholds (< or =0 and < or =5) to predict respectively, all-grade or grade > or =3 VUR, were calculated.

RESULTS

A total of 149 children were included. VUR prevalence was 25%. The rule yielded 100% sensitivity and 3% specificity for all-grade VUR, and 93% sensitivity and 13% specificity for grade > or =3 VUR. Some methodological weaknesses explain this lack of reproducibility.

CONCLUSIONS

The reproducibility of the previously proposed decision rule was poor and its potential contribution to clinical management of children with febrile urinary tract infection seems to be modest.

[Knowledge, attitudes, and practices of adolescents in an urban school environment in Bamako, Mali, around family planning, sexually transmitted infections, and AIDS]

We undertook a study amongst adolescents from Mabile High School in Bamako, Mali. The goal of the study was to determine the knowledge, attitudes and practices of high school students around STI/AIDS and family planning. It was a transversal study using a stratified sampling method. A total of 322 students between ten and 19 years of age were included in the study (191 boys, 131 girls) This study demonstrates that high school students do not often family planning services (only 13.4% of those who knew of the existence of such used them). The method of contraception most often used is still the condom (92.5%). HIV is the most well know STI (97.5%) followed by gonorrhea (45%). An absence of communication between adolescents and their parents around family planning and STI/AIDS was apparent in that information was most often received on these topics through the media (96.3% for family planning, 97.5% for AIDS) followed by friends (72.4% for family planning and 81.7% for AIDS). 59.3% of the students are sexually active. Of sexually active students, 41.3% have had sexual relations with a casual partner and 75.9% with at last two partners. Given their high number of partners and a lack of systematic condom usage, it is apparent that sexually active high school students practice high risk sexual behaviors. It is therefore crucial to develop methods to lead to an improvement in behaviors amongst adolescents.

[Mycoplasma pneumoniae, community-acquired pneumonia and asthma]

Mycoplasma pneumoniae is an intracellular pathogen, devoid of cell wall, able to invade airway epithelial cells. Infection may either remain asymptomatic or induce bronchitis and pneumonia. M. pneumoniae is the first-ranking aetiological agent of community-acquired pneumonias in children over five years of age. Clinical features are usually mild, but this should not preclude the initiation of a treatment, in order to avoid serious sequelae such as impairment of pulmonary gas exchange capacity. In children at high-risk of asthma, infection with M. pneumoniae can induce exacerbation. A survey was performed in children admitted to hospital Saint-Vincent-de-Paul (Paris) for an episode of severe asthma exacerbation with persistent hypoxemia. Mycoplasma infection was identified in 26% of children with a history of asthma and 50% of those for whom the exacerbation was the presenting manifestation of the disease. Furthermore, if the Mycoplasma infection was atypical, asthma exacerbation recurred within one month. M. pneumoniae should be considered not only as a preeminent agent of respiratory infection in children, but also as a triggering factor in exacerbation and even inception of asthma. As a consequence, it is mandatory to carefully search for and actively treat Mycoplasma infection in children.