SPILF update on bacterial arthritis in adults and children

In 2020 the French Society of Rhumatology (SFR) published an update of the 1990 recommendations for management of bacterial arthritis in adults. While we (French ID Society, SPILF) totally endorse this update, we wished to provide further information about specific antibiotic treatments. The present update focuses on antibiotics with good distribution in bone and joint. It is important to monitor their dosage, which should be maximized according to PK/PD parameters. Dosages proposed in this update are high, with the optimized mode of administration for intravenous betalactams (continuous or intermittent infusion). We give tools for the best dosage adaptation to conditions such as obesity or renal insufficiency. In case of enterobacter infection, with an antibiogram result "susceptible for high dosage", we recommend the requesting of specialized advice from an ID physician. More often than not, it is possible to prescribe antibiotics via the oral route as soon as blood cultures are sterile and clinical have symptoms shown improvement. Duration of antibiotic treatment is 6 weeks for Staphylococcus aureus, and 4 weeks for the other bacteria (except for Neisseria: 7 days).

Understanding and preventing vaccination errors

INTRODUCTION

Vaccine-related medication errors can occur at each step of the vaccination process: prescribing, dispensing, preparation, administration, monitoring, transport, and storage. We aimed to describe current knowledge of vaccination-related errors to identify areas for improvement.

MATERIAL AND METHODS

We performed a literature review on PubMed, using MeSH terms, from 1998 to 2020 to identify articles that would illustrate vaccine-related medication errors. We developed a questionnaire for health professionals concerning prescribing, dispensing, or administering vaccines via Facebook, and then identified priority areas for information to reduce vaccine-related medication errors.

RESULTS

A total of 227 answers were collected from midwives (N = 90), pharmacists or technicians (N = 75), and physicians or interns (N = 62). Practitioners gave wrong answers on live vaccines administered during pregnancy (>10 % of physicians), incorrect acronyms for the DTCaP (diphtheria, tetanus, pertussis, poliomyelitis) vaccine corresponding to branded products (72 % of midwives), lack of marketing authorization knowledge for the influenza vaccine (46 %), duration of vaccine conservation outside of the refrigerator (52 %), or intravenous administration of the rotavirus vaccine (23 %). Most health professionals mentioned the possibility of writing procedures for the various steps of the vaccine process, but only few of them have actually done it (15 % for dispensing/administration versus 61 % for storage). Ten key points for initial or ongoing training of health professionals have been summarized.

CONCLUSION

There is partial mastery of vaccine knowledge among health professionals. Our final table presents the most important elements of these results for educating health professionals on potential vaccine-related medication errors.

Economic and disease burden of RSV-associated hospitalizations in young children in France, from 2010 through 2018

BACKGROUND

Respiratory syncytial virus (RSV) is the main cause of infant and child hospitalizations. The study objective is to estimate the RSV-associated hospitalizations and economic burden in young children in France to inform future preventive strategies.

METHODS

We conducted a retrospective analysis of RSV-associated hospitalizations data from the French Hospital database (PMSI-MCO) which covers the entire French population. All children aged < 5 years hospitalized with RSV ICD-10 codes (J210, J219, J45, J121, J205, R062) from 2010 to 2018, were included. Descriptive analyses were conducted by RSV seasons (Oct to March), by respiratory years (July to June) and per age groups.

RESULTS

On average 45,225 RSV-associated hospitalizations (range: 43,715 - 54,616) per season was reported in France, 69% among children < 1 year old. This represents 28% of all-cause hospitalizations that occurred among children < 1 year old, and less than 10% of all-cause hospitalizations in older children. Number of RSV-associated hospitalizations were similar for infants born during (Oct-March) or outside (April-September) their first RSV season. The highest risk being reported for infants born from September through November. The associated hospitalization cost increased between 2010 - 11 and 2017-18, from €93.2 million to €124.1 million, respectively, and infants < 1 year old represented 80% of the economic burden.

CONCLUSION

RSV is an important cause of child hospitalization in France. The burden on healthcare system is mainly driven by < 1 year olds, and preventive strategies should be implemented before the first RSV season.

Retour d’expérience d’un hôpital pédiatrique pendant la crise Covid-19 en Île-de-France

La crise sanitaire de la Covid-19 du printemps 2020 a peu touché les enfants avec peu d’hospitalisations dans les hôpitaux pédiatriques. Le défi a été d’apporter une aide aux hôpitaux adultes avec un personnel principalement formé à la pédiatrie tout en maintenant la permanence des soins urgents pour les enfants atteints ou non de la Covid-19. À l’hôpital universitaire Armand-Trousseau, nous avons créé des unités dédiées pour les enfants atteints de la Covid-19, identifié les spécificités des enfants atteints de la Covid-19 et notamment les formes de Kawasaki like ou PIMS (paediatric multisystem inflammatory syndrome), créé une unité de réanimation adulte au pic de l’épidémie pour augmenter les capacités en lits de réanimation dans notre région, mutualisé notre centre de dépistage pour le personnel d’hôpitaux adultes. Enfin, nous avons envoyé plus de 140 personnels médicaux et paramédicaux dans les hôpitaux adultes de notre groupe hospitalier. Cette aide a pu être organisée grâce aux liens étroits établis par des cellules de crises communes avec les hôpitaux adultes de notre groupe hospitalier. Nous rapportons ainsi un retour d’expérience d’un hôpital pédiatrique au cours de la crise de la Covid-19 en Île-de-France.

Klebsiella pneumoniae and Klebsiella oxytoca meningitis in infants. Epidemiological and clinical features

BACKGROUND

The incidence of meningitis caused by Klebsiella pneumoniae (Kp) and Klebsiella oxytoca (Ko) in high-income countries is unknown, and no series have been published to date.

METHODS

We conducted a nationwide multicenter observational study in France between 2006 and 2016. All children from the French national registry for paediatric bacterial meningitis under the age of 1 year and hospitalized for Kp or Ko meningitis were included. Virulence factors of four Klebsiella spp. strains were explored by whole genome sequencing.

RESULTS

Of 1859 cases of meningitis in children under the age of 1 year, 13 cases (0.7%) of Klebsiella spp. meningitis (nine for Kp meningitis and four for Ko meningitis) were registered in the French national registry. Three of the patients died and 50% of the survivors had developmental delays.

CONCLUSIONS

Prematurity, low birth weight, and congenital anomalies of the urinary tract appear to be risk factors for Klebsiella spp. meningitis as well as virulence factors of the strain.

Antibiotic treatment of skin and soft tissue infections

Bacterial skin and soft tissues infections are common in children and frequently do not require systemic antibiotics, especially if lesions are superficial. Careful washing is always indicated in superficial lesions and is often sufficient. Careful evaluation of symptoms (which may be difficult despite the accessibility of the lesions) should be performed before prescription. Therefore, the need for drainage (spontaneous or surgical) should be assessed considering that antibiotics are mostly useless if purulent lesions are drained. Presence of toxinic symptoms (i.e., generalized cutaneous rash, diarrhea, hypotension) are strongly associated with enhanced severity. The bacterial targets for antibiotics are mainly Staphylococcus aureus (SA) and Streptococcus pyogenes. Considering the low incidence of methicillin-resistant SA in France, the French Pediatric Infectious Disease Group recommends the use of amoxicillin + clavulanate as the first-line antibiotic in most children suffering from severe skin infections requiring antibiotic treatment. In patients presenting toxinic symptoms and signs, the adjunction of an antibiotic with antitoxin properties such as clindamycin should be considered.

Antibiotic therapy of bone and joint infections in children: proposals of the French Pediatric Infectious Disease Group

Acute hematogenous bone and joint infections (osteomyelitis, septic arthritis, osteoarthritis, and spondylodiscitis) affect more frequently children younger than 5 years of age. Early diagnosis and prompt treatment are needed to limit the risk of complications. Children with suspected bone and joint infections (BJI) should be hospitalized at the beginning of treatment. Surgical drainage is indicated in patients with septic arthritis and in those with periosteal abscess. Staphylococcus aureus is involved in BJIs in children at all ages; Kingella kingae is a very common causative pathogen in children under 4 years of age. The French Pediatric Infectious Disease Group recommends in children > 3 months of age empirical antibiotic therapy with appropriate coverage against methicillin-sensitive S. aureus with high doses (150mg/kg/day) of intravenous amoxicillin-clavulanate, cefuroxime or cefazoline. In most children with uncomplicated BJI, short intravenous antibiotic therapy for 3 days can be followed by oral therapy. The minimum total duration of antibiotic therapy should be 10 days for septic arthritis and 3 weeks for osteomyelitis.

Spondylodiscitis in a healthy 12-year-old girl with Extraintestinal pathogenic Escherichia coli (ExPEC) bacteraemia

Background

Escherichia coli (E. coli) is rarely implicated in bone or joint infections in children.

Case presentation

We discuss the case of a healthy 12-year-old girl with an E. coli bacteraemia and a T11-T12 spondylodiscitis revealed by magnetic resonance imaging. The strain harboured serogroup O1:K1 and virulence factors common to highly virulent extra intestinal pathogenic E. coli (ExPEC). Immunological work-up was normal.

Conclusion

The identification of E. coli in a spondylodiscitis should lead to the search for immunosuppression of the host and virulence factors of the strain, particularly those of ExPEC.

[Nosocomial rotavirus gastroenteritis]

Rotavirus is the most common cause of gastroenteritis in children requiring hospitalization. It is a very resistant and contagious virus causing nosocomial gastroenteritis. In France, the vaccine against rotavirus has been available since 2006, but the vaccine is not recommended for infant vaccination. The aim of this retrospective study was to describe nosocomial rotavirus gastroenteritis (NRGE) and to assess its impact on children hospitalized in the General Pediatrics Department of Robert-Debré Hospital (Paris) between 1 January 2009 and 31 December 2013. We analyzed the demographic characteristics of children (age, term birth, underlying diseases) and the severity of the NRGE (oral or intravenous hydration), and assessed whether these children could benefit from vaccination against rotavirus.

RESULTS

One hundred thirty-six children presented nosocomial rotavirus infection, with an incidence of 2.5 NRGE per 1000 days of hospitalization. The incidence of NRGE was stable between 2009 and 2013 despite the introduction of specific hygiene measures. The average age of the children was 7 months (range: 0.5-111 months). Most often NRGE occurred in children hospitalized for respiratory diseases (65% of cases) and requiring prolonged hospitalization (median: 18 days). One-third of children were born premature (25%). Hydration was oral in 80 patients (59%), by intravenous infusion in 18 patients (13%), and intraosseous in one patient. Half of the patients were aged less than 5 months and could benefit from the protection afforded by vaccination.

CONCLUSION

NRGE are common. Rotavirus mass vaccination should have a positive impact on the incidence of NRGE by reducing the number of children hospitalized for gastroenteritis, therefore indirectly reducing the number of hospital cross-infections of hospitalized children who are too young to be vaccinated.

NSAIDs in paediatrics: caution with varicella!

Anti-inflammatory drugs have been suspected on several occasions to have promoted development of bacterial infection among varicella patients. Some countries have not implemented childhood varicella vaccination. Three cases in our hospital suggested the predisposing role of NSAIDs in varicella patient deterioration. Open access to these drugs widely increases their use and patient information should be continually provided in the medical offices and at dispensing pharmacy counters. Taking account of the benefit/risk balance and applying the simple precautionary principle, it would be appropriate to be cautious about the use of NSAIDs in the paediatric population.

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.

Evaluation of frequency of paediatric oral liquid medication dosing errors by caregivers: amoxicillin and josamycin

OBJECTIVE

To study reconstitution and preparation dosing errors of liquid oral medications given by caregivers to children.

METHODS

A prospective observational study was carried out in the departments of general paediatrics and emergency paediatrics at the Robert-Debré Children's University Hospital. An interview with caregivers involved (1) practical reconstitution and preparation of an oral liquid medication from a prescription drawn at random (amoxicillin (Clamoxyl, dosing spoon) or josamycin (Josacine, dose-weight pipette)) and (2) a questionnaire about their use.

RESULTS

One hundred caregivers were included. Clamoxyl and Josacine were incorrectly reconstituted in 46% (23/50) and 56% (28/50) of cases, respectively, with a risk of underdosing of Clamoxyl (16/23) and overdosing of Josacine (23/28). Dose preparation with the dosing spoon was incorrect in 56% of cases, and in 10% of cases with the dose-weight pipette. Female sex, native French speaker, and age were significantly associated with correct reconstitution. Male sex and medication were significantly associated with correct preparation.

CONCLUSIONS

This study highlights the high incidence of errors made by caregivers in reconstituting and preparing doses of these liquid oral medicines, which are associated with considerable risks of over- and underdosing. Factors associated with these errors have been identified which could help health professionals to optimise their strategy for educating families about the use of liquid oral medications and the need to check that they understand these instructions.

A large national cohort of French patients with chronic recurrent multifocal osteitis

OBJECTIVE

To document more fully the characteristics of chronic recurrent multifocal osteomyelitis (CRMO) in pediatric patients, to collect data on the outcomes and management of the disease, and to define prognostic factors.

METHODS

One hundred seventy-eight patients were included (123 female patients and 55 male patients), with a mean ± SD age at diagnosis of 10.9 ± 2.9 years. Inclusion criteria were a diagnosis of CRMO, evidence of at least one lesion of osteitis confirmed by imaging, and development of the syndrome before age 18 years.

RESULTS

Longitudinal clinical and imaging studies revealed that only 12 of 178 CRMO patients (7%) had unifocal lesions at the last medical visit. We were able to apply the clinical chronic nonbacterial osteomyelitis score to 110 of 178 patients (62%), which indicated that bone biopsy could have been avoided in 27 cases (25%). At the last medical visit, disease was in remission in only 73 of 171 patients (43%) (41% receiving therapy) after a mean ± SD of 47.9 ± 38.9 months; 44 of 171 patients (26%) experienced sequelae. Using cluster analysis, the CRMO cohort was separated into 3 homogeneous phenotypes (severe, mild, and intermediate). Patients with the severe phenotype had the worst prognosis. This group was entirely composed of male patients, most of whom had the multifocal form of CRMO and inflammatory syndrome. Patients with the mild phenotype had the best prognosis. This group was primarily composed of female patients with a unifocal form of CRMO and infrequent clavicle involvement and inflammatory syndrome. Patients with the intermediate phenotype had a good prognosis but greater reliance on treatment. This group primarily included female patients with multifocal lesions and inflammatory syndrome.

CONCLUSION

This is the largest CRMO cohort described in the literature to date. Clinical evolution and imaging investigations confirmed the multifocal pattern of the disease. Three distinct subgroups of CRMO patients were distinguished, with very different prognoses.

[Catch-up vaccination of worldwide newcoming (adopted, refugee or migrant) children in France]

In France, international adoption includes around to 90,000 children since 1980 and near 300,000 immigrant children were counted in 2008. This population is heterogeneous, according to age and country of origin, and its large number. It is not easy to completely and surely assess the vaccine status of the child. Due to a great variability of individual situations, it is not possible to have systematic and unchangeable rules. This article aims to give an update of catch-up vaccination of internationally adopted or refugee or migrant children in France. The vaccination status of a child who recently arrived in France is complex and has to be adapted to his country of origin. Some of them were never vaccinated whereas the vaccine status of others is uncertain or unknown. Three parameters have to be considered: the age of the child, the country of origin, and sometimes serology in the case of doubts of his vaccine status. Catch-up vaccination of foreign children has to be adapted to French vaccine recommendations, as a reference, and to vaccines already administered to the child.

[Current events in vaccination]

The annual meeting of the Infectious Disease Society of America (IDSA) ; which brought together nearly 5000 participants from over 80 countries in Vancouver, Canada, October 21 to 24, 2010 ; provided a review of the influenza (H1N1) 2009 pandemic, evaluated vaccination programmes and presented new vaccines under development. With 12,500 deaths in the United States in 2009-2010, the influenza (H1N1) 2009 pandemic was actually less deadly than the seasonal flu. But it essentially hit the young, and the toll calculated in years of life lost is high. The monovalent vaccines, whether live attenuated or inactivated with or without adjuvants, were well tolerated in toddlers, children, adults and pregnant women. In order to protect infants against pertussis, family members are urged to get their booster shots. The introduction of the 13-valent Pneumococcal conjugated vaccine in the beginning of 2010 may solve - but for how long ? - the problem of serotype replacement, responsible for the re-increasing incidence of invasive Pneumococcal infections observed in countries that had introduced the 7-valent vaccine. The efficacy of a rotavirus vaccine has been confirmed, with a reduction in hospitalization in the United States and a reduction in gastroenteritis-related deaths in Mexico. In the United States, vaccination of pre-adolescents against human papillomavirus (HPV) has not resulted in any specific undesirable effects. Routine vaccination against chicken pox, recommended since 1995, has not had an impact on the evolution of the incidence of shingles. Vaccination against shingles, recommended in the United States for subjects 60 years and over, shows an effectiveness of 55 %, according to a cohort study (Kaiser Permanente, Southern California). Although some propose the development of personalized vaccines according to individual genetic characteristics, the priority remains with increasing vaccine coverage, not only in infants but also in adults and the elderly. Vaccine calendars that cover a whole lifetime should be promoted, since the vaccination of adults and seniors is a determining factor of good health at all ages.

[Acute bacterial parotitis in infants under 3 months of age: a retrospective study in a pediatric tertiary care center]

BACKGROUND

Acute bacterial parotitis is a rare infectious disease in infants under 3 months of age.

OBJECTIVES

To describe the clinical characteristics and the course of acute bacterial parotitis in infants less than 3 months old.

PATIENTS AND METHODS

Infants under 3 months of age, hospitalized at Robert Debré university hospital, Paris, France, between January 2005 and December 2009 for acute bacterial parotitis, were included in a retrospective study.

RESULTS

Five infants less than 3 months of age were included in this study, for a frequency of 2.5/1000 hospitalizations in this age group. All were born at term, 4 of 5 were male. Three of the 5 patients had specific clinical signs of parotitis on admission. One patient had septic shock on admission. The ultrasound confirmed the parotitis in all cases. No parotid abscess was demonstrated on imaging. All patients had at least one abnormal inflammatory biological test (WBC, CRP, PCT). Bacteria were identified in 4 of 5 cases: Staphylococcus aureus was isolated in the pus culture of the Stenon duct in 2 patients and a group B Streptococcus was isolated from blood culture of 2 other patients. The duration of intravenous antibiotic therapy varied from 4 to 13 days, and the total duration of antibiotic therapy was between 10 and 16 days. No surgical procedures were needed.

CONCLUSION

Acute bacterial parotitis in infants under 3 months of age might be associated with localized infections due to S. aureus, but also with a more severe clinical presentation due to group B streptococcus infection. Early diagnosis and appropriate antibiotic therapy might prevent the progression to serious complications.

[Evaluation of pre-travel prevention, except vaccination, in children returning from Africa with fever]

OBJECTIVES

Evaluating the frequency and modalities of transmissible infection prevention counseling in children before a stay in tropical or subtropical areas.

METHODS

Description of the frequency and modalities of transmissible infection prevention counseling (except specific vaccination) given prior to travel in children attending a tertiary care center in Paris, France, for fever occurring within 3 months following a return from Africa. Data were collected retrospectively from medical observations and telephone interviews with parents.

RESULTS

A total of 173 children were included; 98 and 75 returned from sub-Saharan Africa and North Africa, respectively. Forty-one percent were less than 2 years old. Eighty-one percent of the children had consulted before leaving. Among children who returned from North Africa, the proportion of children who had a specific preventive consultation before travel was lower than among children who returned from sub-Saharan Africa (respectively, 72.1% versus 94.7%; p<0.001). In children having consulted before traveling, specific hygiene and diet advice had been given in 72% of cases but less frequently in children who traveled in North Africa compared to children who traveled to sub-Saharan Africa (respectively, 57.8% vs. 92.2%; p<0.001). Among children who returned from North Africa, those who had no preventive consultation before travel had febrile gastrointestinal infection more frequently than those who had a consultation before traveling (p=0.003).

CONCLUSION

Although in this study the majority of children traveling to Africa receive transmissible infection prevention counseling before the travel, prevention could be improved, particularly before a stay in North Africa.

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.

[Intricated asthma tracheomalacia: diagnosis and therapeutic aspects]

An asthmatic girl was first hospitalized at age 2(9/12) years because of dyspnoea, lung consolidations and/or atelectasis, and rattling. Between ages 2(9/12) and 6(2/12) years, she required three hospitalizations in ICU out of nine hospitalizations for the same symptoms. Differential diagnosis of this difficult to treat asthma disclosed severe tracheomalacia and persistent asthma. Treatments given according to the clinical, radiological and functional findings failed to decrease frequency and severity of acute respiratory episodes. Eventually, positive pressure ventilation delivered at airway opening (via a mouthpiece) associated to active respiratory physiotherapy succeeded in removing atelectasis and quickly cured the five following acute episodes without any further hospitalization. This case report is about diagnosis procedure, intricate asthma and tracheomalacia, and open mind to unusual therapeutics that may disclose potential help.