Clinical, microbiological, and molecular characterization of pediatric invasive infections by Streptococcus pyogenes in Spain in a context of global outbreak

In December 2022, an alert was published in the UK and other European countries reporting an unusual increase in the incidence of Streptococcus pyogenes infections. Our aim was to describe the clinical, microbiological, and molecular characteristics of group A Streptococcus invasive infections (iGAS) in children prospectively recruited in Spain (September 2022-March 2023), and compare invasive strains with strains causing mild infections. One hundred thirty isolates of S. pyogenes causing infection (102 iGAS and 28 mild infections) were included in the microbiological study: emm typing, antimicrobial susceptibility testing, and sequencing for core genome multilocus sequence typing (cgMLST), resistome, and virulome analysis. Clinical data were available from 93 cases and 21 controls. Pneumonia was the most frequent clinical syndrome (41/93; 44.1%), followed by deep tissue abscesses (23/93; 24.7%), and osteoarticular infections (11/93; 11.8%). Forty-six of 93 cases (49.5%) required admission to the pediatric intensive care unit. iGAS isolates mainly belonged to emm1 and emm12; emm12 predominated in 2022 but was surpassed by emm1 in 2023. Spread of M1UK sublineage (28/64 M1 isolates) was communicated for the first time in Spain, but it did not replace the still predominant sublineage M1global (36/64). Furthermore, a difference in emm types compared with the mild cases was observed with predominance of emm1, but also important representativeness of emm12 and emm89 isolates. Pneumonia, the most frequent and severe iGAS diagnosed, was associated with the speA gene, while the ssa superantigen was associated with milder cases. iGAS isolates were mainly susceptible to antimicrobials. cgMLST showed five major clusters: ST28-ST1357/emm1, ST36-ST425/emm12, ST242/emm12.37, ST39/emm4, and ST101-ST1295/emm89 isolates.

IMPORTANCE

Group A Streptococcus (GAS) is a common bacterial pathogen in the pediatric population. In the last months of 2022, an unusual increase in GAS infections was detected in various countries. Certain strains were overrepresented, although the cause of this raise is not clear. In Spain, a significant increase in mild and severe cases was also observed; this study evaluates the clinical characteristics and the strains involved in both scenarios. Our study showed that the increase in incidence did not correlate with an increase in resistance or with an emm types shift. However, there seemed to be a rise in severity, partly related to a greater rate of pneumonia cases. These findings suggest a general increase in iGAS that highlights the need for surveillance. The introduction of whole genome sequencing in the diagnosis and surveillance of iGAS may improve the understanding of antibiotic resistance, virulence, and clones, facilitating its control and personalized treatment.

[The impact of SARS-CoV-2 pandemic on patients who attend a pediatric emergency department for mental health issues]

The lockdown during the SARS-CoV-2 pandemic and the effect of the virus on the population could be a precipitating factor for mental health disorders in the pediatric population.

OBJECTIVE

To compare the reasons for consultation, diagnoses at discharge, and admission and re-consultation rates of pediatric patients attending the Emergency Department due to mental health disorders before and after the SARS-CoV-2 pandemic lockdown.

PATIENTS AND METHOD

Retrospective, descriptive study. Patients under 16 years of age consulting due to mental health-related disorders during the pre- (07/01/2018-07/01/2019) and post-lockdown (07/01/2020-07/01/2021) periods were included. The frequency of mental health diagnoses, need for drug administration, hospitalization, and reconsultations were compared.

RESULTS

760 patients were included, 399 pre-lockdown and 361 postlockdown. After the lockdown, there was a 45.7% increase in the frequency of mental health-related consultations with respect to the total number of emergency consultations. Behavioral alterations were the most frequent reason for consultation in both groups (34.3% vs. 36.6%, p = 0.54). In the post-lockdown period, consultations related to self-harm attempts (16.3% vs. 24.4%, p < 0.01) and the diagnosis of depression (7.5% vs. 18.5%, p < 0.01) increased significantly. There was an increase of 58.8% in patients who were hospitalized with respect to the total number of ED patients (0.17% vs. 0.27%, p = 0.003) and in the number of re-consultations (12% vs. 17.8%, p = 0.026). No differences were observed in days of hospitalization (7 days [IQR 4-13] vs. 9 days [IQR 9-14], p0.45).

CONCLUSION

In the post-lockdown period, the proportion of pediatric patients presenting to the ED with mental health disturbances increased.

Acute Epstein-Barr virus infection: Diagnostic challenge in young children, risk factors for hospitalization and cytomegalovirus co-detection

AIM

Acute Epstein-Barr virus (aEBV) and cytomegalovirus (CMV) infections frequently have similar manifestations. We aim to evaluate the characteristics of aEBV infection, risk factors for hospitalization, and differences according to CMV IgM detection (EBV-CMV co-detection) in children.

METHODS

Retrospective, single-center study including patients <16 years diagnosed with aEBV infection (positive anti-EBV IgM/Paul-Bunnell test, and acute symptomatology). EBV-CMV co-detection was defined as positive CMV IgM. Factors associated with age, hospitalization and EBV-CMV co-detection were analyzed in a multivariate analysis.

RESULTS

149 patients were included (median age 4.6 years). Most frequent manifestations were fever (77%), cervical lymphadenopathy (64%), and elevated liver enzymes (54%). Younger children had lower rate of positive Paul-Bunnell test (35 vs 87%; p<0.01), but higher rate of EBV-CMV co-detection (54 vs 29%; p=0.03). These children tended to have less typical symptoms of infectious mononucleosis and higher hospitalization rate. The overall antibiotic prescription was 49%. Hospitalization (27 children; 18%) was independently associated with prior antibiotic therapy and anemia. Sixty-two cases (42%) had EBV-CMV co-detection, which was independently associated with elevated liver enzymes and younger age.

CONCLUSION

In this study, younger children with aEBV infection presented more frequently with atypical clinical symptoms, had higher EBV-CMV co-detection rates and were more often hospitalized. Hospitalization was associated with prior antibiotic prescription.

Inhaler technique in a pediatric emergency department: Impact of an education intervention among healthcare professionals

BACKGROUND

Inhaler technique (IT) knowledge among healthcare providers is poor. The aim was to improve Pediatric Emergency Department (PED) healthcare providers' IT technique by carrying out an education intervention and sustain it for 6 months.

METHODS

Open-label, quasi-experimental, prospective, and unicentric study. Healthcare professionals working at the PED were enrolled. The study was developed in three phases: baseline evaluation and education intervention (P1) and reevaluation 1 month (P2) and 6 months (P3) after the education intervention. Participants fulfilled an eight-question theoretical test. Practical skills were evaluated by demonstrating IT in all three phases. The education intervention consisted in a verbal explanation of IT followed by a demonstration of IT with metered-dose inhaler using a mannequin.

RESULTS

A total of 84 healthcare providers (medical residents, nurses, and nursing assistants) were involved. In the theoretical questionnaire, the mean score at baseline was 4.4/8 (SD 1.7) improving to 6.3/8 (SD 1.2) in P2 and 6.47/8 (SD 1.1) in P3. In the IT evaluation for children <7 years old, the score improved from 5.7/7 (SD 1.3) to 6.5/7 in P2 and 6.7/7 in P3 (p < 0.001). For children >7 years old, the mean score of IT at baseline was 3.1/10 (SD 4), which improved to 7.4/10 (SD 3) and 8.2/10 in P2 and P3, respectively (p < 0.001). Only professional category influenced results at baseline.

CONCLUSION

Healthcare providers' theoretical knowledge and practical skills on IT are low. The education intervention performed is a useful strategy to ameliorate IT among healthcare providers.

Quality of life and psychiatric comorbidities in pediatric patients with Gilles de la Tourette syndrome

INTRODUCTION

Tourette Syndrome (TS) is a complex neurodevelopmental disorder which is normally associated to psychiatric comorbidity such as attention deficit hyperactivity disorder, obsessive compulsive disorder, anxiety or depression. Quality of life (QoL) in these patients can be affected by tic severity and associated comorbidities.

AIM

The aim of the study was to describe and analyze QoL and psychiatric comorbidities in a sample of pediatric patients, as well as to develop a Spanish version of the questionnaire CandA-GTS-QoL to measure quality of life in this population.

PATIENTS AND METHODS

Single-center, observational, prospective study. Patients aged 6 to 16 years old with TS were included. Demographic, clinical, diagnostic and treatment data were gathered. Questionnaires regarding tic severity, psychiatric comorbidity and quality of life were used.

RESULTS

Twenty-two patients with DSM-5 diagnosis of TS were included (86.4% male, median age 11 years). Of those, 86.4% had been previously diagnosed of psychiatric comorbidities and 72.7% received psychopharmacologic treatment. The prevalence of an ICD-10 current diagnosis of anxiety was 72.7%, depression 50%, ADHD 40.9% and OCD 7.3%. Median QoL score was 59.5 (RIC: 34.8-71.3) for PedsQL, and 55.5 (RIC: 45-65) for CandA-GTS-QoL, with a correlation between scores of R2 = 0.83 (p < 0.01). Higher tic severity was associated with poorer QoL (PedsQL R2: -0.732, p <0.01, CandA-GTS-QoL R2: -0.501, p = 0.021). A higher EDAH score for ADHD was associated with poorer QoL (PedsQL R2: -0.463, p = 0.03, CandA-GTS-QoL R2-0.534, p < 0.01).

CONCLUSION

Prevalence of psychiatric comorbidities in pediatric TS is high and frequently underdiagnosed. Tics and psychiatric comorbidities affect quality of life. Further studies are needed to validate the Spanish version of CandA-GTS-QoL scale.