Ciprofloxacin in critically ill children

Data regarding the use of fluoroquinolones in critically ill children are scarce. We present our experience regarding the use of ciprofloxacin in this specific patient population. We prospectively identified all paediatric patients who received ciprofloxacin treatment in the intensive care unit of the tertiary care P. & A. Kyriakou Children's Hospital during a three year period (2005 to 2008). Eighteen paediatric patients (mean age 23 months, 12 females) who received intravenous ciprofloxacin were identified. Various underlying diseases, including malignancy and immunodeficiency, were observed. None of the evaluated patients had cystic fibrosis. Fourteen patients had bacteraemia (mainly caused from Gram-negative pathogens), one had Stenotrophomonas maltophilia pneumonia, while no pathogen was identified in three patients. The latter patients received ciprofloxacin due to the severity of their clinical manifestations. All patients with microbiologically documented infections recovered. Three deaths attributed to the underlying diseases were noted. Within a 10-day follow-up, two cases of diarrhoea, one case of vomiting and one case of reversible supraventricular tachycardia were noted. No case of QT prolongation was noted. The short-term follow-up hampered any assessment of joint and cartilage toxicity, potentially associated with ciprofloxacin treatment. Our study suggests that ciprofloxacin may be a useful option for critically ill children without cystic fibrosis. Even though firm conclusions regarding the safety profile of ciprofloxacin in critically ill children could not be drawn, our study provides useful information regarding short-term adverse events associated with ciprofloxacin.

Liposomal amphotericin B in critically ill paediatric patients

WHAT IS KNOWN AND OBJECTIVE

Literature provides much evidence regarding liposomal amphotericin B treatment for fungal infections in neonates and infants. Relevant data regarding critically ill paediatric patients of older age are scarce. We aimed to present our experience regarding liposomal amphotericin B use in critically ill paediatric patients from a tertiary-care paediatric hospital in Athens, Greece.

METHODS

We prospectively identified all paediatric patients who received treatment with liposomal amphotericin B in the intensive care unit of a tertiary-care paediatric hospital during a 3-year period (2005-2008). Data were retrieved from the evaluation of the available medical records.

RESULTS AND DISCUSSION

Twenty-three (nine females, mean age: 26·4 months, range: 5-39 months) critically ill paediatric patients were included; 12 had malignancy. In 16 of the 23 included children, liposomal amphotericin B was administered for the treatment of confirmed fungal infections (all but one were invasive), whereas in seven patients, it was used as pre-emptive treatment. One patient received voriconazole concomitantly. Eleven of the 16 children with documented infections were cured; five improved. Six of the seven children who received pre-emptive treatment also showed clinical improvement. Nine deaths were noted, all attributed to underlying diseases. Two cases of hepatotoxicity and one case of nephrotoxicity (all leading to drug-discontinuation) occurred. Seven and five cases of mild reversible hypokalaemia and hyponatraemia, respectively, were also noted.

WHAT IS NEW AND CONCLUSION

According to the findings of our small case series, liposomal amphotericin B may provide a useful treatment option for fungal infections of vulnerable critically ill paediatric patients with considerable comorbidity.

Budesonide and formoterol inhibit inflammatory mediator production by bronchial epithelial cells infected with rhinovirus

BACKGROUND

Rhinoviruses (RVs) are responsible for the majority of acute asthma and chronic obstructive pulmonary disease (COPD) exacerbations. RVs infect the lower airways and induce the production of pro-inflammatory and remodelling-associated mediators. Budesonide (BUD) and formoterol (FORM) synergize in controlling asthma and COPD exacerbations; however, their effects on virus-induced inflammation and remodelling are less known.

OBJECTIVE

We investigated whether BUD and FORM synergize in suppressing RV-induced inflammation and remodelling in the airways.

METHODS

In vitro models of RV infection of BEAS-2B and primary normal human bronchial epithelial (NHBE) cells were used. We assessed the effects of individual and combined drugs administered post-infection, at a clinically relevant concentration range (10(-6)-10(-10) m), on the production of CCL5, CXCL10, CXCL8, IL-6 and the remodelling-associated VEGF and bFGF, using ELISA and RT-PCR.

RESULTS

BUD effectively suppressed RV-mediated induction of all mediators studied, in a concentration-dependent manner. FORM alone suppressed the production of CXCL8 and bFGF. The combination of BUD and FORM had concentration-dependent, additive or synergistic effects in the suppression of RV-induced CCL5, CXCL8 and CXCL10 in both cell types as well as VEGF in NHBE only. Combination treatment also resulted in an enhanced suppression of RV-induced IL-6, and CCL5 at the mRNA level as compared with BUD or FORM alone.

CONCLUSION

BUD and FORM suppress RV-induced chemokines and growth factors in bronchial epithelial cells in a concentration-dependent, synergistic or additive manner. These data further support the combined use of BUD and FORM in asthma and COPD and intensification of this therapy during exacerbations.

Nationwide surveillance of Streptococcus pneumoniae in Greece: patterns of resistance and serotype epidemiology

This nationwide study assessed the antimicrobial susceptibility and seroprevalence of Streptococcus pneumoniae in paediatric carriage isolates and in clinical isolates from adult pneumococcal disease in Greece during the years 2004-2006. Among 780 isolates recovered from the nasopharynx of children <6 years old attending day-care centres, non-susceptibility rates to penicillin, cefuroxime, ceftriaxone, erythromycin, tetracycline and trimethoprim/sulfamethoxazole were 34.7%, 25.1%, 1.0%, 33.5%, 26.4% and 44.2%, respectively. Among 89 adult clinical isolates, the respective rates were 48.3%, 46.1%, 5.6%, 48.3%, 32.6% and 40.4%. High-level resistance to penicillin, cefuroxime and ceftriaxone was recorded for 14.4%, 23.3% and 0.1% of paediatric carriage isolates, whereas for clinical adult isolates the respective rates were 25.8%, 38.2% and 2.2%. No resistance to levofloxacin and moxifloxacin was recorded, although 3.5% of paediatric carriage isolates and 23.2% of adult clinical isolates had minimum inhibitory concentrations of ciprofloxacin >2mg/L. Serotypes 19F, 14, 23F and 6B were the most prevalent among carriage and clinical isolates. The 7-valent pneumococcal conjugate vaccine was estimated to provide coverage against 71.7% of paediatric carriage isolates and 51.3% of adult clinical isolates. Resistance rates among clinical isolates from adult sources were higher than those recorded among paediatric carriage S. pneumoniae isolates and displayed an increasingly resistant profile compared with previous reports from our country, warranting continuous vigilance.

Meningococcal group C disease in Greece during 1993-2006: the impact of an unofficial single-dose vaccination scheme adopted by most paediatricians

The aim of this study was to evaluate the impact of the meningococcal C conjugate vaccine on the epidemiology of meningococcal C disease in Greece. Data from the National Reference Laboratory for Meningococcal Disease and a questionnaire distributed to Greek paediatricians were assessed. Since the introduction of the vaccine in 2001, 72% of Greek paediatricians have administered it as one single dose to patients aged > or =12 months. This vaccination scheme has probably contributed to a dramatic decrease in the number of meningococcal C infections, which reached zero in 2004.

Safety and tolerability of clarithromycin administered to children at higher-than-recommended doses

A tendency among pediatricians in Greece to use higher-than-recommended doses of clarithromycin was noted over several years, prompting this study of the safety and tolerability of this macrolide in 343 children over a period of 9 months. The study group comprised nonhospitalized patients of 29 pediatricians practicing in Athens. All were prescribed clarithromycin for upper respiratory (n = 257) or lower respiratory tract infection (n = 78). Overall, 77.8% were treated with doses that exceeded the recommended dose of 15 mg/kg/day, and 26% received doses of > or = 30 mg/kg/day (median dose, 20 mg/kg/day). The tolerability of clarithromycin was judged as "very good" in 75% of the children, as "good" in 16%, and as "moderate" in 5%, whereas intolerability was observed in 4% of the cases. Adverse reactions, mainly gastrointestinal in nature, were reported in 17.5% of the cases. With regard to both tolerability and adverse events recorded, there were no statistically significant differences between the group of patients who received the recommended dose and the group who received higher doses. Clarithromycin continues to present a safe and well-tolerated profile for the treatment of common pediatric infections, even when administered at higher-than-recommended doses. Whether it is more efficacious in this setting is a matter for further study.

Human rhinoviruses in otitis media with effusion

Frequent viral upper respiratory tract infections (URTI) are considered to be risk factors for otitis media with effusion (OME). Atopy has also been associated with both OME and viral infections. The aim of this study was to evaluate the presence of viruses in middle ear effusions (MEE) in children 2-7 yr old with OME, and to determine risk factors for virus detection in the MEE. MEE samples, collected at the time of myringotomy from 37 children with OME were assessed. Physical examination, skin prick tests and a standardized questionnaire on OME and allergy were also performed. Viral RNA was detected by the use of reverse transcription PCR (RT-PCR). Fifteen samples (40.5%) were positive for rhinovirus (RV). One enterovirus and no other respiratory viruses were detected. Two out of five (40%), 3/7 (43%) and 10/25 (40%) were positive for RV in acute, subacute and chronic cases, respectively. Children with frequent episodes of OM, with early onset of OM (<2 yr old), and a positive family history of allergy had a statistically increased risk of RV detection. The two groups were comparable with respect to all other parameters examined. RV is the predominant virus recovered by RT-PCR in the middle ear cavity of children with asymptomatic OME, especially those with a history of longstanding OME or repeated episodes, or children with a family history of allergy. Interactions between allergy and RV infections are likely to predispose to middle ear disease.

Preterm birth due to maternal infection: causative pathogens and modes of prevention

Preterm birth represents a major problem for modern obstetrics due to its increasing frequency and the accompanying socioeconomic impact. Although several maternal characteristics related to preterm birth have been identified, the etiology in most cases remains inadequately understood. Various microorganisms have been linked to the pathogenesis of preterm birth. Microbes may reach the amniotic cavity and fetus by ascending from the vagina and cervix, by hematogenous distribution through the placenta, by migration from the abdominal cavity through the fallopian tubes, or through invasive medical procedures. Organisms commonly cultured from the amniotic cavity following preterm delivery include Ureaplasma urealyticum, Mycoplasma hominis, Bacteroides spp., Gardnerella vaginalis, Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis, and group B hemolytic streptococci. Several trials have examined the effect of antibiotic administration to patients with preterm labor and intact membranes, preterm premature rupture of the membranes, genital mycoplasmal infection, asymptomatic bacteriuria, and bacterial vaginosis. The results of such studies, which were variable and often conflicting, are discussed here.

Serotypes and antimicrobial susceptibilities of 1033 pneumococci isolated from children in Greece during 2001–2004

Pneumococci (n = 1033) isolated in the major paediatric hospitals of Athens during 2001-2004 from children with invasive infections (n = 186), non-invasive infections (n = 641) and healthy carriers (n = 206) were studied. The most prevalent serotypes were serotypes 14 (44.6%), 19F (43.5%) and 6B (22.8%) in invasive, non-invasive and carriage isolates, respectively. Among invasive isolates, the potential coverage by the seven-valent conjugate vaccine was 75.3%. Resistance rates to penicillin, amoxycillin, cefotaxime, erythromycin, co-trimoxazole, clindamycin, tetracycline and chloramphenicol were 44.6%, 2.7%, 1.2%, 43.6%, 43.5%, 12.4%, 34.7% and 5.9%, respectively. The M-phenotype accounted for 68.0% of the erythromycin-resistant isolates. All isolates were susceptible to ofloxacin.

IgE sensitization, respiratory allergy symptoms, and heritability independently increase the risk of otitis media with effusion

BACKGROUND AND AIMS

Epidemiological evidence examining the role of atopy and/or allergy in the pathogenesis of otitis media with effusion (OME) is inconclusive. The aim of this study was to assess any increased risk for OME attributable to allergy-related factors, in a well-characterized population using a case-control design and multivariate analysis.

SUBJECTS AND METHODS

Eighty-eight 1-7-year-old children with OME, diagnosed by clinical and tympanometric evaluation and 80 matched controls were enrolled. A standardized questionnaire was completed, in order to assess factors related to OME and allergy-related symptoms and diagnoses using strict clinical definitions. Specific IgE was measured by skin-prick tests and/or CAP-FEIA.

RESULTS

The patient and control groups were well matched. Factors conferring increased risk for OME in the univariate analysis included IgE sensitization, dyspnea, wheezing, asthma, paroxysmal sneezing, rhinitis, eczema, 'any allergic disease,' family history of otitis media, and family history of allergy. After multivariate analysis IgE sensitization, wheezing, nasal obstruction, family history of otitis, and child-care attendance remained as independent risk factors for development of OME.

CONCLUSION

IgE sensitization and respiratory allergy symptoms are independent risk factors for the development of OME, suggesting that both immunological and mechanical pathways may contribute to the development of the disease. Otitis heritability provides additional risk, as well as frequent exposure to viral upper respiratory tract infections in children attending daycare. Treatment and/or prevention of OME using anti-allergic medications should be further examined.

Procalcitonin as a predictor of severe appendicitis in children

The aim of this study was to assess the diagnostic value of procalcitonin (PCT) in 212 children with appendicitis and compare it with that of the standard diagnostic modalities, C-reactive protein (CRP) level, leukocyte count, and abdominal ultrasound findings, in relation to the surgical and histological findings of the appendix. A PCT value of >0.5 ng/ml was found to be indicative of perforation or gangrene with 73.4% sensitivity and 94.6% specificity, a CRP level of >50 mg/l and a leukocyte count of >10(4)/mm3 were useful diagnostic markers for perforation, while abdominal ultrasonography had a sensitivity of 82.8% and a specificity of 91.2% for detecting appendicitis with imaging findings. PCT measurement seems to be a useful adjunctive tool for diagnosing acute necrotizing appendicitis or perforation, and surgical exploration will probably be required in patients with PCT values >0.5 ng/ml.

Treatment of paediatric visceral leishmaniasis: amphotericin B or pentavalent antimony compounds?

Pentavalent antimony compounds and amphotericin B lipid formulations have been found highly active for the treatment of visceral leishmaniasis. This study focuses on which treatment is preferable in the best interests of the child. Records were reviewed of children in our hospital aged 0-14 years, diagnosed with visceral leishmaniasis, during the last 4 years. Twenty-nine children were identified. Ten were treated with meglumine antimonate (20 mg/kg/day for 21 days) and remained in hospital for 11-28 days (median 19 days), while 19 patients received liposomal amphotericin B at four different dosage schemes and were in hospital for 6-11 days (median 7 days). All of the patients were cured regardless of the treatment regime they followed. No relapses were noted. Liposomal amphotericin B would be preferable to meglumine antimonate if the reduction in hospital stay and hence the convenience of the patient balance the cost of medication. The optimal duration of treatment with liposomal amphotericin B remains to be determined.

Etiology of community-acquired pneumonia in hospitalized school-age children: evidence for high prevalence of viral infections

BACKGROUND

Community-acquired pneumonia (CAP) in young children is most commonly associated with viral infections; however, the role of viruses in CAP of school-age children is still inconclusive.

METHODS

Seventy-five school-age children hospitalized with CAP were prospectively evaluated for the presence of viral and bacterial pathogens. Nasopharyngeal washes were examined by polymerase chain reaction for viruses and atypical bacteria. Antibody assays to detect bacterial pathogens in acute-phase and convalescent-phase serum samples were also performed.

RESULTS

A viral infection was identified in 65% of cases. Rhinovirus RNA was detected in 45% of patients; infection with another virus occurred in 31%. The most common bacterial pathogen was Mycoplasma pneumoniae, which was diagnosed in 35% of cases. Chlamydia pneumoniae DNA was not detected in any patient; results of serological tests were positive in only 2 patients (3%). Mixed infections were documented in 35% of patients, and the majority were a viral-bacterial combination.

CONCLUSIONS

The high prevalence of viral and mixed viral-bacterial infections supports the notion that the presence of a virus, acting either as a direct or an indirect pathogen, may be the rule rather than the exception in the development of CAP in school-age children requiring hospitalization.

Otitis and respiratory distress episodes following a respiratory syncytial virus infection

OBJECTIVE

To document, over two consecutive respiratory syncytial virus (RSV) seasons, the occurrence of acute otitis media (AOM) and recurrence of respiratory distress in children < 2 years of age hospitalized for respiratory distress.

METHODS

Patients were examined during hospitalization and at 6 weeks and 6 months after discharge. RSV testing was performed on all patients, and hospitalized patients were evaluated daily for the occurrence of AOM.

RESULTS

In total, 347 children were enrolled; 54.8% were RSV positive, and 45.2% were RSV negative. Children were most frequently diagnosed as having bronchiolitis (71.9%) or asthmatic bronchitis (17.9%); other diagnoses included pneumonia, laryngitis, and rhinitis. During hospitalization, AOM was diagnosed in 16.8% of RSV-positive versus 8.3% of RSV-negative children (P < 0.05). Six weeks after discharge, AOM was reported in 10.4% of RSV-positive as compared with 5.8% of RSV-negative patients. Six months later, AOM was reported in 2.9% of the RSV-positive and 7.6% of the RSV-negative patients. A second episode of acute respiratory distress, which either required (9) or did not require (35) hospitalization, occurred in 18.4% of the total population, with similar proportions of RSV-positive and RSV-negative children (17% versus 18.6%).

CONCLUSION

We conclude that RSV appears to be an important contributing factor for the occurrence of AOM in young children hospitalized with respiratory distress. The occurrence of a second episode of acute respiratory distress did not appear to correlate with the previous RSV infection, but longer-term follow-up is required.

An overview of paediatric leishmaniasis

Leishmaniasis, a parasitic disease transmitted by the bite of some species of sandflies affects various age groups depending on the infecting Leishmania species, geographic location, disease reservoir, and host immunocompetence. Visceral leishmaniasis is the most severe form of the disease affecting children. The extent and presentation of the disease depend on several factors, including the humoral and cell-mediated immune response of the host, the virulence of the infecting species, and the parasite burden. Children are at greater risk than adults in endemic areas. Malnutrition contributes to the development of disease, and incomplete therapy of initial disease is a risk factor for recurrence of leishmaniasis. Children usually present with intermittent fever, paleness, refusal to feed or anorexia, weight loss, and abdominal distension. Splenomegaly, hepatomegaly, lymph node enlargement, thrombocytopaenia, anaemia, leukopaenia and hypergammaglobulinemia are the most common findings in Paediatric leishmaniasis. Molecular methods appear to offer the promise of accurate non-invasive tools for the diagnosis of Leishmaniasis. Till these methods are evaluated, definite diagnosis will rely on the demonstration of the infecting parasite in various tissues. World-wide, with the notable exception of India, pentavalent antimonial compounds remain the most effective and the most affordable therapy for this disease. Lipid formulations of amphotericin B were assessed as short duration treatment and were proved to be effective. However, their cost precludes their wide use in developing countries. Miltefosine, a new oral agent, might prove effective, safe, and affordable. Strategies aimed at control of the micro-population of sandflies, eradication of canine leishmaniasis, and offering personal protection against sandfly bites, together with health education programs in developing countries, can help control the disease. Development of an effective vaccine remains a priority.

Epidemiology, clinical course and impact on hospitalization costs of acute diarrhea among hospitalized children in Athens, Greece

The aim of this study was to describe the etiology, morbidity and hospitalization costs associated with acute diarrhea among hospitalized children in Greece. During 1999, 294 hospitalized children (median age 1 y) with acute diarrhea were prospectively studied. Bacterial and viral enteropathogens were detected in 100 (34%) and 37 (12.5%) patients, respectively; 17 (6%) patients had mixed infections. Isolated agents included Salmonella spp. (43 patients; 15%), rotavirus (32; 11%), Campylobacter spp. (26; 9%), enteropathogenic Escherichia coli (16; 5.5%), Shigella spp. (11; 4%), Aeromonas spp. (7; 2.5%), adenovirus (6; 2%), Yersinia enterocolitica (6; 2%), enterohemorrhagic Escherichia coli (2; 0.5%) and Giardia lamblia (1; 0.5%). Of the patients with bacterial infection, 70% were admitted between April and September 1999. A rotavirus-associated peak was noted in March. Patients with a bacterial infection were hospitalized for longer periods than those with viral infections. It is concluded that bacterial enteropathogens account for one-third of admissions due to acute diarrhea among children in Greece and are associated with significant hospitalization costs. Rotavirus is also a frequent cause of acute diarrhea necessitating hospitalization.

Burden of respiratory syncytial viral infections on paediatric hospitals: a two-year prospective epidemiological study

This study was designed to prospectively investigate the hospitalisation patterns for respiratory syncytial virus (RSV) disease in children up to 2 years of age, both healthy full-term children and high-risk children. The aim was to evaluate children hospitalised for a respiratory tract infection in four regions and seven paediatric hospital departments or clinics in Greece and to estimate the burden of RSV disease on paediatric hospital beds, as well as to determine the target high-risk age group over two consecutive respiratory infection seasons. Among a total of 1,710 children, the overall prevalence of RSV disease was 33.1%, but prevalence differed between seasons (27% vs. 37.7%, P<0.01). The peak prevalence of RSV disease occurred in February, with the onset in November and the end in May. The monthly distribution was similar in all regions. RSV positivity was strongly associated with young age (4.7 vs. 6.6 months, P<0.001); classification within a high-risk group (43% vs. 32.6%, P=0.04); lower respiratory tract infection (93.8% vs. 86%, P=0.001), particularly bronchiolitis (80.9% vs. 63.9%, P=0.001); more severe disease (P<0.001); longer stay in hospital (P<0.001); and poorer outcome (P<0.001). RSV infections accounted for 38% of the total hospitalisation days for all respiratory infections, and 77% of the hospitalisation days for RSV infection were for infants less than 6 months of age.

Mycobacterial cervical lymphadenitis in children: clinical and laboratory factors of importance for differential diagnosis

The role of epidemiological and clinical features for the early differential diagnosis between Mycobacterium tuberculosis (MTB) complex and non-tuberculous mycobacterial (NTM) cervical lymphadenitis in children was examined in this study. From 1982 to 1997, 24 MTB complex cases and 26 NTM cases were diagnosed, of which 75% and 25%, respectively, presented during the first half of the study period. Epidemiological and lymph-node features and anatomical areas were not helpful in the differential diagnosis between the 2 groups. Fulfilment of 2 out of 3 criteria (positive tuberculin skin test reaction, abnormal chest radiograph, contact with a person with infectious tuberculosis) was associated with 92% sensitivity for the diagnosis of MTB lymphadenitis. 37.5% of the MTB cases and 88.5% of the NTM cases were culture-confirmed; all inconclusive cultures concerned patients with spontaneous drainage and fistula. Surgical intervention was required in 67% of the MTB cases. All NTM cases were managed by surgery alone. Fistulae or cheloids occurred in all patients in whom incision and drainage were applied instead of total excision. Excellent aesthetic results were achieved in patients who presented within 1 month following the onset of lymphadenitis. The spectrum of mycobacterial cervical lymphadenitis in children in Greece has changed during the 1990s. Early and prompt treatment contributes to the diagnosis and response.

Comparison of isepamicin with amikacin for the empirical treatment of febrile neutropenic children with malignancies

The efficacy and safety of isepamicin at 7.5 mg/kg i.v. q 12 h was prospectively compared with that of amikacin at the same dose for the treatment of febrile neutropenic children with malignancies. Thirty-nine patients were enrolled in the study; 25 received isepamicin and 14 amikacin. Clinical and bacteriological response rates were 100% for both groups. No adverse events occurred. Median peak serum levels were 19.7 mg/l for isepamicin and 19.20 mg/l for amikacin. Median trough serum levels were 0.72 mg/l for isepamicin and 0.68 mg/l for amikacin. It was concluded that isepamicin was as effective and safe as amikacin for the treatment of febrile neutropenic children with malignancies, and might be used in areas where resistance to other aminoglycosides is a problem.

Piperacillin/Tazobactam versus cefotaxime plus metronidazole for treatment of children with intra-abdominal infections requiring surgery

The efficacy of piperacillin/tazobactam at 100/12.5 mg/kg every 8 h (35 patients) was compared to cefotaxime plus metronidazole at 50/7.5 mg/kg every 8 h (35 patients) in 70 children with intra-abdominal infections requiring surgery. Diagnoses were gangrenous or perforated appendicitis (n =56), peritonitis (n =12), and abscess (n =2). Clinical cure was observed in 35 of 35 evaluable patients treated with piperacilin/tazobactam and in 34 of 34 evaluable patients treated with cefotaxime plus metronidazole. Presumed bacteriological eradication was noted in 29 of 30 evaluable patients in the piperacillin/tazobactam group and in 31 of 31 evaluable patients in the cefotaxime plus metronidazole group. In this study, piperacillin/tazobactam was as effective as cefotaxime plus metronidazole for treating children with intra-abdominal infections requiring surgery.

Acute diarrhoea in children treated in an outpatient setting in Athens, Greece

OBJECTIVE

To describe the epidemiology and aetiology of acute diarrhoea among children treated exclusively in an outpatient setting in Greece.

METHODS

During 1999, children with acute diarrhoea who attended the emergency department of our hospital were prospectively studied. Patients requiring hospitalization were excluded. Stool specimens were tested microscopically, for bacterial enteropathogens by standard and selective medium cultures and for rotavirus and adenovirus by latex agglutination test.

RESULTS

One hundred and thirty-two children (median age: 2 years) were included in the study; an enteropathogen was detected in 63 (48%) of them. Isolates included rotavirus (19 patients), Salmonella sp (12), Campylobacter sp (10), Aeromonas sp (9), enteropathogenic Escherichia coli (6), adenovirus (6), Giardia lamblia (4), Yersinia enterocolitica (2) and Shigella sp (1). Half of the bacterial cases occurred from August to October, and two rotavirus-associated peaks occurred during February and August. Acute diarrhoea caused by viruses affected exclusively children under six years of age, mainly those attending day care centres. Macroscopic blood in stools was reported only among patients with a bacterial infection. Socioeconomic characteristics were not helpful in differentiating disease due to specific enteropathogens.

CONCLUSIONS

Bacterial enteropathogens account for a significant proportion of acute diarrhoea in children treated in the outpatient setting in Greece. Rotavirus is also a frequent cause affecting mostly younger children and those attending day care centers. The presence of blood in stools and the seasonality of bacterial infections may enable their presumptive diagnosis.

Hemolytic-uremic syndrome associated with Coxiella burnetii infection

Acute Q fever most commonly manifests as a self-limited febrile illness, pneumonia or hepatitis. We report the case of a 12-year-old child with documented exposure to sources of Coxiella burnetii who was admitted to our hospital because of hemolytic-uremic syndrome. Serologic tests established the diagnosis of acute Q fever.

Lack of association between Kawasaki syndrome and infection with Rickettsia conorii, Rickettsia typhi, Coxiella burnetii or Ehrlichia phagocytophila group

BACKGROUND

The etiology of Kawasaki syndrome (KS) is unknown. Rickettsiae, intracellular microorganisms that invade the vascular endothelium, might cause KS.

OBJECTIVES

To investigate whether there is an association between KS and infection with Rickettsia conorii, Rickettsia typhi, Coxiella burnetii or Ehrlichia phagocytophila group.

METHODS

All children who were diagnosed with KS at the University of Athens Second Department of Pediatrics from December, 1999, through November, 2000, were prospectively studied. Paired serum specimens were obtained from all patients and antibody titers against R. conorii, R. typhi, C. burnetii and E. phagocytophila group were assessed by microimmunofluorescence assay.

RESULTS

Eleven children with a median age of 2.5 years were included in the study. A 15-month-old child had a 4-fold rise of antibody titers against C. burnetii, which is indicative of acute Q fever. The patient had a history of recent exposure to possible sources of C. burnetii. The remaining patients tested negative for the presence of antibodies against R. conorii, R. typhi, C. burnetii and E. phagocytophila group.

CONCLUSIONS

Our study does not provide serologic evidence that KS is the result of infection with R. conorii, R. typhi, C. burnetii or E. phagocytophila group. It is suggested that C. burnetii may cause a KS-like illness in young children.

Visceral leishmaniasis during childhood in southern Greece

Records were reviewed of 82 immunocompetent children (median age, 2. 5 years) from southern Greece who were diagnosed with visceral leishmaniasis from 1986 through 1998. Forty-nine (58%) patients originated from the city of Athens; of them, 46 (94%) lived by hills bordering the city. The median interval from the onset of symptoms to admission was 10 days. Fever and splenomegaly were observed in >95% of the patients. Thrombocytopenia was the most frequent hematological finding (80%). All patients were treated with meglumine antimonate; 20 (24%) of them were partially treated on an outpatient basis. Rapid clinical response was noted in all patients but one. Five patients relapsed; 3 responded to reintroduction of meglumine antimonate, 1 responded to liposomal amphotericin B, and 1 underwent splenic artery ligation. We conclude that pentavalent antimonials remain the first choice of treatment for visceral leishmaniasis in immunocompetent children in areas where resistance has not become a problem. It is possible to treat affected patients with outpatient administration of these agents, making them feasible options for therapy.

Extra-pulmonary tuberculosis in children

METHODS

The clinical and epidemiological features of 102 children with extra-pulmonary tuberculosis, diagnosed between 1982 and 1998 at P & A Kyriakou Children's Hospital were reviewed.

RESULTS

During the past decade, a 50% increase of admissions for extra-pulmonary tuberculosis was observed. The source of infection was disclosed in 48 patients. Diagnoses included superficial lymphadenitis (n = 48), pleural effusion (n = 27), meningitis (n = 16), skeletal tuberculosis (n = 5), miliary tuberculosis (n = 3), abdominal tuberculosis (n = 2), and pericarditis (n = 1). Miliary tuberculosis developed in infants, lymphadenitis and meningitis in preschool children, and pleural effusion and skeletal tuberculosis in older children. None of the patients with extra-pulmonary tuberculosis died; however, six patients with meningitis developed permanent neurological deficits. In these patients, antituberculous treatment was introduced at a median of six days following admission as compared with one day in patients with no complications. Poverty, immigration, and limited access to medical services were common among patients with meningitis.

Tuberculosis during infancy

SETTING

A worldwide re-emergence of tuberculosis has been observed during the last decade. However, few studies of infants with tuberculosis appear in the literature.

OBJECTIVE

To describe tuberculosis during infancy.

DESIGN

The records of all infants diagnosed with tuberculosis at a tertiary care hospital from 1982 to 1998 were reviewed.

RESULTS

Thirty-nine infants with a median age of 10 months were identified, 59% of whom presented during the second half of the study period. Diagnoses included endothoracic tuberculosis (33 patients), meningitis (3), miliary tuberculosis (2) and cervical lymphadenitis (1). Reasons for medical evaluation were the onset of symptoms (25 patients), contact investigation (12) and tuberculin skin test screening (2). Common signs and symptoms included fever (22 patients), cough (7), appetite loss (4) and wheezing/rales (4). Chest X-ray revealed hilar adenopathy (22 patients), infiltrates (16), atelectases (3) and miliary pattern (2). Cultures were attempted in nine patients and were positive in seven. All patients responded promptly to treatment. No complications or deaths occurred.

CONCLUSION

Tuberculosis in infants has been diagnosed increasingly during the last decade. Endothoracic tuberculosis predominates. One third of the patients were diagnosed due to contact investigation. As early diagnosis and treatment appears to prevent complications and reduce mortality, pediatricians should be alert for tuberculosis in an infant with an atypical picture suggestive of infection.

Viral infections in children undergoing hematopoietic stem cell transplant

BACKGROUND

Although viral infection is a major clinical problem for hematopoietic stem cell transplant recipients, there are few large series reporting on these infections in the pediatric population. We performed a retrospective analysis of the impact of viral infections in this patient population in our center, managed by a uniform antiviral prophylaxis protocol.

METHOD

We reviewed the medical records of consecutive children and adolescents who received hematopoietic stem cell transplantation at the Division of Pediatrics, The University of Texas M. D. Anderson Cancer Center in Houston, TX, from July, 1992 to August, 1996.

RESULTS

During the study period there were 70 episodes of viral infections in 96 transplants. The viruses most commonly encountered were cytomegalovirus (24), varicella-zoster (21) and herpes simplex (10). Fifty of these episodes resulted in clinically apparent diseases, affecting 39 patients. The Kaplan-Meier estimated probability for the development of viral diseases was 62%. Ten percent of these patients died as a direct result of the infectious process, all within 4 months of transplant. Significant factors for development of viral disease were the development of acute graft-vs.-host disease and the duration of preengraftment neutropenia.

CONCLUSIONS

Viruses are common pathogens after hematopoietic stem cell transplantation in the pediatric population. Despite routine antiviral prophylaxis the morbidity and mortality of viral infections remain high. Enhancement of immune recovery after hematopoietic stem cell transplantation together with the development of new classes of antiviral agents may impact the incidence and prognosis of viral infections in this setting.

Isepamicin versus amikacin for the treatment of acute pyelonephritis in children

In this study we compared the efficacy and safety of isepamicin versus amikacin at a dose of 7.5 mg/kg i.v. q12h for 10-14 days in children with pyelonephritis. Sixteen children were enrolled in the study; ten received isepamicin and six amikacin. Urine cultures grew Escherichia coli in all patients. All patients were treated successfully with either isepamicin or amikacin. Clinical and bacteriological response rates were 100% for both groups. No adverse events occurred. Peak serum levels ranged from 9.05 to 30.70 mg/l (median: 16.165) and from 12.20 to 25.90 mg/l (median: 19.05) for isepamicin and amikacin, respectively. Trough serum levels ranged from 0.11 to 3.20 mg/l (median: 0.75) and from 0.1 to 2.1 mg/l (median: 0.655), respectively. Isepamicin was shown to be as effective and safe as amikacin in the treatment of children with pyelonephritis and might prove an advantageous alternative in areas with high incidence of resistance to other aminoglycosides.

Nontuberculous mycobacterial lymphadenitis in children

OBJECTIVES

To describe the clinical and epidemiologic features, management and outcome associated with the development of nontuberculous mycobacterial (NTM) superficial lymphadenitis in children.

METHODS

The medical records of all children 0 to 14 years of age with NTM superficial lymphadenitis who were diagnosed at P. and A. Kyriakou Children's Hospital between January, 1982, and December, 1997, were reviewed.

RESULTS

Forty-seven children were identified, 76.5% during the second half of the study period. Mycobacterium avium complex was the predominant isolate. Children with NTM lymphadenitis noted satisfactory aesthetic results when total excision was performed within 1 month after its onset.

CONCLUSIONS

NTM superficial lymphadenitis in children has been increasingly recognized during the last decade. Prompt total excision of the involved lymph node is required in such patients.

Wound infections after minor limb lacerations: risk factors and the role of antimicrobial agents

BACKGROUND

The requirement for antimicrobial agents in patients with minor limb lacerations was prospectively studied.

METHODS

The development of wound infections in patients with minor limb lacerations who received amoxicillin plus clavulanate acid treatment (group A, 52 patients) was studied and compared with patients who did not (group B, 48 patients).

RESULTS

Wound infection occurred in 6 (11.5%) and 10 (21%) patients in groups A and B, respectively (p>0.10). Statistically significant risk factors for the development of infection were diabetes mellitus (odds ratio [OR], 15.8; p<0.001), lower limb lacerations (OR, 33.5; p<0.001), lacerations caused by compressive forces (OR, 21.6; p = 0.007), laceration length from 5 to 8 cm (OR, 7.04; p = 0.001), ragged laceration edge (OR, 2.55; p = 0.049), and skin tension (OR, 2.00; p = 0.006).

CONCLUSION

The use of antimicrobial agents in minor limb injuries was not associated with a significant reduction of infection rate. Routine antimicrobial treatment is discouraged.

Resistance pattern of Streptococcus pneumoniae in children during a four-year period in Greece

The resistance pattern of 432 Streptococcus pneumoniae strains isolated from children with various infections over a 4-year period (1992-1995) was determined. The rates of resistance to penicillin, chloramphenicol, tetracycline, trimethoprim-sulfamethoxazole, erythromycin, clindamycin, cefotaxime, and vancomycin were 10%, 2.8%, 4.6%, 4.9%, 4.4%, 2.5%, 0.9%, and 0%, respectively. All strains not susceptible to penicillin were intermediately susceptible to penicillin-(MIC >0.06-< or = 1 microg/ml). Isolates not susceptible to penicillin were encountered significantly more often in children with localized infections than in those with invasive disease; these isolates displayed significantly lower susceptibility to non-beta-lactam agents as compared with their penicillin-susceptible counterparts.

Five-day versus ten-day treatment of acute otitis media with cefprozil

A randomized comparative clinical trial was conducted to investigate the possibility of decreasing the duration of treatment of acute otitis media by comparing the clinical outcome and safety of a five-day and a ten-day course of cefprozil. A total of 708 pediatric patients were enrolled in the study, 560 of whom were evaluable for efficacy. Cefprozil was found to be completely effective in 87.1% of cases after five days of treatment, and in 91.2% after ten days of treatment. Of 19 patients with three or more previous episodes of acute otitis media, ten patients in the ten-day treatment group had a 100% cure rate, while in the five-day group four experienced cure, three improvement, and two failure. A five-day course of treatment with cefprozil can be recommended only if children have no history of recurrent acute otitis media.

Concentrations of cefpodoxime in plasma, adenoid, and tonsillar tissue after repeated administrations of cefpodoxime proxetil in children

Cefpodoxime proxetil was administered to 36 children undergoing tonsillectomy, adenoidectomy or both. It was very well tolerated. The detectable tissue concentrations of cefpodoxime were moderate but remained constant (approximately 0.05 mg/kg) 3, 6, and 12 h after the last dose of the drug, while the respective plasma concentrations were declining. This suggests the possibility of twice-daily administration. However, 30% of children did not have quantifiable concentrations in the tonsil and more than half the adenoids did not have quantifiable levels. Whether a higher dosage would lead to higher and more satisfactory tissue concentrations is a matter for further investigation.

Multinational multicenter controlled trial comparing ceftibuten with cefaclor for the treatment of acute otitis media. Members of the Ceftibuten Otitis Media International Study Group

A randomized, controlled, single blind clinical trial was conducted in children with acute otitis media to evaluate the safety and efficacy of a 10-day course of therapy with ceftibuten 9 mg/kg taken as a single daily dose, up to a maximum daily dose of 400 mg, compared with cefaclor 40 mg/kg/day in three divided doses, up to a maximum of 1 g/day. Patients were evaluated any time from 1 to 3 days after completion of therapy (posttreatment follow-up). A total of 154 patients (106 ceftibuten, 48 cefaclor) were evaluable for efficacy. Clinical success as determined by resolution (cure) or improvement of signs and symptoms of infection were seen in 89 and 88% of patients treated with ceftibuten and cefaclor, respectively, at the posttreatment follow-up visit. At the extended follow-up visit (any time from 2 to 4 weeks after completion of therapy), clinical success was sustained in 88 and 82% of the ceftibuten-treated and cefaclor-treated patients, respectively. A total of 391 patients (264 ceftibuten, 127 cefaclor) were included in the safety analysis. Treatment-related adverse experiences occurred in 8% of ceftibuten-treated patients and 14% of cefaclor-treated patients. All were mild or moderate and the majority were gastrointestinal. There were no deaths or serious adverse events. The results of this study suggest that ceftibuten is an effective and well-tolerated alternative to other antibiotic therapies for the treatment of children with acute otitis media.

Multi-investigator evaluation of the efficacy and safety of cefprozil, amoxicillin-clavulanate, cefixime and cefaclor in the treatment of acute otitis media

Cefprozil was evaluated in the treatment of acute otitis media with effusion in three open, randomized, multicenter comparative clinical trials. In two trials, 891 pediatric patients were enrolled to either cefprozil or amoxicillin-clavulanate dosage regimens. The treatment groups were comparable in demographic characteristics, and presented with otalgia, middle-ear effusion, or inflamed or bulging tympanic membrane on otoscopic examination. In all patients, tympanocentesis and a culture were required. Two cefprozil oral doses were evaluated, 30 mg/kg/day and 40 mg/kg/day divided into two equal doses (b.i.d.). Amoxicillin-clavulanate was administered at 40 mg/kg/day in three divided doses (t.i.d.). The recommended duration of therapy was ten days. The predominant bacteria isolated were Haemophilus influenzae and Moraxella catarrhalis. The overall satisfactory clinical response rates were similar for cefprozil (83%) and amoxicillin-clavulanate (81%). The bacteriological response rates did not differ significantly, at 84% and 82%. Cefprozil eradicated the most common pathogen, Streptococcus pneumoniae, more often at 91%, vs. 84% for amoxicillin-clavulanate. The eradication rates were similar against Haemophilus influenzae and Moraxella catarrhalis. The patients treated with cefprozil had a lower rate of adverse clinical events (11%) compared to those with amoxicillin-clavulanate (20%). More gastrointestinal adverse experiences, including diarrhea, were reported in the amoxicillin-clavulanate-treated patients. In Study 3, cefprozil 30 mg/kg/day (b.i.d.) was compared to cefaclor 40 mg/kg/day (t.i.d.) and cefixime 8 mg/kg/day (q.d) in the treatment of acute otitis media in 388 pediatric patients. The patients were treated for 10 days, with a follow-up of 18 days. The overall clinical cure rates were 85%, 89% and 85%, respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Clinical and pharmacokinetic study of a single daily dose of amikacin in paediatric patients with severe gram-negative infections

The efficacy and safety of a single 20 mg/kg daily dose of amikacin was studied in an open, uncontrolled trial in 56 infants and children. Most of the patients suffered from severe Gram-negative infection which had failed to respond to previous antibacterial therapy. Amikacin was given in combination with a beta-lactam antibiotic in 43 cases, with other antibiotics in five cases and monotherapy in eight cases. Pseudomonas aeruginosa was the most frequently isolated organism (27 cases). Clinical results were satisfactory in 98% of the infections treated. Two patients died, one from the infection and the other 8 weeks after therapy from unrelated causes. Amikacin serum concentrations were high during the first hour after iv infusion, low after 8 h and undetectable at 24 h. Nephrotoxicity and ototoxicity was not detected in any patient. Amikacin when used as a single daily dose in combination with a beta-lactam antibiotic was effective and safe in treating infants and children with severe Gram-negative infection.

Pharmacokinetics of roxithromycin in paediatrics

Macrolides are well known for their high lipid solubility and good tissue penetration. The pharmacokinetic properties of roxithromycin, a new semisynthetic macrolide, appear to be very interesting in healthy adult patients. Five paediatric pharmacokinetic studies are summarized and show that the pharmacokinetic properties of roxithromycin in paediatrics are very similar to those previously reported in adults and suggest that the same dose every 12 h is appropriate in paediatrics, 2.5 mg/kg. The diffusion of roxithromycin into upper respiratory tract tissues appears to be good in children.

Efficacy and safety of roxithromycin in treating paediatric patients. A European multicentre study

Roxithromycin sachets of 50 mg were given to 304 infants and children, aged 2 months to 14 years, suffering from respiratory and skin infections treated in 25 hospitals in France and one in Greece. The dosage range was from 2.5 to 5.0 mg/kg/12 h and the mean duration of therapy was 8.9 days. The cure rate was 89% of the 266 children evaluable for clinical efficacy and 90.3% of the 50 bacteriologically identified cases. The overall bacteriological efficacy was 82%. The antibiotic was well accepted by the 90% of the 304 children, while in 6.9% an adverse effect was reported, mainly vomiting. There were no toxic effects. Roxithromycin should be considered as an effective and safe oral antibiotic to treat children with upper and lower respiratory tract and skin infections due to common pathogens.

Materno-fetal transfer of azlocillin

We studied 20 patients to assess transfer of azlocillin to the fetus at parturition. The elimination half-life of approximately 1.3 h in these mothers was similar to that reported for normal subjects. Azlocillin quickly reached umbilical cord blood, amniotic fluid, the placenta and the urine of the neonate, achieving substantial concentrations. Azlocillin then disappeared from umbilical cord blood with an elimination half-life of 2.3 h, i.e., similar to that of the mother. At 6 h, concentrations of azlocillin were still increasing in amniotic fluid and placenta. In addition, in two stillborn infants, azlocillin was found to reach substantial concentrations in all tissues analysed except brain. Concentrations of azlocillin achieved in fetal tissues are sufficient to have important therapeutic effects.

Ceftriaxone distribution between maternal blood and fetal blood and tissues at parturition and between blood and milk postpartum

The penetration of ceftriaxone into the fetus at parturition was studied in 17 subjects. Despite its high protein binding, ceftriaxone quickly reached the umbilical cord blood, amniotic fluid, and placenta, achieving substantial concentrations, which then disappeared, with elimination half-lives of approximately 6 h, identical to that of the mother. The elimination half-life of ceftriaxone of 5 to 6 h in these mothers was somewhat shorter than that reported for normal subjects. The concentrations of ceftriaxone achieved in fetal tissues were sufficient for therapeutic effects. The penetration of ceftriaxone into milk was studied 3 days postpartum in 20 other patients. This antimicrobial agent entered breast milk rapidly and disappeared with a half-life of 12 to 17 h. The concentrations achieved were only 3 to 4% of those in maternal serum and were most likely of little clinical relevance.

Treatment of severe neonatal infections with cefotaxime. Efficacy and pharmacokinetics

We studied the pharmacokinetics and efficacy of cefotaxime in 32 neonates with severe gram-negative infections. Many of these patients had been treated unsuccessfully with combinations of antibiotics. Eighty-one percent of these patients were cured, 6% improved, and 13% had treatment failures; there were three deaths. Eighteen patients received cefotaxime alone; 16 were cured and two improved. These data indicate an efficacy of cefotaxime sufficient to warrant more rigorous future trials. The elimination half-life of cefotaxime ranged from 2.0 +/- 0.4 hours in term neonates more than one week of age to 5.7 +/- 0.8 hours in preterm neonates less than one week of age. A volume of distribution of approximately 0.63 L was similar for all infants irrespective of age and maturity. These kinetic data can be used in design of future therapeutic regimens in more rigidly controlled trials assessing indications for cefotaxime therapy in neonates. We recommend dosing as follows, using a dose of 25 mg/kg: every 12 hours for preterm infants less than one week of age, every 8 hours for preterm infants one to four and term infants less than one week of age, and every 6 hours for term infants more than one week of age.

Clinical pharmacology of cefotaxime in pediatric patients

Cefotaxime is a new cephalosporin with a spectrum of activity which may make it appropriate for use in pediatric patients. In 33 infants and children, administration of cefotaxime resulted in cure or improvement in 97% of patients, with eradication of 94% of isolated pathogens. Toxicity was minimal. The disposition of cefotaxime in this age group was similar to that reported for adults, with an elimination half-life of approximately 1.5 h, a volume of distribution of 1 liter/kg, a total serum clearance of 10 ml/min per kg, and a renal clearance of 6 ml/min per kg.