French national diagnostic and care protocol for Kawasaki disease

Kawasaki disease (KD) is an acute vasculitis with a particular tropism for the coronary arteries. KD mainly affects male children between 6 months and 5 years of age. The diagnosis is clinical, based on the international American Heart Association criteria. It should be systematically considered in children with a fever, either of 5 days or more, or of 3 days if all other criteria are present. It is important to note that most children present with marked irritability and may have digestive signs. Although the biological inflammatory response is not specific, it is of great value for the diagnosis. Because of the difficulty of recognising incomplete or atypical forms of KD, and the need for urgent treatment, the child should be referred to a paediatric hospital as soon as the diagnosis is suspected. In the event of signs of heart failure (pallor, tachycardia, polypnea, sweating, hepatomegaly, unstable blood pressure), medical transfer to an intensive care unit (ICU) is essential. The standard treatment is an infusion of IVIG combined with aspirin (before 10 days of fever, and for a minimum of 6 weeks), which reduces the risk of coronary aneurysms. In case of coronary involvement, antiplatelet therapy can be maintained for life. In case of a giant aneurysm, anticoagulant treatment is added to the antiplatelet agent. The prognosis of KD is generally good and most children recover without sequelae. The prognosis in children with initial coronary involvement depends on the progression of the cardiac anomalies, which are monitored during careful specialised cardiological follow-up.

Antibiotic treatment of lower respiratory tract infections

Lower respiratory tract infections, i.e., bronchitis, bronchiolitis, and pneumonia, are the second leading cause of antibiotic prescriptions. The vast majority of these infections are due to viruses and are self-limited diseases: most patients recover spontaneously. These two facts explain that antibiotic prescriptions must be limited to some clinical situations for which the diagnosis has to be done early. The first message of this manuscript is to strengthen non-antibiotic prescriptions in many situations such as bronchitis and bronchiolitis. Implementation of pneumococcal conjugate vaccines (PCVs) has reduced the incidence of pneumonia and empyema, and induced a dramatic decrease in the proportion of pneumococcus in these diseases. However, pneumococcus remains probably the leading cause of bacterial pneumonia and empyema and the main target of antibiotic treatment. Furthermore, the implementation of PCVs has reduced resistance to antibiotics including penicillins and macrolides antibiotics, explaining the de-escalation proposed in the last few years, with the reduction of the use if third generation cephalosporins and vancomycin. The therapeutic choices proposed in this article follow the previous official guidelines in France. Serious infections represented by empyema and severe pneumonia remain therapeutic emergencies, most often warranting hospitalization and IV antibiotics.

[The emergency department: an appropriate place for identifying troubled teens]

OBJECTIVES

The main objective of this study was to estimate the prevalence of psychological distress among adolescents seen in emergency departments, and the secondary objective was to highlight their main reasons for consulting.

METHODS

Cross-sectional study in three multicenter emergency departments receiving adolescents in Île-de-France conducted in 2010. All adolescents completed a questionnaire including the ADRS (Adolescent Depression Rating Scale, a screening questionnaire for depression) and a series of questions relating to somatization and risk behaviors.

RESULTS

The study included 346 adolescents, 320 of which were fully analyzed. The ADRS score was considered normal (score < 3) for 70.6% of the sample (n = 226), 19.4% of adolescents (n = 62) had moderate depressive symptoms (3 ≤ score < 6), and 10.0% severe depressive symptoms (score ≥ 6) (n = 32). The majority of patients consulted for trauma and less than 10% for acute psychiatric problems; 17% of adolescents who came to the emergency department for a nonpsychiatric reason had an ADRS ≥ 3, i.e., with mental distress.

CONCLUSION

The routine use of a self-administered questionnaire in the emergency services could identify adolescents with moderate to severe depressive symptoms.

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

[Mycoplasma pneumoniae, community-acquired pneumonia and asthma]

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