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

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

Objective. To determine the clinical outcome of children with chronic recurrent multifocal osteomyelitis (CRMO). Methods. We retrospectively reviewed clinical, biological and radiological data of children with CRMO at five French paediatric centres. Outcome data were obtained through review of hospital charts and questionnaires sent to all patients to assess disease activity and educational and vocational achievement. Results. Forty patients were assessed (34 females and 6 males) with a median age at diagnosis of 11.5 yrs (range 2–17). Median number of initial bony lesions was 2 at onset, and 3.5 over disease course. Median time since diagnosis was 3.5 yrs (range 0.5–15) and median duration of active disease 2.7 yrs (range 0.5–13.5). Nine (22.5%) patients had psychological or physical sequelae. Twenty-nine children (72.5%) responded to the questionnaire. Twenty-six had no physical disability as judged by the HAQ 0–1, two had moderate disability (HAQ: 1–2) and one had severe disability (HAQ: 2–3). Seventeen patients (58.6%) had active disease at follow-up (after 6 months to 15 yrs since diagnosis) and continued to have pain (median value of visual analogue scale: 10/100). CRMO had interfered with patient’s education in two cases. Conclusions. Clinical outcome of children with CRMO is generally good, but a sizeable proportion of patients have active disease at followup, and a minority of patients can have a severe and prolonged disease course despite intensive treatments. Further studies are required to determine predictive factors for severe disease.

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

The aim of this study was to determine the etiologic agents associated with community-acquired pneumonia in 104 French children ages 18 months to 13 years. Potential respiratory pathogens were identified in 87 (85%) cases; these included respiratory syncytial virus in ten, other viruses in 20,Streptococcus pneumoniae in 14, andMycoplasma pneumoniae (diagnosed by serologic procedures) in 43. Of 32 patients withMycoplasma pneumoniae infection who were initially treated with beta-lactam antibiotics, 30 failed treatment. Recovery from mycoplasma infection occurred rapidly in patients treated with macrolide antibiotics (which included spiramycin in 31 patients, josamycin in 7, and erythromycin in 3); however, cough persisted in 12 patients for one month. The high frequency ofMycoplasma pneumoniae infection in community-acquired pneumonia in children over 18 months of age must be considered when selecting an antibiotic for initial therapy.

Escherichia coli is both a gastrointestinal tract commensal and a major pathogen. In recent years, E. coli is under fire from the news due to a better understanding of pathogenic factors, outbreaks of infections caused by enterohaemorrhagic strains, and last but not least, the worrying development of antibiotic resistance. Due to the absence of new compounds active against these strains, producing extended-spectrum ß-lactamases (ESBL) and frequently multiresistant to other antibiotics, their emergence will pose therapeutic problems for practitioners of all pediatric specialties. The gold standard treatment for severe infections due to ESBL-E. coli family is the penem class. The frequent use of penems promotes the emergence of strains resistant to carbapenems. Sparing carbapenems should be a clear objective for non life-threatening infections.

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

Background Recent data about hepatitis A virus (HAV) seroprevalence in industrialized countries and the impact of travels to endemic areas are sparse or absent, particularly for children. Objective To determine the impact of travel to endemic areas on HAV seroprevalence and estimate the overall HAV seroprevalence in children in France. To identify risk factors for positive HAV serologic results. Study design This prospective multicentre cross-sectional seroprevalence study took place in eight paediatric emergency units throughout France. Children 1–16 years of age following all inclusion and exclusion criteria were included. Demographic, socioeconomic, and travel data were prospectively collected with a standardized questionnaire before measurement of specific HAV antibodies. HAV seroprevalence was determined and its association with diverse variables assessed by univariate and multivariate analyses. Results 430 children were included, of whom 116 had travelled to endemic areas. The HAV seroprevalence in the overall population was 5% (95%CI, 3–7) and was higher among the travellers (12% [95%CI, 6–18]) than among the others (2% [95%CI, 0–3]), OR = 7.0 [95%CI, 2.6–18.8]. Risk factors identified for positive serologic results for HAV were travel to an endemic area >7 days (adjusted OR [aOR] = 4.3 [95%CI, 1.5–12]), age of 14–16 years (aOR = 7.7 [95%CI, 1.6–38.3]) and mother's birth in an endemic area (aOR = 5.2 [95%CI, 1.8–14.8]). Conclusion Statistical evidence showed that travel to endemic areas and parents’ place of birth both play a role in HAV serologic results in children with a significant difference of HAV seroprevalence between traveller and non-traveller children in France.

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

International audience; 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.

The hepatitis A-seropositivity rate for children born in France is very low: 0 of 81 born to two French-born parents and 5 of 126 (4 %) infants for whom at least one parent was born in an endemic area. In contrast, the rate was high (28.8 %, 17/59) for children born in an endemic area. Hence, recommendations to vaccinate children who could be exposed during overseas trips to visit family or by visiting family members coming from endemic areas are fully justified.

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

During the months of October and November 2006-2008, norovirus was detected in the stools of 14 children hospitalized with acute diarrhea (no sapovirus). Nine of these noroviruses belonged to a unique GGII4 strain, which produced severe clinical symptoms, present only in 2007 and 2008 and absent in 2006. This strain, identified in Europe mainly in the elderly, seems to be on the rise in children in the Paris area over the past few years.

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

Invasive pneumococcal diseases were reduced after introduction of pneumococcal conjugate vaccine, but infections due to non-vaccine serotypes persisted. The pneumococcal origin of community-acquired pneumonia remains difficult to affirm, but high procalcitonin and C-reactive protein blood levels and duration of fever 48 h or less after initial antibiotic treatment are excellent predictors of pneumococci. Among 259 patients under 7 years of age hospitalized from 2003 to 2008 for community-acquired pneumonia, 47 met these criteria, including 27 of 141 hospitalized between 2006 (date of vaccine generalization) and 2008. Of these 27, 21 had previously received pneumococcal conjugate vaccine and 19 of 21 were attendees of nursery school or day care centers versus only 2 in 2003-2006. These data show that pneumococcal pneumonias are possible in immunized children cared for in-group settings.

Consequence of the introduction of vaccines against bacteria involved in meningitis in children and various recommendations concerning antibiotics, the epidemiology of bacterial meningitis has changed during the last fifteen years. The GPIP/ACTIV (Groupe de Pathologie Infectieuse Pédiatrique and Association Clinique et Thérapeutique Infantile du Val de Marne) set up an active surveillance network to analyze the clinical and biological features of bacterial meningitis.From 2001 to 2007, 252 French pediatric wards working with 168 microbiology laboratories enrolled all children (0-18 years old) with bacterial meningitis. Risk factors, vaccination status, signs and symptoms, cerebrospinal fluid analysis, treatments and case fatality rate were recorded.2951 cases of bacterial menigitis were recorded by 237 pediatric wards. Geographical distribution covered a large part of the national territory. Overall, the annual number of cases varied from 452 (in 2001 and 2003) to 378 (in 2004). Meningococcal and pneumococcal meningitis respectively represented about the half (46 %) and the third (28 %) of cases. Few cases of Haemophilus influenzae meningitis were reported (3 %). For the neonatal period, group B Streptococcus and E. coli were the most frequently identified pathogens. In children less than one year old, pneumococcus was the first one, and after 1 year, meningococcus was predominant. The mortality rate varied according to bacteria, 6.6 % for the meningococcus, 11.6 % for pneumococcus, 14.1 % for group B streptococcus and 16.7 % for Listeria meningitis. It varied also with age, 14.9 % among infants 1 to 2 months old and 6.3 % in children over 5 years.Closed to 3000 meningitis were recorded during seven years in children, which underlines the interest of the survey. This network is principally supported by the goodwill and availability of pediatricians and microbiologists who participate in the study. This special supplement issue of Archive de Pédiatrie allows a complete presentation of our results. In next following years, any amendment to the immunization schedule, any perspective of implementation of new vaccines will transform the epidemiology and clinical caracteristics of bacterial menigitis. Therefore, continued surveillance appears necessary.

The need to limit unnecessary antibiotic treatments and recent studies with unusual antibiotics in pediatrics (fluoroquinolones) or in digestive tract infections (azithromycin) have led to update the treatment of acute gastro-enteritis. In 2007, the European Society for Pediatric Infectious Diseases and the European Society for Gastroenterology Hepatology and Nutrition have issued guidelines. The proven shigellosis as well as the strong suspicion have to be treated promptly with antibiotics, mainly azithromycin. There is no argument to treat moderate salmonella gastroenteritis or carriage. However, the severe cases and those occurring in high risk patient must be treated (ciprofloxacin or ceftriaxone). It is recommended to treat diarrhoea due to Campylobacter jejuni in case of early diagnosis. The presumptive antibiotic treatment should be limited but can not be dismissed, in invasive cases gastro-enteritis, especially in traveller children.

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

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

To refine and to re-validate the best current tool (the Nigrovic rule: ''outpatient management may be considered for children without seizure, blood neutrophil countor=10,000/mm(3), positive cerebrospinal fluid -CSF- Gram-staining, CSF proteinor=80 mg/dl, or CSF neutrophil countor=1,000/mm(3)'') proposed to distinguish between aseptic meningitis (AM) and bacterial meningitis (BM) in the emergency department.Children hospitalized for BM between 1995 and 2004, or AM between 2000 and 2004 were included, and randomly divided into derivation (111 children, 14 BM) and internal validation (57 children, 7 BM) sets. The Nigrovic rule was refined on the derivation set, introducing new variables (purpura, toxic appearance and high serum procalcitonin), changing variables thresholds (CSF protein) and withdrawing some variables (blood neutrophil count, CSF neutrophil count), according to previous results, with the aim to obtain 100% sensitivity user friendly tool. The refined rule was then applied on the internal validation set, stayed blinded during the derivation process.The refined rule was: start antibiotics in case of seizure, purpura, toxic appearance, procalcitoninor=0.5 ng/ml, positive CSF Gram-staining, or CSF proteinor=50 mg/dl. The refined rule had 100% sensitivity on the derivation and the internal validation sets (95% confidence interval 78-100, and 65-100, respectively) with 62 and 51% specificity, respectively.The refined rule (called Meningitest) was a highly sensitive, specific and user friendly tool that could allow to safely avoid50% a posteriori unuseful antibiotic treatments for patients with AM.

The heterogeneity of clinical presentations of children in contact with a tuberculous adult do not allow simple guidelines for treatment and exams. Indications of thoracic computed tomography (CT) in young children and the risk of a follow-up without antituberculous treatment are always discussed.Sixty-nine children, belonging to 50 families, living in close contact with an adult treated for tuberculosis were explored during 7 years in a General Pediatric Unit. A CT was performed in 51 patients.Mantoux test was negative in 3/17 children with typical tuberculous disease on X-ray. When results of CT were compared with those of standard thoracic X-ray, a difference for the diagnosis of mediastinal adenopathies was found only in children younger than 5 years. Fifty-eight patients were given usual treatment of latent or patent tuberculosis if indicated, or a chemoprophylaxis. All of them had normal clinical and X-ray exam 2 to 4 years later. Eleven children, initially checked in an other unit, were given no treatment, but a follow-up was set up. However, after 6 to 24 months, 4/11 had a patent tuberculosis and 5/11 a latent tuberculosis, 6/9 being aged more than 3 years.This study shows that risk of tuberculosis after familial contamination is high, and that the choice of absence of treatment with following re-evaluation, is sometimes questionable because families or doctors do not perform the prescribed follow-up. To perform systematically a thoracic CT, searching for mediastinal adenopathies, is useful only before the age of 5 years.

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.

A serological test for the diagnosis of Helicobacter pylori infection (Cobas Core Roche, IgG, 2nd Generation; Roche, France) was compared with the examination of biopsy samples (culture and histology) obtained after endoscopy in 115 children to assess its value. In 94 children (42 positive and 52 negative), results were concordant. In 10 children a positive serological test was associated with an absence of Helicobacter pylori, while in 11 others a negative serological test was associated with a positive culture. Sensitivity of the test was 79.2% and specificity 83.9%. A relationship between IgG titers and age (r = 0.31, p0.05) was found. Serological tests could be useful for the diagnosis of Helicobacter pylori infection, but a negative test result does not rule out infection, particularly in children under 10 years of age.

OBJECTIVE: To establish whether changes of lung transfer for carbon monoxide (TLCO) are related to the phase of IgA nephropathy. METHODS: Respiratory function was tested in 12 children with IgA nephropathy assessed by percutaneous renal biopsy. This was done during acute exacerbations or haematuria-free phases of the disease. RESULTS: TLCO was low in 12/13 measurements made in the haematuric phase of IgA nephropathy or during the month following gross haematuria (mean TLCO 64% of expected values). Lung volumes and blood gas values were normal and only minor radiological signs of interstial lung involvement were observed in 11/12 patients. When respiratory tests were performed more than three months after gross haematuria, TLCO was low in 4/9 patients, with no relation to the significance of residual proteinuria or severity of findings at renal biopsy. There was a significant difference between tests performed when haematuria was present or recent and those performed more than three months after an episode of gross haematuria (p < 0.01). CONCLUSIONS: The decrease of TLCO in the acute phases of the disease is probably related to alterations of the lung alveolarcapillary membrane by immune complexes containing IgA. This non-invasive technique, easy to perform and repeat, could be of value in the diagnosis of IgA nephropathy in haematuric children.

In France, immunization against hepatitis A is recommended for children attending health-care institutions, presenting chronic liver disease, and traveling to endemic areas. This recommendation is based on the fact that, while more than 80% of cases of hepatitis A occurring in children less than 5 years of age are asymptomatic, infected children without jaundice can shed the virus and serve as a source of infection for others. Immunization of children traveling to endemic areas protects the whole family from secondary infection that often leads to severe manifestations. Because the cost of the vaccine is not covered by health insurance, African families living in France must have children vaccinated in advance before travel to Africa. Vaccination early in childhood is possible since the protective effect is durable and perhaps definitive. The dramatic decrease of incidence in France has eliminated the need for routine vaccination except in children traveling to international destinations. The main problem is prophylaxis around index cases in situations involving single family units, small closed communities and localized outbreaks. Immediate vaccination within 7 days after exposure to the index case should be considered since the immunoglobulins are not available in France. Limited trials in families and closed communities show that this vaccination approach is effective and well tolerated even by young children attending nurseries. However this indication is currently not recognized in France even though it has often been applied and has been recommended by the British advisory board. It is the responsibility of pediatricians to inform parents of this risk and propose individual prophylaxis for the family.

IFN-alpha detection is useful in some clinical circumstances, but its use has never been validated in young infants with viral infections.The authors wanted to determine it there was any difference in the assessment of IFN-alpha production between infants under or over six months of age.A series of 233 children with identified common viral infections who had been assessed for IFN-alpha production was retrospectively analyzed. The viral infections were enteroviral meningitis (n =103), respiratory syncytial virus infections (n =60), and rotavirus gastroenteritis (n =70). Data collected from the group of infants under six months of age (n =105) was compared to that of the older children (n =128). Qualitative and quantitative values of interferon-alpha were determined for each group.Interferon-alpha was detected in very young infants (81.9% of cases) as often as in the older age group (80.3% of cases), for any of the three viral infections (P =0.3-0.63). The mean level of interferon-alpha production detected was not lower in the youngest group, and even higher in the group under six months of age with enteroviral meningitis.Interferon-alpha detection in very young infants is efficient and may be useful to differentiate between viral and bacterial infection particularly when the etiological diagnosis appears uncertain.

Hepatitis A is usually considered as a mild disease and is asymptomatic in more than 80% of children less than 5 years of age. Furthermore, incidence of the disease decreased dramatically in France during the past decades. For these reasons mass routine vaccination is not required in our country. However, infected children shed the virus in the community and are responsible for secondary cases, sometimes severe. That is why, despite the cost and the absence of reimbursement of the vaccine, immunisation against hepatitis A is recommended in children attending health-care institutions, in children with chronic liver disease and in those travelling in endemic areas. Prophylaxis around an index case is the main problem because non-specific immunoglobulins, although recommended, are not available in France for this indication. Vaccination in the few days following exposition has been reported to be efficient in household contacts and small communities, including nurseries. This strategy is recommended by the British Advisory Board within the 7 days following exposition, but not in France. However, it can be proposed to the family by paediatricians.

Almost all children living in endemic zones are infected by gastrointestinal parasites. However only 3 to 5% develop diarrhea directly related to parasite infection. Entamoeba hystolytica and Entamoeba dispar coexist in many areas. In the past Entamoeba dispar was called non-pathogenic ameba. The vegetating forms are microscopically identical and detection of wall differences using biochemical tests is unreliable. Thus since it is rarely possible to determine whether or not a vegetating ameba found in stools is hematophagous treatment using metronidazole is the only alternative. Failure of such treatment indicates that dysentery is probably due to a cause other than amibiasis, e.g., bacterial infection in most cases. Another protozoan commonly found in endemic areas is Giardia. Giardia can cause diarrhea and this is frequently the case in undernourished children. Giardia infection leads to severe atrophic villosity requiring appropriate specific treatment. In children cryptosporidioses may be asymptomatic or lead to diarrhea especially in cases associated with malnutrition or immunodeficiency related in particular to AIDS. Helminths are a rare cause of significant diarrhea except Anguillula in undernourished children. In children presenting severe malnutrition, anguilluliasis can lead to serious consequences and requires immediate treatment using ivermectin. To avoid severe diarrhea in children presenting immunodeficiency induced by corticotherapy or chemotherapy for cancer, prophylaxis is mandatory against anguilluliasis using ivermectin and usually against giardiasis using metronidazole.

Children without chronic or serious medical conditions are at increased risk for hospitalization during influenza seasons, mainly with respiratory tract infections. But influenza virus infections frequently remain undiagnosed, even in hospitalized patients. We prospectively studied the rate of concomitant and preceding influenza infections in children hospitalized with a community acquired pneumonia (CAP).All 1-15-year-old children with CAP requiring hospitalization between 1st April 2000 and 2002 had nasopharyngeal aspirate for viruses, immunofluorescence and serologies for respiratory pathogens. The peak of influenza IgG measured by complement fixation (CF) is transient, and a titer of 1/64 or more indicates an acute influenza infection in the preceding weeks. Children with chronic disease were excluded and a control group of patients from outpatient clinic was measured.Among 33 previously healthy children (age 4.9 years, range 1.2-14 years), 8 had a pneumococcal pneumonia, 10 a pneumonia caused by Mycoplasma pneumoniae (MP), 1 by Chlamydia pneumonia, and 8 of unknown origin. In six patients immunofluorescence was positive: Respiratory Syncitial Virus, 2, Adenovirus, 1 and Influenza A, 3 (including a patient with concomitant MP infection). Thirteen of the 33 children (39.4%) had evidence of a recent influenza A infection with CF abor = 1/64: with pneumococcal pneumonia, 5/10 with MP pneumonia, 3/8 with unknown origin pneumonia, 9/13 of these previous influenza infections being clinically inapparent. Only 1/30 children of control group (3.3%) had CF abor = 1/64.In this study, influenza infection is the direct cause of CAP of children in 12% of cases. In other children with CAP, 39.4% of patients had an influenza infection in the preceding weeks which leads to secondary infection caused by Streptococcus pneumoniae or by MP or other pathogens.

Children with enteric fever or severe salmonella infections are usually treated with beta-lactam antibiotics, particularly ceftriaxone. Due to their poor penetration into cells, beta-lactam antibiotics, even if active in vitro, are sometimes clinically ineffective because they cannot reach the intracellular sites of Salmonella multiplication.To evaluate in a retrospective study usefulness, efficacy and safety of oral ciprofloxacin in patients with severe salmonellosis and clinical failure of ceftriaxone or beta-lactam antibiotics.From July 1, 1995 to 2000, the bacteriology laboratory of a French pediatric hospital had identified 215 patients aged between 1 month and 15 years with positive blood or stools for Salmonella sp, 113 of them requiring hospitalization due to their clinical symptoms. Three were excluded for sickle-cell disease or poor nutritional status. None of the 110 strains (including 4 S. typhi, 51 S. typhimurium, 25 S. enteritidis, 6 S. hadar and 5 S. heidelberg) isolated was resistant to ceftriaxone or ciprofloxacin. Forty-one of the 110 strains (37.3%) produced a beta-lactamase. Twelve patients had a rapid recovery without antibiotic treatment, and 98 (mean age 3.9 years) were given antibiotics (ceftriaxone in 91 and amoxicillin in 7) for dysentery (43%), shock (15%) or persistent high fever and severe diarrhea (42%).In 72 children (mean age = 3.6 years) ceftriaxone treatment (amoxicillin in 5) for 5 or 7 days was rapidly effective: apyrexia was obtained in 1.5 day after the start of treatment and the number of stools per day was 4 or less in 2.2 days. Two to 3 weeks after clinical recovery, asymptomatic carriage was present in 22/38 patients. In the 26 other patients ceftriaxone (amoxicillin in 2) treatment was clinically ineffective, despite good in vitro activity, and was switch for oral ciprofloxacin (20 mg kg(-1) d(-1), 5 days) after 2 to 7 days of lasted fever and/or severe diarrhea. Clinical improvement with ciprofloxacin was obtained in less than 48 h. The strains involved in these 26 patients included the 4 S. typhi and 15 S. typhimurium (P0.05), 13/15 (P0.01) producing beta-lactamase. Asymptomatic carriage was found in 5/22 patients (P0.05) after recovery. None of the patient treated with ciprofloxacin had side effect.In severe salmonellosis, the clinical failure of treatment with ceftriaxone is not rare, particularly in S. typhimurium producing beta-lactamase infection and short treatment with oral ciprofloxacin is safe and allows to obtain a rapid recovery.

We studied thrombocytopenia during acute Plasmodium falciparum malaria in 64 traveller children from Paris (France), 85 children from Dakar (Senegal) with an intermittent exposure (69 with severe attack or cerebral malaria), and 81 children from Libreville (Gabon) with a perennial exposure (43 with severe attack or cerebral malaria). Initial thrombocytopenia was present in 43-58% of children with P falciparum malaria but was not more frequent in severe outcome or cerebral malaria. Low parasitaemia may lead to the misdiagnosis of malaria and delayed treatment when there is associated thrombocytopenia

Severe forms of Plasmodium falciparum malaria are one of the world's leading causes of infection-related death in children. The World Health Organization (WHO) has defined a set of severity criteria to improve diagnosis and speed antimalarial treatment. Although the pertinence of these criteria has not been documented in France, child travelers presenting such features require hospitalization in intensive care. The gold standard therapy is intravenous administration of quinine. According WHO recommendations, quinine therapy should begin with a loading dose barring contraindications. However French recommendations do not include the loading dose due to potentially dangerous side-effects in young children and lack of proven life-saving effect. Artemisinin derivatives have been shown to be as effective as quinine and are increasingly used in endemic zones due to good tolerance and convenience of use. However due to concerns about neurotoxicity, artemisinin derivatives are rarely used in France, except in patients with contraindications or resistance to quinine. Management of specific complications is also necessary to reduce the high mortality of severe malaria, even in Western countries, and to prevent neurological damage.

The only currently recommended pediatric use of fluoroquinolones involves ciprofloxacine for treatment of pyocyanic infection in children with cystic fibrosis. The main contraindication for use of fluoroquinolones in children is arthrotoxicity. Notwithstanding they are occasionally used for serious infections when there is no other therapeutic alternative. In addition to cystic fibrosis, potential pediatric indications include multidrug-resistant salmonella and shigellosis, certain enterobacterial infections in newborns, complicated urinary tract infections, and severe multidrug-resistant bacterial infection especially in immunocompromised subjects. The availability of new quinolones against pneumococcus should have little impact on current therapeutic strategies for upper or lower respiratory tract infections since potential indications in children are limited. However when the new generation reaches the market, fluoroquinolones should offer new alternatives for treatment of penicillin-resistant pneumococcal meningitis. Studies comparing children and adults have shown that arthrotoxicity is approximately the same or only slightly higher. The main problem for assessment of adverse effects is that pediatricians often fail to report the limited number of cases in which fluoroquinoles have been prescribed. Regardless fluoroquinolones must remain a second or third line agent for treatment of severe infection in cases in which no other alternative especially by the oral route is available. Use must be restricted to situations in which the risks are outweighed by potential benefits. Limiting pediatric use will slow down the emergence of resistant bacteria.

To identify pathogenic microorganisms responsible for hospital-acquired bloodstream infections and to evaluate the associated risk factors in pediatric units, in a case-control study over 30 months from January 1st 1997 to June 30th 1999.Forty-six of 855 (5.4%) positive blood cultures were attributed to nosocomial infections. They were related to 32 infectious episodes in 28 patients hospitalized for more than 48 hours. The incidence rate was 0.11 per 100 admissions. Gram-positive cocci (n = 14; 38.8%) were the most frequently isolated pathogens (7 cases of Staphylococcus aureus, 5 of coagulase-negative staphylococci), followed by enterobacteria (n = 9; 25%), Pseudomonas aeruginosa (n = 5; 13.8%) and yeasts (n = 5; 13.8%). The major risk factors for hospital-acquired bloodstream infections were: length of stay before positive blood culture (32 +/- 51 days in cases vs 15 +/- 43 days in controls, p0.01), presence of central venous catheter [odds ratio (OR): 6.05, 95% confidence interval (CI): 1.87-20.42], number of days with central venous catheter (p0.001) and parenteral nutrition (OR: 9.44, 95% CI: 2.03-50.05).Central venous catheter use, length of stay, parenteral nutrition and particularly intravenous lipids are major risk factors for the acquisition of bloodstream infection in hospitalized children.

Viral meningitis are often treated with antibiotics in emergency because routine analysis of CSF is not always efficient for distinguishing between viral and bacterial infection. The aim of the study was to evaluate the usefulness of procalcitonin (PCT) to reduce antibiotic treatments.A blood PCT level0.5 ng/mL was prospectively used for the diagnosis of viral origin of meningitis in 58 patients (two months-14 years), in which enterovirus was isolated by culture or PCR during an outbreak (May-June 2000). CSF cells range was 10 to 2800/mL (m: 244), PMN 5 to 2464/mL and CSF proteins range was 0.19 to 0.92 mg/dL (m: 0.37). Seventeen patients received antibiotic therapy in admission. In nine patients, PCT (dosage was routinely measured 3/week) result0.5 ng/mL was obtained in 24 h and in 48 h in six: treatment was then stopped and children led hospital. In two patients, PCT was1 ng/mL because of bacterial coinfection. CSF and PCT values were similar to those of an already published control group.PCT dosage allowed to shorten hospitalization of 4.47 (controls) to 2.06 (patients) days in patients receiving unnecessary antibiotic treatments. During this outbreak, PCT dosage allowed to reduce 40 days of hospitalization.