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This cohort study examines the frequency, timing, risk factors, and outcomes associated with oxygen desaturation in infants with acute bronchiolitis and initially normal oxygen saturation., Key Points Question What are the frequency, timing, risk factors, and outcomes associated with oxygen desaturation in infants with acute bronchiolitis and initially normal oxygen saturation? Findings In this cohort study of 239 infants, desaturation occurred in most infants, regardless of whether they were hospitalized or discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation, but desaturation was not a risk factor associated with rehospitalization. Meaning These findings suggest that desaturation in acute bronchiolitis was frequent, especially for infants with a more severe clinical presentation, but it was not a risk factor associated with rehospitalization., Importance Little is known about the natural course of oxygen desaturation in acute bronchiolitis. Information on risk factors associated with desaturation as well as the time to desaturation in infants with bronchiolitis could help physicians better treat these infants before deciding whether to hospitalize them. Objective To prospectively determine the frequency of desaturation in infants with bronchiolitis, along with the time to desaturation and risk factors associated with desaturation, and to compare infants who were hospitalized with those discharged home and evaluate risk factors for rehospitalization. Design, Setting, and Participants This cohort study was conducted during the 2017 to 2018 and 2018 to 2019 respiratory syncytial virus seasons in a tertiary care pediatric emergency department in Switzerland. Included individuals were 239 otherwise-healthy infants aged younger than 1 year, diagnosed with acute bronchiolitis and oxygen saturation of 90% or more on arrival. Data were analyzed from July 2019 to October 2020. Exposures After receiving triage care, study participants admitted to the emergency department were equipped with a pulse oximeter to continuously record oxygen saturation (Spo2 levels), regardless of subsequent hospitalization or discharge home. Main Outcomes and Measures The primary outcome was desaturation (ie, Spo2 .99). Conclusions and Relevance These findings suggest that rates of desaturation in infants with acute bronchiolitis were high and similar between infants who were hospitalized and those discharged home. A more severe initial clinical presentation was the only risk factor associated with desaturation. However, for infants discharged home, desaturation was not a risk factor associated with rehospitalization.

Introduction: While fever is the main complaint among pediatric emergency services and high antibiotic prescription are observed, only a few studies have been published addressing this subject. Therefore this systematic review aims to summarize antibiotic prescriptions in febrile children at the ED and assess its determinants. Methods: We extracted studies published from 2000 to 2017 on antibiotic use in febrile children at the ED from different databases. Author, year, and country of publishing, study design, inclusion criteria, primary outcome, age, and number of children included in the study was extracted. To compare the risk-of-bias all articles were assessed using the MINORS criteria. For the final quality assessment we additionally used the sample size and the primary outcome. Results: We included 26 studies reporting on antibiotic prescription and 28 intervention studies on the effect on antibiotic prescription. In all 54 studies antibiotic prescriptions in the ED varied from 15 to 90.5%, pending on study populations and diagnosis. Respiratory tract infections were mostly studied. Pediatric emergency physicians prescribed significantly less antibiotics then general emergency physicians. Most frequent reported interventions to reduce antibiotics are delayed antibiotic prescription in acute otitis media, viral testing and guidelines. Conclusion: Evidence on antibiotic prescriptions in children with fever presenting to the ED remains inconclusive. Delayed antibiotic prescription in acute otitis media and guidelines for fever and respiratory infections can effectively reduce antibiotic prescription in the ED. The large heterogeneity of type of studies and included populations limits strict conclusions, such a gap in knowledge on the determining factors that influence antibiotic prescription in febrile children presenting to the ED remains.

BACKGROUND The identification of serious bacterial infection (SBI) in children with fever without source remains a challenge. A risk score called Lab-score, based on C-reactive protein, procalcitonin and urinary dipstick results was derived to predict SBI. However, all biomarkers were initially dichotomized, leading to weak statistical reliability and lack of transportability across diverse settings. We aimed to refine and validate this risk-score algorithm. METHODS The Lab-score was refined using a secondary analysis of a multicenter cohort study of children with fever without source via multilevel regression modeling. The external validation was conducted on data from a Canadian cohort study. RESULTS Eight hundred seventy-seven children (24% SBI) were included for the derivation study, and 347 (16% SBI) for validation. Only C-reactive protein, procalcitonin, age and urinary dipstick remained independently associated with SBI. The model achieved an area under the receiver operating characteristic (ROC) curve of 0.94 (95% confidence interval [CI]: 0.93-0.96), which was significantly higher than any other isolated biomarker (P < 0.0001), and the original Lab-score (P < 0.0001). According to a decision curve analysis, the model yielded a better strategy than those based on independently considered biomarkers, or on the original Lab-score. The threshold analysis led to a cutoff that yielded 96% (95% CI: 92-98) sensitivity and 73% (95% CI: 70-77) specificity. The external validation found similar predictive abilities: 0.96 area under the ROC curve (95% CI: 0.93-0.99), 95% sensitivity (95% CI: 85-99) and 87% specificity (95% CI: 83-91). CONCLUSION The refined Lab-score demonstrated higher prediction ability for SBI than the original Lab-score, with promising wider applicability across settings. These results require validation in additional populations.

BACKGROUND: Hospital discharge is a complex multidisciplinary process that can lead to non-compliance and drugs-related problems. Crucial issue for children is parental knowledge of discharge treatments, especially in the time-limited and stressful environment of an emergency department (ED). OBJECTIVE: To compare parental correct knowledge of treatment with and without supply of customised drug information leaflets for the 10 most commonly prescribed drugs. METHOD: Inclusion criteria: paediatric patients (0–16 years) with French-speaking parents discharged from ED of the paediatric department of Geneva University Hospitals before (phase A) and after (phase B) intervention. INTERVENTION: Supply and brief comment of drug information leaflets focusing on specific information not available in official drugs information documents. Follow-up Semi-structured phone interview within 72 h after discharge to evaluate the percentage of parents with correct knowledge of dose, frequency, duration and indication of drugs. Multivariate analysis to identify factors associated with correct knowledge (phases A/B, drugs collection at usual pharmacy, drugs categories). RESULTS: 125 patients were included (phase A: 56; phase B: 69). Drug information leaflets were given to 63/69 ED patients (91%), covering 96/138 prescribed drugs (70%). Parental knowledge was significantly improved in phase B (dose: 62.3% to 89.1%; frequency: 57.9% to 85.5%; duration: 34.2% to 66.7%; indication: 70.2% to 94.9%; p

Resume Contexte et objectif L’infection neonatale (INN) est un probleme de sante publique dans les pays en voie de developpement. Sa difficulte diagnostique a conduit a la recherche de marqueurs precoces, sensibles, avec une valeur predictive negative elevee, de meme qu’un dosage facile et un rendu rapide de resultats. L’objectif de la presente etude etait d’evaluer l’apport du dosage de la procalcitonine serique (PCT) dans le diagnostic et le suivi des INN d’origine bacterienne. Methodologie Il s’est agi une etude transversale menee au centre mere et enfant de la fondation Chantal-Biya a Yaounde, Cameroun. La population d’etude etait constituee de nouveau-nes a terme suspects d’INN. Deux dosages de PCT ont ete realises (a l’admission et 48 heures apres). Nous avons calcule les sensibilite, specificite, valeurs predictives positive et negative de cet examen. Resultats Quatre-vingt-dix-huit nouveau-nes ont ete inclus. Le diagnostic d’INN a ete retenu chez 25 d’entre eux qui avaient une PCT positive dans 92,3 % des cas. La sensibilite, la specificite, les valeurs predictives positive et negative ont ete respectivement de 96,0 %, 77,7 %, 85,3 % et 93,3 %. Six deces ont ete enregistres dont cinq chez des nouveau-nes ayant des valeurs de PCT ≥ 10 ng/mL (p Conclusion Le dosage de la PCT serique permettrait un tri rapide et fiable de nouveau-nes presentant une INN bacterienne. Son evolution pendant l’hospitalisation serait un indicateur de la reponse therapeutique tandis que son elevation importante constituerait un facteur de mauvais pronostic.

BACKGROUND Accurate diagnosis and appropriate treatment of group A streptococcal (GAS) pharyngitis are important to prevent complications. Most available rapid antigen detection tests (RADTs) have shown excellent specificity but often lack sensitivity. Our objective was to compare the diagnostic performances of a new fluorescence-based immunoassay and a classic immunochromatographic RADT using standard throat culture or polymerase chain reaction as references. METHODS Prospective observational study in 2 pediatric emergency departments in children 3-15 years of age presenting with pharyngitis and a McIsaac score ≥2. Three throat swabs were obtained simultaneously: one for culture and one for each of both RADTs. Polymerase chain reaction assay of the DNaseB sequence was performed in case of discordant results (culture negative and either RADTs positive). RESULTS A total of 1002 patients were analyzed, with an overall 37.1% prevalence of GAS pharyngitis. Sensitivity, specificity, positive and negative predictive values were, respectively, 84.9%*, 96.8%, 94.0% and 91.6% for the new fluorescence-based immunoassay, and 75.3%*, 98.1%, 95.9% and 87.0% for the immunochromatographic test (*P < 0.05). CONCLUSIONS The immunofluorescence-based assay demonstrated improved diagnostic performances over the standard immunochromatographic RADT. Similarly specific for GAS detection, it demonstrates significantly higher sensitivity in children with McIsaac scores 2 or more. A negative result rules out a risk of GAS pharyngitis in 91.6% of children, making it an appropriate tool in pediatric emergency settings. Combined to the low incidence of rheumatic strains, critical appraisal of current practice to routinely perform a backup throat culture from children with pharyngitis and with negative GAS RADT could be reconsidered.

Recommendations for the management of community-acquired pneumonia (CAP) advocate that, in the absence of the clinical and laboratory findings typical of bacterial CAP, antibiotics are not required. However, the true value of the clinical and laboratory predictors of pediatric CAP still needs to be assessed. This prospective cohort study in three emergency departments enrolled 142 children with radiological pneumonia. Pneumonia with lung consolidation was the primary endpoint; complicated pneumonia (bacteremia, empyema, or pleural effusion) was the secondary endpoint. We showed that three clinical signs (unilateral hypoventilation, grunting, and absence of wheezing), elevated procalcitonin (PCT), C-reactive protein (CRP), negative nasopharyngeal viral PCR, or positive blood pneumococcal PCR (P-PCR) were significantly associated with both pneumonia with consolidation and complicated pneumonia. Children with negative clinical signs and low CRP values had a low probability of having pneumonia with consolidation (13%) or complicated pneumonia (6%). Associating the three clinical signs, CRP >80��mg/L and a positive P-PCR ruled in the diagnosis of complicated pneumonia with a positive predictive value of 75%. CONCLUSION A model incorporating clinical signs and laboratory markers can effectively assess the risk of having pneumonia. Children with negative clinical signs and low CRP are at a low risk of having pneumonia. For children with positive clinical signs and high CRP, a positive blood pneumococcal PCR can more accurately confirm the diagnosis of pneumonia. What is Known: ��� Distinguishing between bacterial and viral pneumonia in children is challenging. ��� Reducing the inappropriate use of antibiotics is a priority. What is New: ��� Children with negative clinical signs and low C-reactive protein (CRP) values have a low probability of having pneumonia. ��� Children with high CRP values can be tested using a pneumococcal PCR to rule in the diagnosis of pneumonia with a high positive predictive value.

Background: The American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) are nowadays recognized as the world’s most authoritative resuscitation guidelines. Adherence to these guidelines optimizes the management of critically ill patients and increases their chances of survival after cardiac arrest. Despite their availability, suboptimal quality of CPR is still common. Currently, the median hospital survival rate after pediatric in-hospital cardiac arrest is 36%, whereas it falls below 10% for out-of-hospital cardiac arrest. Among emerging information technologies and devices able to support caregivers during resuscitation and increase adherence to AHA guidelines, augmented reality (AR) glasses have not yet been assessed. In order to assess their potential, we adapted AHA Pediatric Advanced Life Support (PALS) guidelines for AR glasses. Objective: The study aimed to determine whether adapting AHA guidelines for AR glasses increased adherence by reducing deviation and time to initiation of critical life-saving maneuvers during pediatric CPR when compared with the use of PALS pocket reference cards. Methods: We conducted a randomized controlled trial with two parallel groups of voluntary pediatric residents, comparing AR glasses to PALS pocket reference cards during a simulation-based pediatric cardiac arrest scenario—pulseless ventricular tachycardia (pVT). The primary outcome was the elapsed time in seconds in each allocation group, from onset of pVT to the first defibrillation attempt. Secondary outcomes were time elapsed to (1) initiation of chest compression, (2) subsequent defibrillation attempts, and (3) administration of drugs, as well as the time intervals between defibrillation attempts and drug doses, shock doses, and number of shocks. All these outcomes were assessed for deviation from AHA guidelines. Results: Twenty residents were randomized into 2 groups. Time to first defibrillation attempt (mean: 146 s) and adherence to AHA guidelines in terms of time to other critical resuscitation endpoints and drug dose delivery were not improved using AR glasses. However, errors and deviations were significantly reduced in terms of defibrillation doses when compared with the use of the PALS pocket reference cards. In a total of 40 defibrillation attempts, residents not wearing AR glasses used wrong doses in 65% (26/40) of cases, including 21 shock overdoses >100 J, for a cumulative defibrillation dose of 18.7 Joules per kg. These errors were reduced by 53% (21/40, P

A growing number of human infections incriminate environmental bacteria that have evolved virulent mechanisms to resist amoebae and use them as a replicative niche. These bacteria are designated amoeba-resisting bacteria (ARB). Despite the isolation of these ARB in various human clinical samples, the possible source of infection remains undetermined in most cases. However, it is known that the ARB Legionella pneumophila, for instance, causes a respiratory infection in susceptible hosts after inhalation of contaminated water aerosols from various sources. The Chlamydiales order contains many ARB, such as Parachlamydia acanthamoebae or Simkania negevensis, previously implicated in human respiratory infections with no identified contamination sources. We thus investigated whether domestic water systems are a potential source of transmission of these Chlamydiales to humans by using amoebal culture and molecular methods. Other important ARB such as mycobacteria and Legionella were also investigated, as were their possible amoebal hosts. This work reports for the first time a very high prevalence and diversity of Chlamydiales in drinking water, being detected in 35 (72.9%) of 48 investigated domestic water systems, with members of the Parachlamydiaceae family being dominantly detected. Furthermore, various Legionella and mycobacteria species were also recovered, some species of which are known to be causal agents of human infections.

BACKGROUND: Reliably distinguishing bacterial from viral infections is often challenging, leading to antibiotic misuse. A novel assay that integrates measurements of blood-borne host-proteins (tumor necrosis factor-related apoptosis-inducing ligand, interferon γ-induced protein-10, and C-reactive protein [CRP]) was developed to assist in differentiation between bacterial and viral disease. METHODS: We performed double-blind, multicenter assay evaluation using serum remnants collected at 5 pediatric emergency departments and 2 wards from children ≥3 months to ≤18 years without (n = 68) and with (n = 529) suspicion of acute infection. Infectious cohort inclusion criteria were fever ≥38°C and symptom duration ≤7 days. The reference standard diagnosis was based on predetermined criteria plus adjudication by experts blinded to assay results. Assay performers were blinded to the reference standard. Assay cutoffs were predefined. RESULTS: Of 529 potentially eligible patients with suspected acute infection, 100 did not fulfill infectious inclusion criteria and 68 had insufficient serum. The resulting cohort included 361 patients, with 239 viral, 68 bacterial, and 54 indeterminate reference standard diagnoses. The assay distinguished between bacterial and viral patients with 93.8% sensitivity (95% confidence interval: 87.8%–99.8%) and 89.8% specificity (85.6%–94.0%); 11.7% had an equivocal assay outcome. The assay outperformed CRP (cutoff 40 mg/L; sensitivity 88.2% [80.4%–96.1%], specificity 73.2% [67.6%–78.9%]) and procalcitonin testing (cutoff 0.5 ng/mL; sensitivity 63.1% [51.0%–75.1%], specificity 82.3% [77.1%–87.5%]). CONCLUSIONS: Double-blinded evaluation confirmed high assay performance in febrile children. Assay was significantly more accurate than CRP, procalcitonin, and routine laboratory parameters. Additional studies are warranted to support its potential to improve antimicrobial treatment decisions.

Sepsis is an important cause of morbidity and mortality in neonates and clinicians are typically required to administer empiric antibiotics while waiting for blood culture results. However, prolonged and inappropriate use of antibiotics is associated with various complications and adverse events. Better tools to rapidly rule out bacterial infections are therefore needed.We aimed to assess the negative predictive value of PCR coupled with Electrospray Ionization Mass Spectrometry (PCR/ESI-MS) compared to conventional blood cultures in neonatal sepsis.Prospective observational study.All consecutive neonates (28days old) with clinical suspicion of sepsis. Samples for PCR/ESI-MS analysis were collected at the same time as samples for the blood culture, before the initiation of antibiotics.Our primary objective was to evaluate the negative predictive value of PCR/ESI-MS for the detection of bacteria in the bloodstream of newborns with suspected sepsis. Our secondary objective was the evaluation of the sensitivity, specificity and positive predictive value of the PCR/ESI-MS in such a neonatal population.We analysed 114 samples over 14months. The median age and weight were 32weeks+3days and 1840g, respectively. Two patients had negative PCR/ESI-MS results, but positive blood cultures. Overall, the negative predictive value was 98% (95%CI: 92% to 100%).Based on these results, PCR/ESI-MS analysis of blood samples of neonates with suspected sepsis appears to have a very good negative predictive value when compared to blood cultures as gold standard. This novel test might allow for early reassessment of the need for antibiotics.

Patient centred care fosters a holistic approach of care switching the focus from a disease perspective to a patient's experience perspective. Patient centred care is of particular importance in the context of paediatric emergency medicine. Indeed, parents entering a paediatric emergency department (PED) are usually under stress caused by their children's illness, the unfamiliar setting of the PED and delays of care. All these factors can deteriorate their experience as well as the relationships between healthcare providers, the patients and their parents.We explore potential areas to improve the patient experience during his journey into PED. The dimensions of the picker's patient centred care are used to guide observations, conduct interviews and focus groups. The areas of improvement are then operationalized through their translation into app functionalities.Our novel application allows supporting users on 7 of the 8 dimensions of picker's patient centred care model. The app supports parents in their decision-making to consult a PED, it provides relevant medical information to avoid unrealistic expectations and accompany the family after discharge thanks to tailored information sheets about diagnostics.Our mobile app allows to make a big step toward the improvement of the patient-caregiver relationship. The direct benefits will be shared by patients and caregivers, as well as the institution.

The aim of this study was to evaluate the clinical, therapeutic, laboratory, and radiological differences between respiratory syncytial virus (RSV) and non-RSV bronchiolitis in order to assess if the prior knowledge of viral etiology changed management decisions and would be able to predict outcomes. Medical charts of children

Waddlia chondrophila, an obligate intracellular bacterium of the Chlamydiales order, is considered as an agent of bovine abortion and a likely cause of miscarriage in humans. Its role in respiratory diseases was questioned after the detection of its DNA in clinical samples taken from patients suffering from pneumonia or bronchiolitis. To better define the role of Waddlia in both miscarriage and pneumonia, a tool allowing large-scale serological investigations of Waddlia seropositivity is needed. Therefore, enriched outer membrane proteins of W. chondrophila were used as antigens to develop a specific ELISA. After thorough analytical optimization, the ELISA was validated by comparison with micro-immunofluorescence and it showed a sensitivity above 85% with 100% specificity. The ELISA was subsequently applied to human sera to specify the role of W. chondrophila in pneumonia. Overall, 3.6% of children showed antibody reactivity against W. chondrophila but no significant difference was observed between children with and without pneumonia. Proteomic analyses were then performed using mass spectrometry, highlighting members of the outer membrane protein family as the dominant proteins. The major Waddlia putative immunogenic proteins were identified by immunoblot using positive and negative human sera. The new ELISA represents an efficient tool with high throughput applications. Although no association with pneumonia and Waddlia seropositivity was observed, this ELISA could be used to specify the role of W. chondrophila in miscarriage and in other diseases.

Background Diagnosing viral pneumonia in children is challenging. Chest radiographic imaging and clinical findings cannot reliably distinguish viral from bacterial pneumonia. Furthermore, pathogen-based diagnosis is limited by inaccessible site of infection and high asymptomatic detection rates. The objectives of this analysis were twofold: first, to establish pneumonia etiology by applying a rigorous expert panel process, and second, to evaluate whether a novel host-immune signature that integrates viral induced proteins TRAIL and IP-10 together with bacterial CRP, can accurately differentiate viral from bacterial pneumonia. Methods This analysis included 1025 febrile children enrolled in two multi-center clinical studies that evaluated the host-immune signature performance: ‘Curiosity’ study (Oved et al., PLoS One 2015) and ‘Pathfinder’ study (Srugo et al., Pediatrics 2017). Pneumonia etiology – viral or bacterial – was determined by a panel of 3 independent experts, after reviewing patients’ clinical, laboratory, microbiological, and radiological data. Only cases with majority panel assignment were included. The host-signature generated one of the three results: viral, equivocal or bacterial, based on predetermined cut-offs. Results A total of 709 children were eligible for analysis and had an expert panel etiology determination. Of them, 114 were diagnosed with pneumonia: 51 assigned viral and 63 assigned bacterial (Figure 1). The signature separated viral from bacterial pneumonia with a sensitivity of 94% (95% CI: 85%–99%) and specificity of 95% (85%–99%) with 14% equivocal test results. Out of the 51 children diagnosed with viral pneumonia by the expert panel, 40 (78%) were given antibiotics, and 43 (83%) underwent chest x-ray evaluation. The signature correctly classified 42 of these 51 viral children, indicating its potential to reduce antibiotic overuse rates by 4.4-fold (from 78% to 18%; P < 0.001) and chest x-ray examination by 4.8-fold (from 83% to 18%; P < 0.001). Conclusion The TRAIL/IP-10/CRP signature exhibits high accuracy for diagnosing viral pneumonia in children. The signature’s potential to safely decrease unnecessary antibiotics and chest radiographic imaging should be examined in future utility studies. Disclosures All authors: No reported disclosures.

BackgroundPain management is essential and opioids side effects are of major concern. Tramadol safety and efficacy is influenced by CYP2D6 activity. Phenotyping measurement is available to assess CYP2D6 activity and allow a safe precision medicine approach.4 However need for administration of a probe drug and invasive sampling limit its use. Our objective is to evaluate direct measurement of M1/tramadol ratio and pupillometry as phenotyping methods to identify CYP2D6 ultrarapid (UM) and poor (PM) metabolizers in children treated with tramadol.1-6MethodsWe plan to include 53 children receiving their 1st dose of tramadol at the Emergency Department (ED) of the Geneva Children’s Hospital. Children with concomitant inhibitors/inducers of CYP2D6 and CYP3A or drug with an impact on pupil size are exclude. Standard CYP2D6 phenotyping is performed by measuring blood dextrorphan/dextromethorphan (DOR/DEM) using dried blood spots (DBS) at least 90min after dextromethorphan and tramadol administration. Tramadol and its active metabolite, M1, concentrations are also performed using DBS at the same time. Pupillometry is performed at time of tramadol administration and 1 to twice per hour, during the stay in the ED.ResultsWe included 26 children, median age 10.7 years, of which 2 are UM (8%) and 3 PM (12%), corresponding to what is expected in the Caucasian population. We found a positive correlation between DOR/MED and M1/tramadol ratio (R2= 0.389, p = 0.0006). Pupillometry analyses are in progress. Tramadol 2 mg/kg orally was well tolerated in all children, including UM and PM.ConclusionOur study shows that it is possible to determine CYP2D6 activity in order to provide safe and effective tramadol prescription in children in a less invasive manner than by administering a probe drug, by directly determining the metabolic ratio between tramadol and its metabolite, M1 in children treated with tramadolReferencesFliegert, F., B. Kurth, and K. Gohler, The effects of tramadol on static and dynamic pupillometry in healthy subjects-the relationship between pharmacodynamics, pharmacokinetics and CYP2D6 metaboliser status Eur J Clin Pharmacol, 2005. 61(4): p. 257–66.Slanar, O., et al., CYP2D6 polymorphism, tramadol pharmacokinetics and pupillary response Eur J Clin Pharmacol, 2006. 62(1): p. 75–6; author reply 77–8.Slanar, O., et al., Miotic action of tramadol is determined by CYP2D6 genotype Physiol Res, 2007. 56(1): p. 129–36.Kirchheiner, J., et al., Effects of the CYP2D6 gene duplication on the pharmacokinetics and pharmacodynamics of tramadol J Clin Psychopharmacol, 2008. 28(1): p. 78–83.Matouskova, O., et al., Pupillometry in healthy volunteers as a biomarker of tramadol efficacy J Clin Pharm Ther, 2011. 36(4): p. 513–7.Connelly, M.A., et al., Pupillometry: a non-invasive technique for pain assessment in paediatric patients Arch Dis Child, 2014. 99(12): p. 1125–31.Disclosure(s)Nothing to disclose

Amoxicillin is a first-line antibiotic treatment for acute otitis media in children and one of the most commonly used antibiotics for human bacterial infections. We investigated changes in salivary bacterial communities among children treated with amoxicillin for acute otitis media (n = 18), using a culture-independent approach based on pyrosequencing of the V3 region of the bacterial 16S rRNA gene. The control group consisted of children with acute otitis media who were not given antibiotics (n = 15). One species-level phylotype assigned to the genus Streptococcus was identified across all (n = 99) saliva samples. Two additional species-level phylotypes from the genera Gemella and Granulicatella were shared by all (n = 45) samples of control subjects. Amoxicillin treatment resulted in reduced species richness and diversity, and a significant shift in the relative abundance of 35 taxa at different ranks from phylum to species-level phylotype. At the phylum level, prevalence of TM7 and Actinobacteria decreased at the end of treatment, whereas Proteobacteria had a higher relative abundance post-treatment. Multivariate analysis showed that samples from the same control subject taken over time intervals tended to cluster together. Among antibiotic-treated subjects, samples taken before and at the end of amoxicillin treatment formed two relatively well-separated clusters both of which greatly overlapped with samples taken about 3 weeks post-treatment. Our results point to a substantial but incomplete recovery of the salivary bacterial community from the antibiotic about 3 weeks after the end of treatment.

BACKGROUND AND OBJECTIVE: Urinary tract infections (UTIs) are common childhood bacterial infections that may involve renal parenchymal infection (acute pyelonephritis [APN]) followed by late scarring. Prompt, high-quality diagnosis of APN and later identification of children with scarring are important for preventing future complications. Examination via dimercaptosuccinic acid scanning is the current clinical gold standard but is not routinely performed. A more accessible assay could therefore prove useful. Our goal was to study procalcitonin as a predictor for both APN and scarring in children with UTI. METHODS: A systematic review and meta-analysis of individual patient data were performed; all data were gathered from children with UTIs who had undergone both procalcitonin measurement and dimercaptosuccinic acid scanning. RESULTS: A total of 1011 patients (APN in 60.6%, late scarring in 25.7%) were included from 18 studies. Procalcitonin as a continuous, class, and binary variable was associated with APN and scarring (P < .001) and demonstrated a significantly higher (P < .05) area under the receiver operating characteristic curve than either C-reactive protein or white blood cell count for both pathologies. Procalcitonin ≥0.5 ng/mL yielded an adjusted odds ratio of 7.9 (95% confidence interval [CI]: 5.8–10.9) with 71% sensitivity (95% CI: 67–74) and 72% specificity (95% CI: 67–76) for APN. Procalcitonin ≥0.5 ng/mL was significantly associated with late scarring (adjusted odds ratio: 3.4 [95% CI: 2.1–5.7]) with 79% sensitivity (95% CI: 71–85) and 50% specificity (95% CI: 45–54). CONCLUSIONS: Procalcitonin was a more robust predictor compared with C-reactive protein or white blood cell count for selectively identifying children who had APN during the early stages of UTI, as well as those with late scarring.

Urinary tract infections (UTIs) are one of the most common sources of bacterial infections among young febrile children. Accurate diagnosis of acute pyelonephritis (APN) and vesico-ureteral reflux (VUR) are important because of their association with renal scarring, sometimes leading to long-term complications. However, the gold standard examinations are either a DMSA scan for APN and scarring, or cystography for VUR, but both present limitations (feasibility, pain, cost, etc.). Procalcitonin, a reliable marker of bacterial infections, was demonstrated to be a good predictor of renal parenchymal involvement in the acute phase and in late renal scars, as well as of high-grade VUR. These findings need further broad validations and impact studies before being implemented into daily practice. However, procalcitonin may play a role in the complex and still debated picture of which examination should be performed after UTI in children.

BACKGROUND:A sequential approach to young febrile infants on the basis of clinical and laboratory parameters, including procalcitonin, was recently described as an accurate tool in identifying patients at risk for invasive bacterial infection (IBI). Our aim was to prospectively validate the Step-by-Step approach and compare it with the Rochester criteria and the Lab-score.METHODS:Prospective study including infants ≤90 days with fever without source presenting in 11 European pediatric emergency departments between September 2012 and August 2014. The accuracy of the Step-by-Step approach, the Rochester criteria, and the Lab-score in identifying patients at low risk of IBI (isolation of a bacterial pathogen in a blood or cerebrospinal fluid culture) was compared.RESULTS:Eighty-seven of 2185 infants (4.0%) were diagnosed with an IBI. The prevalence of IBI was significantly higher in infants classified as high risk or intermediate risk according to the Step by Step than in low risk patients. Sensitivity and negative predictive value for ruling out an IBI were 92.0% and 99.3% for the Step by Step, 81.6% and 98.3% for the Rochester criteria, and 59.8% and 98.1% for the Lab-score. Seven infants with an IBI were misclassified by the Step by Step, 16 by Rochester criteria, and 35 by the Lab-score.CONCLUSIONS:We validated the Step by Step as a valuable tool for the management of infants with fever without source in the emergency department and confirmed its superior accuracy in identifying patients at low risk of IBI, compared with the Rochester criteria and the Lab-score.

Pneumonia should be considered in febrile children with tachypnea and/or chest recession. Virus are the most common cause of pneumonia in children under 5 years old. Streptococcus pneumonia can be found at any age. Mycoplasma pneumonia is more frequent in older children. Systematic chest radiograph is not necessary but must be obtained in patients with hypoventilation and in those with failed initial antibiotic therapy. Mycoplasma pneumonia should be tested according to patient age and response to initial antibiotic. First line antibiotherapy is amoxicilline. Antibiotic treatment is frequently not necessary in children under 5 but should be considered depending on clinical presentation and C reactive protein value.

Acute otitis media (AOM) is an important reason for medical visits and antibiotic use in children, with possible complications. Pneumococcal conjugate vaccines (PCV) have been developed from 2000, with first the apparition of the 7-valent PCV (PCV7), and from 2013, of the 13-valent PCV (PCV13). First developed to prevent invasive pneumococcal infections, they have been shown to reduce the number of AOM as well. PC13 has allowed to reduce the nasopharyngeal carriage of the majority of pneumococcal serotypes found in AOM, with a reduction of 77% of pneumococcal AOM, according to one study.

Recent publications have established the pulse oxygen saturation (SpO2) threshold of 90% for the hospitalization and discharge of infant patients with bronchiolitis. However, there is no clear recommendation regarding the Emergency Department (ED) observation period necessary before allowing safe home discharge for patients with SpO2 above 90%-92%. Our primary aims were to evaluate the risk factors associated with delayed desaturation in infants with SpO2 ≥ 92% on arrival at the ED as well as the ED observation period necessary before allowing safe home discharge. A secondary aim was to identify the risk factors for ED readmission. Of 581 episodes of bronchiolitis in patients < 1 year old admitted to the ED, only 47 (8%) had SpO2 < 92% on arrival there, although 106 (18%) exhibited a delayed desaturation (to < 92%) during ED observation. Female sex, age < 3 months old, ED readmission, more severe initial clinical presentation, and higher pCO2 level (> 6KPa) were risk factors for delayed desaturation with OR varying from 1.7 to 7.5. In patients < 3 months old, mean desaturation occured later than in older patients [6.0 hours (IQR 3.0–14.0) vs. 3.0 hours (IQR 2.0–6.0), P = 0.0018]. In 95% of patients with a delayed desaturation this decrease occurred within 25 hours for patients < 3 months old and within 11 hours for patients ≥ 3 months old. In patients < 3 months old with respiratory rates above the normal range for their age the desaturation occurred earlier than in patients < 3 months with normal respiratory rates [4.4 hours (IQR 3.0–11.7) vs. 14.6 hours (IQR 7.6–22.2), P = 0.037]. Based on the present study’s results, we propose a five step guide for pediatricians on discharging children with bronchiolitis from the ED. By using the threshold of an 11 hour ED observation period for patients ≥ 3 months old and a 25 hour period for patients < 3 months old we are able to detect 95% of the patients with bronchiolitis who are at risk of delayed desaturation.

Objective To examine emergency department (ED) staff's knowledge of traumatic stress in children, attitudes toward providing psychosocial care, and confidence in doing so, and also to examine differences in these outcomes according to demographic, professional, and organizational characteristics, and training preferences. Study design We conducted an online survey among staff in ED and equivalent hospital departments, based on the Psychological First Aid and Distress-Emotional Support-Family protocols. Main analyses involved descriptive statistics and multiple regressions. Respondents were 2648 ED staff from 87 countries (62.2% physicians and 37.8% nurses; mean years of experience in emergency care was 9.5 years with an SD of 7.5 years; 25.2% worked in a low- or middle-income country). Results Of the respondents, 1.2% correctly answered all 7 knowledge questions, with 24.7% providing at least 4 correct answers. Almost all respondents (90.1%) saw all 18 identified aspects of psychosocial care as part of their job. Knowledge and confidence scores were associated with respondent characteristics (eg, years of experience, low/middle vs high-income country), although these explained no more than 11%-18% of the variance. Almost all respondents (93.1%) wished to receive training, predominantly through an interactive website or one-off group training. A small minority (11.1%) had previously received training. Conclusions More education of ED staff regarding child traumatic stress and psychosocial care appears needed and would be welcomed. Universal education packages that are readily available can be modified for use in the ED.

Background Bacterial and viral infections are often clinically indistinguishable, particularly in upper respiratory tract infections (URTI), which leads to antibiotic misuse. A novel assay (ImmunoXpert™) that integrates measurements of three host-response proteins (TRAIL, IP-10, CRP) was recently developed to assist in differentiation between bacterial and viral etiologies. We evaluated the assay performance in URTI patients and compared it with standard laboratory measures. Methods We performed a sub-analysis of 464 patients with clinical suspicion of URTI enrolled in three previously conducted multi-center clinical studies that evaluated the assay performance in patients with acute infections: ‘Curiosity’ study (NCT01917461), ‘Opportunity’ study (NCT01931254), and ‘Pathfinder’ study (NCT01911143). Comparator method was predetermined criteria combined with expert panel adjudication, which was blinded to the test results. Diagnostic performance was evaluated by comparing test and comparator method outcomes. Results A unanimous panel adjudication was attained for 61 bacterial (13%) and 241 viral (52%) patients (162 patients (35%) had an indeterminate diagnosis). The assay distinguished between bacterial and viral infected patients with a sensitivity of 92% (95% CI: 82%- 98%) and specificity of 93% (88%-96%) with 11% equivocal test results. Overall the assay outperformed other routine laboratory tests (FIG 1), including: white blood cell count (WBC; cutoff 15,000 cells/µL, sensitivity 48% (35%-60%), P < 10-−6; specificity 85% (80%-90%), P < 0.05); CRP (cutoff 40 mg/L, sensitivity 82% (72%–92%), P = 0.16, specificity 79% (74%–84%), P < 10-4); Procalcitonin (PCT; cutoff 0.5 ng/mL, sensitivity 22% (11%–32%), P < 10–14, specificity 80% (74%–85%), P < 0.001); absolute neutrophil count (ANC; cutoff 10,000 cells/µL, sensitivity 58% (45%–71%), P < 10-−4, specificity 94% (91%–97%), P = 0.7). Conclusion The novel assay demonstrated superior performance compared with routine laboratory tests (WBC, ANC) and biomarkers (CRP, PCT), in distinguishing bacterial from viral etiologies in patients with URTI. It has the potential to help clinicians avoid missing bacterial infections or prescribing unwarranted antibiotics for viral URTIs. Disclosures K. Oved, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary E. Eden, MeMed Diagnostics: Board Member, Employee and Shareholder, Salary T. Gottlieb, MeMed Diagnostics: Employee, Salary R. Navon, MeMed Diagnostics: Employee, Salary A. Cohen, MeMed Diagnostics: Employee, Salary O. Boico, MeMed Diagnostics: Employee, Salary M. Paz, MeMed Diagnostics: Employee, Salary L. Etshtein, MeMed Diagnostics: Employee, Salary G. Kronenfeld, MeMed Diagnostics: Employee, Salary T. Friedman, MeMed Diagnostics: Employee, Salary E. Bamberger, MeMed Diagnostics: Employee, Salary I. Chistyakov, MeMed Diagnostics: Consultant, Consulting fee I. Potasman, MeMed Diagnostics: Holding stock options, stock options

The use of rescue benzodiazepines in the management of seizures is widely accepted in emergency pediatric practice. They can, however, cause severe side effects, such as respiratory depression. We describe five patients who presented with severe respiratory depression following benzodiazepine administration for seizures with autonomic manifestations. We also discuss the relationship between the complications observed in our patients and the rescue treatment. A reduction in the dosage of benzodiazepines in the setting of epileptic patients with predominant autonomic symptoms may need to be considered.

Objective: Human immunodeficiency virus (HIV) infection is the most important chronic health condition among women in childbearing age in sub-Saharan Africa. There is sparse data about socio-economic factors in the context with adverse outcome in pregnancy. The objective of the study was to identify such factors for prematurity, low birth weight (LBW) and intrauterine growth retardation (IUGR) in infants born to HIV-positive women in Cameroon. Methods: The study was done in Yaounde between December 2001 and November 2007. Neonates born to HIV-positive mothers were monitored and clinical data as well as socio-economic factors were tested for association with prematurity, LBW and IUGR. Findings: In total, 264 neonates were analyzed. More prematurity occurred when mothers attended less than 4 prenatal care visits (OR [95% CI]: 2.7 [1.21-6.05]; p=0.015). HIV-classification >1 resulted in more IUGR (OR [95% CI]): 3.15 [1.4-7.4]; p=0.01) and LBW (2.20 [1.1-4.6]; p=0.03). Single women were more likely to attend 4 prenatal care visits or more (OR [CI95%]: 2.4 [1.6-3.4]; p

Background Fever without source (FWS) is defined as a fever in which an extensive history and clinical examination fail to identify a cause. Although the vast majority of children with FWS have a self-limited viral infection, up to 10–25% have a serious bacterial infection (SBI). Therefore, many children require invasive diagnostic tests, hospital admission, and empirical administration of broad-spectrum antibiotics. The aim of this study was to assess the respective role of Human enterovirus (HEV), human parechovirus (HPeV), adenovirus (ADV) and herpesvirus type 6 (HHV6) viremia in children Methods Prospective monocentric diagnostic study. Between November 2015 to December 2017, children Results One hundred thirty-five patients had plasma PCR for ADV, HHV6, HEV, and HPeV. Male:female ratio was 1.45:1 and median age was 2.4 months (interquartile range 1.3–9.7). Among those, 47/135 (34.8%) had at least 1 virus detected in the plasma. More specifically, HEV was detected in 19 patients (14.1%), HHV6 in 15 (11.1%), HPeV in 8 (5.9%), and ADV in 7 (5.2%). Co-infection with 2 viruses was detected in 2 patients (ADV/HEV and ADV/HPeV). No patient with positive plasma PCR had a positive blood or CSF culture. Two patients with positive plasma PCR fulfilled American Academy of Pediatrics criteria for urinary tract infection. The first was HEV+ in plasma and CSF, midstream urine was positive for leukocytes and grew E. coli 106 CFU/mL, whereas the second was HHV6+ in plasma and catheter urine was positive leukocytes/nitrites and grew P. mirabilis 105 CFU/mL. Conclusion This epidemiological study highlights the frequent detection of active enteroviral, adenoviral, and HHV6 infections in plasma of children with FWS. Virus–virus and virus–bacteria co-infections are rare. Further studies are needed to establish causality between FWS and viremia. Disclosures A. G. L’Huillier, Gertrude Von Meissner foundation: Investigator, Research grant. Ernst and Lucie Schmidheiny foundation: Investigator, Research grant. Research and Development Grant, Geneva University Hospitals: Investigator, Research grant. L. Kaiser, Swiss National Funds: Investigator, Research grant. A. Galetto-Lacour, Gertrude Von Meissner foundation: Investigator, Research grant. Ernst and Lucie Schmidheiny foundation: Investigator, Research grant. Research and Development Grant, Geneva University Hospitals: Investigator, Research grant.

Nasal carriage of Staphylococcus aureus contributes to an increased risk of developing an infection with the same bacterial strain. Genetic regulatory elements and toxin-expressing genes are virulence factors associated with the pathogenic potential of S. aureus. We undertook an extensive molecular characterization of methicillin-susceptible S. aureus (MSSA) carried by children. MSSA were recovered from the nostrils of children. The presence of Panton-Valentine leukocidin (PVL), exfoliatins A and B (exfoA and exfoB), and the toxic-shock staphylococcal toxin (TSST-1) and agr group typing were determined by quantitative PCR. A multiple-locus variable-number of tandem repeat analysis (MLVA) assay was also performed for genotyping. Five hundred and seventy-two strains of MSSA were analysed. Overall, 30% were positive for toxin-expressing genes: 29% contained one toxin and 1.6% two toxins. The most commonly detected toxin gene was tst, which was present in 145 (25%) strains. The TSST-1 gene was significantly associated with the agr group 3 (OR 56.8, 95% CI 32.0–100.8). MLVA analysis revealed a large diversity of genetic content and no clonal relationship was demonstrated among the analysed MSSA strains. Multilocus sequence typing confirmed this observation of diversity and identified ST45 as a frequent colonizer. This broad diversity in MSSA carriage strains suggests a limited selection pressure in our geographical area.

OBJECTIVE: The identification of severe bacterial infection (SBI)in children with fever without source (FWS) remains a diagnostic problem. The authors previously developed in their Swiss population a risk index score, called the Lab-score, associating three independent predictors of SBI, namely C reactive protein (CRP), procalcitonin (PCT) and urinary dipstick. The objective of this study was to validate the Lab-score in a population of children with FWS different from the derivation model. METHODS: A prospective study, conducted in Padova, on 408 children aged 7 days to 36 months with FWS was recently published. PCT, CRP, white blood cell count (WBC) and urinary dipstick were determined in all children. The Lab-score was applied to this population and the diagnostic characteristics for the detection of SBI were calculated for the Lab-score and for any single variable used in the Italian study. RESULTS: For the identification of SBI, the sensitivity of a score >/=3 was 86% (95% CI 77% to 92%) and the specificity 83% (95% CI 79% to 87%). The area under the receiver operating characteristic curve for the Lab-score (0.91) was significantly superior to that of any single variable: 0.71 for WBC, 0.86 for CRP and 0.84 for PCT. The Lab-score performed better than other laboratory markers, even when applied to children of different age groups (12 months). The results obtained in this validation set population were comparable with those of the derivation set population. CONCLUSIONS: This study validated the Lab-score as a valuable tool to identify SBI in children with FWS.

Objective To compare procalcitonin measurements between semi-quantitative and quantitative assays. Method Procalcitonin was measured with the PCT-Q® and the Kryptor® assays in a pediatric emergency department. Results Among the 359 pairs of results, 103 had discordant results. The linear weighted kappa was 0.44 (95% CI 0.36, 0.51). The concordant/discordant results distribution varied depending on the laboratory technician ( p = 0.018). Conclusion Agreement between procalcitonin measured semi-quantitatively and quantitatively was moderate. This is probably due to a subjective interpretation of the assay result.

Rotavirus gastroenteritis (RV GE) is a leading cause of diarrhoea in young children. The purpose of this epidemiological surveillance was to measure the disease burden of RV GE among children

Uncertainty persists about risk factors for community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections in Europe and the long-term efficacy of decolonization strategies. To evaluate risk factors for CA-MRSA in Geneva, Switzerland, a hospital-based, retrospective case–control study of 26 patients with CA-MRSA infection and 60 control patients was performed. To evaluate the long-term effect of a systematic decolonization strategy (with and without concomitant systemic antibiotic therapy) for CA-MRSA patients, a prospective cohort study of 79 patients with Panton–Valentine leukocidin-producing CA-MRSA isolates was conducted. Nationality other than European Union or Swiss (adjusted OR 6.09; 95% CI 1.07–34.65) and absence of healthcare contact (adjusted OR 0.11, 95% CI 0.02–0.59) were independent predictors of CA-MRSA infection. Forty-five cases were followed (median, 22 months) to assess the long-term efficacy of the decolonization strategy; 39/45 (86.7%) had no clinical relapse and were MRSA-negative at their last follow-up, whereas six remained MRSA-positive. Five of these six cases belonged to a family cluster. Decolonization rates were similar between infected patients and asymptomatic carriers (92.6% vs. 77.8%, p = 0.20). This study shows a lack of readily modifiable risk factors for CA-MRSA infection in this population, and suggests the potential usefulness of conducting decolonization procedures in a setting with sporadic CA-MRSA infection. Further studies are needed to elucidate the role of migration as a factor contributing to the emergence of CA-MRSA in Europe.

Molecular characterization of methicillin-resistant Staphylococcus aureus (MRSA) strains different from those of an endemic healthcare-associated clone was conducted over 13 years in Geneva, Switzerland. We demonstrated strain diversity, including clones rarely found in Europe. Local epidemiology of community-associated MRSA is diverse and is evolving by importation and transmission of new strains.

The hypothesis was tested that oral antibiotic treatment in children with acute pyelonephritis and scintigraphy-documented lesions is equally as efficacious as sequential intravenous/oral therapy with respect to the incidence of renal scarring. A randomised multi-centre trial was conducted in 365 children aged 6 months to 16 years with bacterial growth in cultures from urine collected by catheter. The children were assigned to receive either oral ceftibuten (9 mg/kg once daily) for 14 days or intravenous ceftriaxone (50 mg/kg once daily) for 3 days followed by oral ceftibuten for 11 days. Only patients with lesions detected on acute-phase dimercaptosuccinic acid (DMSA) scintigraphy underwent follow-up scintigraphy. Efficacy was evaluated by the rate of renal scarring after 6 months on follow-up scintigraphy. Of 219 children with lesions on acute-phase scintigraphy, 152 completed the study; 80 (72 females, median age 2.2 years) were given ceftibuten and 72 (62 females, median age 1.6 years) were given ceftriaxone/ceftibuten. Patients in the intravenous/oral group had significantly higher C-reactive protein (CRP) concentrations at baseline and larger lesion(s) on acute-phase scintigraphy. Follow-up scintigraphy showed renal scarring in 21/80 children treated with ceftibuten and 33/72 with ceftriaxone/ceftibuten (p = 0.01). However, after adjustment for the confounding variables (CRP and size of acute-phase lesion), no significant difference was observed for renal scarring between the two groups (p = 0.2). Renal scarring correlated with the extent of the acute-phase lesion (r = 0.60, p < 0.0001) and the grade of vesico-ureteric reflux (r = 0.31, p = 0.03), and was more frequent in refluxing renal units (p = 0.04). The majority of patients, i.e. 44 in the oral group and 47 in the intravenous/oral group, were managed as out-patients. Side effects were not observed. From this study, we can conclude that once-daily oral ceftibuten for 14 days yielded comparable results to sequential ceftriaxone/ceftibuten treatment in children aged 6 months to 16 years with DMSA-documented acute pyelonephritis and it allowed out-patient management in the majority of these children.

Occult bacteraemia is the most frequent invasive disease caused by Streptococcus pneumoniae in children less than 3 years of age. Despite the relative frequency of this infection, its management is still a challenging task for paediatricians because fever is often the only symptom and a considerable overlap exists in the clinical presentation of children with fever without a focus due to viral illness and children with occult bacteraemia. Management protocols take into account the age of the patient, the clinical score for severity and the results of laboratory tests such as the white blood cell count, the C-reactive protein and the blood procalcitonin level in order to define accurately who will benefit from an antibiotic treatment. Despite appropriate healthcare facilities and access to care the case fatality rate in developed countries is around 9% in children aged less than 1 year. Prevention with the 7-valent conjugate vaccine against S. pneumoniae will decrease morbidity and mortality associated with invasive disease due to these bacteria. However, replacement by non-vaccine serotypes has been noted in countries where the vaccine is widely used and this concern needs to be monitored carefully over the next few years.

Objective To validate high serum procalcitonin (PCT) as a predictor of vesicoureteral reflux (VUR) in children with a first febrile urinary tract infection (UTI). Study design This secondary analysis of prospective hospital-based cohort studies included children ages 1 month to 4 years with a first febrile UTI. Results Of the 398 patients included in 8 centers in 7 European countries, 25% had VUR. The median PCT concentration,vas significantly higher in children with VUR than in those without: 1.6 versus 0.7 ng/ml, (P = 10(-4)). High PCT (>= 0.5 ng/ml) was' associated with VUR (OR: 2.3. 95% Cl, 1.3 to 3.9; P = 10(-3)). After adjustment for all cofactors, the association remained significant (OR: 2.5: 95% Cl, 1.4 to 4.4; P = 10(-3)). The strength of the relation increased with tire grade of reflux (P = 10(-5).). The sensitivity of procalcitonin was 75% (95% Cl, 66 to 83) for all-grade VUR and 100% (95% Cl, 81 to 100) for grade >= 4 VUR. both with 43% specificity (95% Cl, 37 to 48). Conclusions High PCT is a strong, independent and now validated predictor of VUR that can be used to identify low-risk patients and thus avoid one third of the unnecessary cystourethrographies in children with a first febrile UTI.

Background Community-acquired-pneumonia is the leading cause of child mortality worldwide. Very few studies have explored the predictive value of Proadrenomedullin and Copeptin in pediatric severe pneumonia and bacteremia. Methods Proadrenomedullin and Copeptin were assessed as predictors for complicated community-acquired pneumonia (bacteremia, empyema) in 88 children aged 0 to 16 years presenting to the pediatric emergency department, using B.R.A.H.M.S. Kryptor Compact pro-ADM and Copeptin with the TRACE technology (time-resolved amplified cryptase emission). STARD standard reporting was used. Results A complicated community-acquired pneumonia was found in 11 out of 88 children (12.5 %). Proadrenomedullin median values increased more than twofold, in complicated vs. uncomplicated (0.18 vs. 0.08 nmol/L, p = 0.039), and fivefold in bacteremic vs. non-bacteremic pneumonia (0.40 vs. 0.08 nmol/L, p = 0.02). Proadrenomedullin > 0.16 nmol/L showed 100 % sensitivity (95 % CI 39.8 – 100.0) and 70 % (95 % CI 58.7 – 79.7) specificity for bacteremia. Copeptin showed no added-value. Conclusions Proadrenomedullin seems a reliable and available predictor for complicated CAP, and could therefore help the physician with the decision to hospitalize, and choose the antibiotics administration route. Larger studies are needed. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-1095-5) contains supplementary material, which is available to authorized users.

Human Enterovirus (EV) and Parechovirus (HPeV) are well recognised as agents causing disease in neonates, but their importance is poorly described in the general paediatric population consulting with a suspicion of infection.We investigated the prevalence of EV- or HPeV-associated infections in children presenting to a paediatric emergency department with a suspicion of infection.Plasma specimens collected in our paediatric emergency room for clinical reasons were screened by specific real-time RT-PCR for the presence of EV and HPeV.Based on an analyses of 233 plasma specimens, up to 6.9% and 2.6% were positive for EV and HPeV, respectively. Amongst the population3y.o, prevalence of EV and HPeV viraemia was 11% and 3.7%, respectively. Importantly, 56.3% of positive EV specimens were detected in infants3 months of age.The prevalence of EV and HPeV viraemia in children3 years old is largely underestimated. Our results confirm that EV should be suspected and included in the work-up in children3 months of age and not restricted to neonates.

To control an outbreak of community-associated MRSA (CA-MRSA) in a neonatology unit, an investigation was conducted that involved screening neonates and parents, molecular analysis of MRSA isolates and long-term follow-up of cases. During a two-month period in the summer of 2000, Panton-Valentine leukocidin (PVL)-producing CA-MRSA (strain ST5-MRSA-IV) was detected in five neonates. The mother of the index caseshowed signs of mastitis and wound infection and consequently tested positive for CA-MRSA. A small cluster of endemic, PVL-negative MRSA strains (ST228-MRSA-I) occurred in parallel. Enhanced hygiene measures, barrier precautions, topical decolonization of carriers, and cohorting of new admissions terminated the outbreak. Four months after the outbreak, the mother of another neonate developed furunculosis with the epidemic CA-MRSA strain. One infant had persistent CA-MRSA carriage resulting in skin infection in a sibling four years after the outbreak. In conclusion, an epidemic CA-MRSA strain was introduced by the mother of the index case. This spread among neonates and was subsequently transmitted to another mother and a sibling. This is the first report of a successfully controlled neonatology outbreak of genetically distinct PVL-producing CA-MRSA in Europe.

Background Spontaneous bacterial peritonitis (SBP) is a rare affection in the pediatric population. It usually occurs when concurrent conditions are present, such as nephrotic syndrome, peritoneal dialysis or liver disease. We report a case of spontaneous bacterial peritonitis due to Kocuria marina in a 2-year-old child with no underlying risk factor. This is both the first description of an infection caused by this rare pathogen in a child and the first reported case of primary peritonitis caused by K. marina in a patient with no predisposing condition. Case presentation A 2 year-old boy presented to the Pediatric Emergency Department with clinical signs of peritonitis. Laparoscopic surgical exploration confirmed purulent, generalized peritonitis without perforation. Culture of the peritoneal fluid revealed the presence of Kocuria marina, a Gram-positive coccoid environmental bacteria. After peritoneal lavage and appropriate antibiotic treatment, the patient improved and was discharged without sequel. Conclusion The present report illustrates the first clinical presentation of Kocuria marina SBP in a child with no underlying risk factor. Although never previously described in healthy patients, this pathogen may therefore be considered as a possible cause of SBP in a child. This unusual finding extends the spectrum of infectious diseases caused by Kocuria marina beyond the scope of the previously described susceptible population. Electronic supplementary material The online version of this article (doi:10.1186/s12879-014-0719-5) contains supplementary material, which is available to authorized users.

Von Januar bis Mitte Februar 2005 wurden dem Kantonsarzt von Genf 15 Fälle von bestätigten Masern gemeldet; verglichen zu einem einzelnen Fall im 2004. Ungewöhnlich an dieser Epidemie war das Alter der betroffenen Personen von 17 bis 44 Jahren. Vier unter ihnen waren Mitarbeiter eines öffentlichen Spitals, die sich nach Kontakt zu einem einzigen, 44-jährigen Patienten ansteckten und die Infektion zum Teil weiter übertrugen. Die Annahme, dass Masern eine pädiatrische Infektion sind, erschwerte die Diagnose. Keiner der betroffenen Erwachsenen war immun nach dem heutigen Stand der Empfehlungen. Trotz vorhandenem Impfplan, behördlichen Empfehlungen, Kostenübernahme durch die Krankenkassen und den guten Impfergebnissen mit den heute zur Verfügung stehenden Vakzinen, ist die freiwillige Durchimpfungsrate in der Schweiz unter Kindern und Erwachsenen zu gering um den Ausbruch von Epidemien zu verhindern. Im Gegensatz zu den Zielen des Bundesamt für Gesundheit (BAG) und der Weltgesundheitsorganisation (WHO) sind wir in der Schweiz aus verschiedenen Gründen noch nicht so weit eine genügend hohe Herdimmunität aufzubauen, um gesundheitliche und volkswirtschaftliche Schäden durch aufflackernde Epidemien zu verhindern.

Bacteria increasingly resistant to antibiotics are a major treatment concern of respiratory tract pathogens in children. The aim of this study was to assess the trends of resistance of Streptococcus pneumoniae, Haemophilus influenzae and Moraxella catarrhalis to several classes of antibiotics in children

Background:: Infective endocarditis (IE) is a rare and feared infection that mainly occurs in patients with underlying cardiac disease or altered function of the immune system. Recent epidemiological data on both sepsis and nosocomial infections indicate a rise in gram-negative bacterial and fungal infection, particularly in patients requiring critical care support. This study sought to characterize the change in the spectrum of IE encountered in a single pediatric tertiary care center during the last 18 years, to evaluate emergence of fungal IE and to identify contributing factors. Patients and Methods:: Review of all cases of IE diagnosed between January 1986 and August 2003 at a single university children's hospital. Patients were distributed between two equal time periods and compared according to the era of IE diagnosis. Results:: In 43 patients, 44 episodes of IE were identified with most cases occurring in children with congenital or acquired heart disease. The annual number of diagnosed cases fluctuated during the study (mean 2.4 cases/year). Blood or specimen cultures were positive in 34 cases (77%) with gram-positive organisms most frequently observed (n = 20, 44.4%). Fungal IE cases (n = 9, 20%) occurred preferentially during the second period (p < 0.03), and were more common in children with noncardiac diseases (p = 0.023). Factors associated with fungal IE were the use of broad-spectrum antibiotics (p < 0.001) and the presence of an infected central venous catheter (p = 0.01). Overall mortality did not differ between the two eras. Conclusion:: The incidence of fungal IE seems to have significantly increased in more recent years. Use of broadspectrum antibiotics for prolonged time or/and central venous catheters were identified as predisposing factors to fungal infective endocarditis

Cardiopulmonary bypass induces a generalized inflammatory response, with fever and leukocytes, which is difficult to differentiate from an infection. Recently, procalcitonin has been proposed as an early and specific marker of bacterial infection. The influence of cardiopulmonary bypass on production of procalcitonin, therefore, must be assessed before considering this molecule as a valuable marker of infection after cardiac surgery in children. With this in mind, we measured levels of procalcitonin, interleukin 6, and C-reactive protein before and 6 h, 1, 3 and 5 days after cardiopulmonary bypass, in 25 children undergoing cardiac surgery. Cardiopulmonary-bypass induced a transient increase in procalcitonin, with a peak at 24 h, with a median of 1.13 μg/l, a 25th and 75th interquartile of 0.68–2.25, and a p value of less than 0.001. The value had returned to normal in the majority of the children by the third day after surgery. Peak values correlated with the duration of cardiopulmonary-bypass, with a r-value of 0.58 and a p value of 0.003; cross-clamp time, with a r-value of 0.62 and a p value of 0.001; days of mechanical ventilation, with a r-value of 0.62 and a p value of 0.001; and days of stay in intensive care, with a r-value of 0.68, and a p value of 0.0003. The value returned to normal after 3 days in 83% of the patients. Levels of interleukin 6 and C-reactive protein also increased significantly after surgery, and remained elevated for up to 5 days.Thus, in contrast to other markers, levels of procalcitonin in the serum are only slightly and transiently influenced by cardiopulmonary bypass, and may prove to be useful in the early recognition of an infection subsequent to cardiopulmonary bypass.

Objectives To assess the concordance of procalcitonin values at 3 cut-off ranges in a cohort of pediatric samples presenting with fever without source, using two different automated immunoassays. Design and methods 65 frozen samples from children presenting with fever without source were thawed, tested on both Kryptor and VIDAS systems, and compared using a regression analysis, a Bland–Altman difference plot, and analysis of concordance at the clinically relevant cut-off points. Results Kryptor and VIDAS PCT results correlated remarkably well (r = 0.952), with no significant difference in the frequency distribution over the 3 cut-off ranges (p = 0.1384). The strength of the agreement was good (κ = 0.759) with an overall concordance of 84.6%. Conclusion Correlation and concordance of PCT values measured by both systems were good. This finding allows clinical implementation of both techniques with the same nominal PCT cut-off values for detection of serious bacterial infection in children presenting with fever without source.