A. Martinot

Paediatric skin disorders encountered in an emergency hospital facility: a prospective study.

To determine the frequency of skin disorders encountered in a paediatric emergency care unit and to evaluate the benefits of advice from a dermatologist, we prospectively recorded data of children admitted with skin disorders to the emergency care unit during a 5-month period. Diagnostic agreement between paediatricians and dermatologists evaluating the patients separately was assessed. Three hundred and ninety-five children (median age 3 years; interquartile 1-6) were included. Skin disorders represented 4% of all paediatric emergency care unit visits. Visits were considered as appropriate in 19-30% of cases according to different criteria. Six diseases accounted for 57% of cases: viral exanthema, urticaria, atopic dermatitis, varicella, diaper dermatitis and herpetic gingivostomatitis. The dermatologist modified the diagnosis in 42% of cases and the treatment in 30%. Greater emphasis on teaching the skin disorders encountered in this setting and efforts to provide easy access to advice from dermatologist would improve the quality of care.

Diagnosis of Viral Infections Using Myxovirus Resistance Protein A (MxA)

BACKGROUND: Myxoma resistance protein 1 (MxA) is induced during viral infections. MxA testing could be helpful to differentiate between viral and bacterial infections. METHODS: A prospective multicenter cohort study was performed in pediatric emergency departments. MxA blood values were measured in children with confirmed viral or bacterial infections, uninfected controls, and infections of unknown origin. First patients were used to determine MxA threshold for viral infection. The diagnostic performance of MxA was determined by using receiver operating characteristic (ROC) analysis. Sensitivities (Se), specificities (Sp), and positive and negative likelihood ratios (LR+, LR–) were calculated. RESULTS: The study included 553 children; 44 uninfected controls and 77 confirmed viral infections (mainly respiratory syncytial virus and rotavirus) were used to determine an MxA threshold at 200 ng/mL. In the 193 other patients with confirmed infections and uninfected controls (validation group), MxA was significantly higher in patients with viral than in those with bacterial infections and uninfected controls (P < .0001). The area under the ROC curve (AUC) were 0.98, with 96.4% Se and 85.4% Sp, for differentiating uninfected from virus-infected patients and 0.89, with 96.4% Se and 66.7% Sp, for differentiating bacterial and viral infections. MxA levels were significantly higher in patients with clinically diagnosed viral versus clinically diagnosed bacterial infections (P < .001). Some patients with Streptococcus pneumonia infections had high MxA levels. Additional studies are required to elucidate whether this was due to undiagnosed viral coinfections. CONCLUSIONS: MxA is viral infection marker in children, at least with RSV and rotavirus. MxA could improve the management of children with signs of infection.

Bacterial Skin Infections in Children Hospitalized with Varicella: A Possible Negative Impact of Non-steroidal Anti-inflammatory Drugs?

This 1-year multicentre prospective study in northern France sought to evaluate the incidence of secondary bacterial skin complications related to varicella, describe these superinfections, and analyse risk factors for their onset. The study included every child admitted to a district paediatric unit with a varicella infection. Patients with varicella infection, with and without secondary bacterial skin complication, were compared. The study included 159 children, 43 of whom had a secondary bacterial skin complication on admission, 21 of them had a severe secondary bacterial skin complication (respective incidence: 7.5 and 3.7/100,000 children younger than 16 years old). Persistence or recurrence of fever > or =38.5 degrees C for > or =3 days after the beginning of varicella infection (adjusted odds ratio (aOR)=8.1; 95% confidence interval (CI): 2.3-28.4) and the use of non-steroidal anti-inflammatory drugs (aOR=4.8; 95% CI: 1.6-14.4) were independent factors associated with severe secondary bacterial skin complication.

Why children with severe bacterial infection die: a population-based study of determinants and consequences of suboptimal care with a special emphasis on methodological issues.

Introduction Suboptimal care is frequent in the management of severe bacterial infection. We aimed to evaluate the consequences of suboptimal care in the early management of severe bacterial infection in children and study the determinants. Methods A previously reported population-based confidential enquiry included all children (3 months- 16 years) who died of severe bacterial infection in a French area during a 7-year period. Here, we compared the optimality of the management of these cases to that of pediatric patients who survived a severe bacterial infection during the same period for 6 types of care: seeking medical care by parents, evaluation of sepsis signs and detection of severe disease by a physician, timing and dosage of antibiotic therapy, and timing and dosage of saline bolus. Two independent experts blinded to outcome and final diagnosis evaluated the optimality of these care types. The effect of suboptimal care on survival was analyzed by a logistic regression adjusted on confounding factors identified by a causal diagram. Determinants of suboptimal care were analyzed by multivariate multilevel logistic regression. Results Suboptimal care was significantly more frequent during early management of the 21 children who died as compared with the 93 survivors: 24% vs 13% (p = 0.003). The most frequent suboptimal care types were delay to seek medical care (20%), under-evaluation of severity by the physician (20%) and delayed antibiotic therapy (24%). Young age (under 1 year) was independently associated with higher risk of suboptimal care, whereas being under the care of a paediatric emergency specialist or a mobile medical unit as compared with a general practitioner was associated with reduced risk. Conclusions Suboptimal care in the early management of severe bacterial infection had a global independent negative effect on survival. Suboptimal care may be avoided by better training of primary care physicians in the specifics of pediatric medicine.

Évaluation du traitement ambulatoire de la varicelle de l’enfant

Resume Le contexte La varicelle, affection quasi obligatoire de l’enfant, se complique dans 2 % des cas. Certains traitements tels que poudres et anti-inflammatoires non steroidiens (AINS) pourraient favoriser ou aggraver les complications infectieuses. Objectif Evaluer les prescriptions ambulatoires dans la varicelle de l’enfant. Methodes Trois methodes ont ete utilisees : un recueil des prescriptions ambulatoires chez des enfants (n = 122) se presentant ensuite avec une varicelle dans un des hopitaux du Nord etait effectue de janvier a mai 2003 ; une enquete telephonique a ete menee aupres de 50 medecins generalistes du departement du Nord en mars 2003. Elle recueillait d’une part la prescription du dernier cas traite, d’autre part les intentions de prescription devant un cas clinique simule de varicelle. Resultats Les poudres etaient prescrites dans 44 % a 54 % des cas, les AINS dans 14 % a 16 %, l’aspirine dans 2 % a 4 %, l’acyclovir per os dans 4 %. Les trois methodes d’evaluation ne donnaient des resultats differents que pour les prescriptions d’antibiotiques, plus frequentes chez les enfants se presentant ensuite a l’hopital (25 % vs 6 %) et les prescriptions de paracetamol. Seules 38 % des prescriptions lors du cas clinique repondaient aux recommandations. Conclusion Une information des medecins sur le traitement des varicelles et le risque de surinfections cutanees graves favorise par certaines prescriptions est indispensable.

Recommandations sur l’utilisation des nouveaux outils diagnostiques étiologiques des infections respiratoires basses de l’enfant de plus de trois mois

Recommendations for the use of diagnostic testing in low respiratory infection in children older than 3 months were produced by the Groupe de Recherche sur les Avancées en Pneumo-Pédiatrie (GRAPP) under the auspices of the French Paediatric Pulmonology and Allergology Society (SP(2)A). The Haute Autorité de santé (HAS) methodology, based on formalized consensus, was used. A first panel of experts analyzed the English and French literature to provide a second panel of experts with recommendations to validate. Only the recommendations are presented here, but the full text is available on the SP(2)A website.

Méthodologie de l'analyse des soins sub-optimaux

1Clinique médicale et service d’urgences pédiatriques, Hôpital Mère-Enfant, 8 quai Moncousu, 44000 Nantes, France 2Unité d’urgences pédiatriques et de maladies infectieuses, Hôpital R. Salengro, CHU de Lille, Université de Lille-2, 2, avenue Oscar-Lambret, 59037 Lille, France 3Inserm U149, hôpital Saint-Vincent-de-Paul, 74, avenue Denfert-Rochereau, 75014 Paris, France 4Service de pédiatrie générale, hôpital Saint-Vincent-de-Paul, AP–HP, Université Paris-Descartes, 74, avenue Denfert-Rochereau, 75014 Paris, France Table ronde

Erratum à l’article « Recommandations sur l’utilisation des nouveaux outils diagnostiques étiologiques des infections respiratoires basses de l’enfant de plus de trois mois » [Arch. Pediatr. 21(4) (2014) 418–423]

V. Houdouina,*,1, G. Pouesselb,s,1, F. Angoulvantc,1, J. Brouardd,1, J. Derellee, M. Fayonf,1, A. Ferronig,1, J.-P. Gangneuxh,1, I. Haui,1, M. Le Bourgeoisj,1, M. Lorrotk,1, J. Menottil,1, N. Nathanm,1, A. Vabretn,1, F. Walleto,1, S. Bonacorsip,2, R. Cohenq,2, J. de Blicr,2, A. Deschildres,2, V. Gandemert,2, I. Pinu,2, A. Labbev,2, P. Le Rouxw,2, A. Martinotx,2, B. Rammaerty,2, Groupe de recherche sur les avancees en pneumo-pediatrie (GRAPP), J.-C. Dubusz, C. Delacourtaa, C. Marguetab Recu le : 27 mai 2014 Accepte le : 27 mai 2014 Disponible en ligne 1er juillet 2014