Beatriz Marcondes Machado

Fever without source: evaluation of a guideline

OBJECTIVE To evaluate the applicability of a standardized guideline for children up to 36 months of age with fever without source (FWS). METHODS Prospective cohort study involving children with FWS treated at the emergency department of Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil, from June 2006 to May 2007. The guideline classifies the risk of serious bacterial infection (SBI) according to the presence or absence of toxemia, age, and temperature. Laboratory screening was based on risk assessment: complete blood count, blood culture, urinalysis, urine culture, and, if necessary, chest radiography, cerebrospinal fluid, and coproculture. RESULTS We studied 251 children and, of these, 215 were followed up until the final diagnosis. Toxemia was found in 20 children, and 195 were well-appearing (30 up to 3 months old and 165 from 3 to 36 months old). Among those children from 3 to 36 months without toxemia, 95 had axillary temperature > 39 degrees C. In 107 (49.8%) children, there was spontaneous resolution of fever; in 88 (40.9%), benign self-limited disease was identified; and in 20 (9.3%), there was SBI. Among the cases of SBI, we identified 16 urinary tract infections, three cases of pneumonia and one occult bacteremia. Of the 215 children, 129 (60%) received no antibiotics, and 86 received antibiotics at some point (45 empirically). Empirical antibiotic treatment was maintained for an average of 72 hours. CONCLUSION The guideline was shown to be appropriate to follow up these children using simple laboratory tests that can be carried out at most health facilities. The most frequent SBI in this sample was urinary tract infection.

Impacto do uso da prova rápida para estreptococo beta-hemolítico do grupo A no diagnóstico e tratamento da faringotonsilite aguda em pronto-socorro de Pediatria

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Febre sem sinais localizatórios: avaliação de um protocolo de atendimento

OBJECTIVE: To evaluate the applicability of a standardized guideline for children up to 36 months of age with fever without source (FWS). METHODS: Prospective cohort study involving children with FWS treated at the emergency department of Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil, from June 2006 to May 2007. The guideline classifies the risk of serious bacterial infection (SBI) according to the presence or absence of toxemia, age, and temperature. Laboratory screening was based on risk assessment: complete blood count, blood culture, urinalysis, urine culture, and, if necessary, chest radiography, cerebrospinal fluid, and coproculture. RESULTS: We studied 251 children and, of these, 215 were followed up until the final diagnosis. Toxemia was found in 20 children, and 195 were well-appearing (30 up to 3 months old and 165 from 3 to 36 months old). Among those children from 3 to 36 months without toxemia, 95 had axillary temperature > 39 oC. In 107 (49.8%) children, there was spontaneous resolution of fever; in 88 (40.9%), benign self-limited disease was identified; and in 20 (9.3%), there was SBI. Among the cases of SBI, we identified 16 urinary tract infections, three cases of pneumonia and one occult bacteremia. Of the 215 children, 129 (60%) received no antibiotics, and 86 received antibiotics at some point (45 empirically). Empirical antibiotic treatment was maintained for an average of 72 hours. CONCLUSION: The guideline was shown to be appropriate to follow up these children using simple laboratory tests that can be carried out at most health facilities. The most frequent SBI in this sample was urinary tract infection.

Treatment of pediatric outpatients with complicated urinary tract infections

In an open and prospective study involving outpatient children with complicated urinary tract infections (UTI), we evaluated the therapeutic efficacy of ceftriaxone administered intramuscularly, once-daily--50 to 70 mg/kg, during 8 to 10 days. Initially, the selected patients exhibited at least two of the following clinical criteria: age below 6 months, any degree of toxicity, fever, strong suspicion or proved abnormalities of their urinary tracts and lumbar pain in children older than 4 years. Significant bacteriuria was demonstrated by urine culture in 40 patients (21 boys, 19 girls), whose ages ranged from 15 days to 6 years 9 months (median 3 months). The radiological studies revealed vesicoureteral reflux in 6 patients, urethral posterior valve in 1, and neurogenic bladder in 4. The main causative agents were Escherichia coli isolated in 30 patients, Klebsiella (4) and Proteus (4). The treatment was found to be effective in 38 patients (95%). There was failure of treatment in 1 patient and a symptomatic reinfection in another one. It was concluded that children with complicated UTI could be treated alternatively by once daily ceftriaxone.

Impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngotonsillitis in a pediatric emergency room.

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

The impact of rotavirus vaccination on emergency department visits and hospital admissions for acute diarrhea in children under 5 years.

Introduction: Acute diarrheal disease is the second cause of death in children under 5 years. In Brazil, from 2003 to 2009, acute diarrhea was responsible for nearly 100,000 hospital admissions per year and 4% of the deaths in children under 5 years. Rotavirus is the leading cause of severe acute diarrhea worldwide. In 2006, the rotavirus monovalent vaccine (RV1) was added to the Brazilian National Immunization Program. Objectives: To analyze the impact of the RV1 on emergency department (ED) visits and hospital admissions for acute diarrhea. Method: A retrospective ecologic study at the University Hospital, University of São Paulo. The study analyzed the pre-vaccine (2003-2005) and the post-vaccine (2007-2009) periods. We screened the main diagnosis of all ED attendances and hospital admissions of children under 5 years in an electronic registry system database and calculated the rates of ED visits and hospital admissions. The reduction rate was analyzed according to the following formula: reduction (%) = (1 - odds ratio) x 100. Results: The rates of ED visits for acute diarrhea was 85.8 and 80.9 per 1,000 total ED visits in the pre and post vaccination periods, respectively, resulting in 6% reduction (95CI 4 to 9%, p<0.001). The rates of hospital admissions for acute diarrhea was 40.8 per 1,000 in the pre-vaccine period and dropped to 24.9 per 1,000 hospitalizations, resulting in 40% reduction (95CI 22 to 54%, p<0.001). Conclusion: The introduction of the RV1 vaccine resulted in 6% reduction in the ED visits and 40% reduction in hospital admissions for acute diarrhea.

Impacto del uso de la prueba rápida para estreptococos beta-hemolíticos del grupo A en el diagnóstico y tratamiento de la faringotonsilitis en emergencia de Pediatría

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Impact of the use of rapid antigen detection test in the diagnosis and treatment of acute pharyngitis in pediatric emergency room

Methods: Retrospective analysis of 11 years bronchoscopy data in the Pediatric Pulmonologic Institute of Hadassah University Hospital and prospective telephonic follow up. Results: Out of 3700 bronchoscopies (mean age 2.5 years), 2268 (61%) were performed due to suspected airway obstruction. Tracheo or Broncho malacia was found in 827 children, of them, 102 children performed chest CT angiography, of them, 47 performed also echocardiography. Telephone follow up was performed to 58 children (mean 4.5 years after bronchoscopy). Thirteen children underwent operation due to double aortic arch (n =10), aberrant innominate artery (n =1), right aortic arch with fibrotic band (n =1), severe right primary bronchomalacia (n = 1). All these children had moderate to severe airway obstruction (>50%) by bronchoscopy and CT. Echocardiography diagnosed 9 out of 10 vascular rings. Conclusions: Echocardiography should be performed in every pulsate tracheo-bronchomalacia. Mild (<50%) airway obstruction can be followed up. In moderate to severe airway obstruction with continues respiratory symptoms, MRI or CT focused to the level of the pathology should be performed. Using this workup diagnosis the use of CT will be decreased in 40% at least.

Padronização do método para cálculo da captação renal absoluta do99mTc-DMSA em cria

OBJECTIVE: To standardize a method and determine normal values for absolute renal uptake of 99mTc-DMSA in children with normal creatinine clearance. MATERIALS AND METHODS: Twenty-two children (between 7 months and 10 years of age; mean 4.5 years) without clinical evidence of renal disease were studied using 99mTc-DMSA scintigraphy. Eighteen had normal renal ultrasonography, micturating urethrocystography, creatinine clearance and visual interpretation of the scintigraphy with 99mTc-DMSA. Four children were excluded, one with incomplete creatinine clearance and three due to reduction in the creatinine clearance. Absolute renal uptake of 99mTc-DMSA (DMSA-Abs) was expressed as the fraction of the administered dose retained by each kidney six hours after administration of the radiopharmaceutical. RESULTS: DMSA-Abs was 21.8 ± 3.2% for the right kidney and 23.1 ±3.3% for the left kidney. There was no correlation between renal uptake and the age groups studied, although there was a tendency to an increase in the creatinine clearance with age. CONCLUSION: Normal values of DMSA-Abs can be used as an additional parameter for the initial diagnostic evaluation and during follow-up of renal diseases, mainly when bilateral impairment of renal function is suspected or in a patient with a single functioning kidney (in which renal differential function is of limited value).

Standardization of Normal Values for Absolute Renal Uptake of DMSA-Tc 99m in Children - Correlation with Age and Creatinine Clearance

Standardization of Normal Values for Absolute Renal Uptake of DMSA-Tc 99m in Children - Correlation with Age and Creatinine Clearance