C. Luaces Cubells

Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker

Background. Procalcitonin (PCT) is a potentially useful marker in pediatric Emergency Departments (ED). The basic objectives of this study were to assess the diagnostic performance of PCT for distinguishing between viral and bacterial infections and for the early detection of invasive bacterial infections in febrile children between 1 and 36 months old comparing it with C-reactive protein (CRP) and to evaluate the utility of a qualitative rapid test for PCT in ED. Methods. Prospective, observational and multicenter study that included 445 children who were treated for fever in pediatric ED. Quantitative and qualitative plasma values of PCT and CRP were correlated with the final diagnosis. To obtain the qualitative level of PCT the BRAHMS PCT-Q rapid test was used. Results. Mean PCT and CRP values in viral infections were 0.26 ng/ml and 15.5 mg/l, respectively. The area under the curve obtained for PCT in distinguishing between viral and bacterial infections was 0.82 (sensitivity, 65.5%; specificity, 94.3%; optimum cutoff, 0.53 ng/ml), whereas for CRP it was 0.78 (sensitivity, 63.5%; specificity, 84.2%; optimum cutoff, 27.5 mg/l). PCT and CRP values in invasive infections (PCT, 24.3 ng/ml; CRP 96.5 mg/l) were significantly higher than those for noninvasive infections (PCT, 0.32 ng/ml; CRP, 23.4 mg/l). The area under the curve for PCT was 0.95 (sensitivity, 91.3%; specificity, 93.5%; optimum cutoff, 0.59 ng/ml), significantly higher (P < 0.001) than that obtained for CRP (0.81). The optimum cutoff value for CRP was >27.5 mg/l with sensitivity and specificity of 78 and 75%, respectively. In infants in whom the evolution of fever was <12 h (n = 104), the diagnostic performance of PCT was also greater than that of CRP (area under the curve, 0.93 for PCT and 0.69 for CRP; P < 0.001). A good correlation between the quantitative values for PCT and the PCT-Q test was obtained in 87% of cases (kappa index, 0.8). The sensitivity of the PCT-Q test (cutoff >0.5 ng/ml) for detecting invasive infections and differentiating them from noninvasive infections was 90.6%, with a specificity of 83.6%. Conclusions. PCT offers better specificity than CRP for differentiating between the viral and bacterial etiology of the fever with similar sensitivity. PCT offers better sensibility and specificity than CRP to differentiate between invasive and noninvasive infection. PCT is confirmed as an excellent marker in detecting invasive infections in ED and can even make early detection possible of invasive infections if the evolution of the fever is <12 h. The PCT-Q test has a good correlation with the quantitative values of the marker.

Clinical data in children with meningococcal meningitis in a Spanish hospital

Neisseria meningitidis is the main cause of bacterial meningitis in Spain. Of the 213 children included in this study with meningococcal meningitis, 7 died. Mortality was linked to a shorter time from the first symptom to diagnosis (mean time for fatal cases was 9.5 h, mean time for survivors was 19h, p= 0.034), to deteriorated consciousness (DC) (mortality rate (MR) with DC = 6/87, MR without DC = 1/124, p= 0.02) and to shock (MR with shock = 5/7, MR without shock = 2/206, p < 0.0001). Previous treatment reduced the yield from blood culture (36/54 versus 45/137, p < 0.0001). Positivity in both Gram stain (GS) and cerebrospinal fluid (CSF) culture increased with longer duration of symptoms (mean GS+= 25h, GS‐= 16h, p= 0.004; CSF+= 20h, CSF‐= 12h, p= 0.001), and blood culture (BC) gave more positive results when carried out earlier (mean BC+= 14 h, BC = 24 h, p < 0.001). Reduced susceptibility to penicillin was seen in 34% of the strains, and rapidly evolving forms were responsible for most of the deaths; reduced susceptibility was more frequent among strains responsible for death or sequelae (9/15 = 60%) as compared with the more harmless strains (69/ 215 = 32%) (p= 0.04). The progressive reduction of susceptibility to penicillin indicates that it should be replaced by a third‐generation cephalosporine.

Guía de práctica clínica sobre la bronquiolitis aguda: recomendaciones para la práctica clínica

There are scientific controversies about the management of acute bronchiolitis that generate a great variability in the approach to this entity. A clinical practice guideline (CPG) is a set of systematically developed recommendations to assist practitioners and patients to make decisions based on evidence. A working group (WG) of experts has been selected and they have developed the clinical questions. A systematic search for evidence on the acute bronchiolitis has been done and the evidence has been assessed. The information obtained has been summarized in evidence tables and recommendations have been done from them. The WG has produced a total of 46 clinical questions grouped into sections (diagnosis, complementary tests, treatment, monitoring, prevention and evolution), resulting in 133 recommendations. The CPG on acute bronchiolitis provides an opportunity to unify clinical practice based on scientific evidence, which could rationalize the use of health resources, improving health care quality and equity of access to services.

Procalcitonina para el diagnóstico precoz de infección bacteriana invasiva en el lactante febril

Antecedentes La procalcitonina es un parametro nuevo de infeccion bacteriana. Por su vida media mas corta y ascenso masprecoz puede ofrecer ventajas respecto a la proteina C re-activa (PCR). Objetivo Evaluar la rentabilidad diagnostica de la procalcitonina en la deteccion precoz de infeccion bacteriana invasiva en el lactante febril frente a la PCR. Material y metodo Estudio prospectivo y observacional realizado en la sec-cion de urgencias entre enero de 1998 y febrero de2000 que incluyo lactantes entre 1 y 36 meses, atendidospor fiebre, en los que debieron practicarse determinacio-nes analiticas sanguineas. Se evaluaron los valores plas-maticos de procalcitonina y PCR y se correlacionan con el diagnostico final. Se elaboran las curvas ROC (receiva ope-rating characteristic) para ambos marcadores. Resultados Se incluyeron en el estudio 100 lactantes con edad media de 8,8 meses (DE, 7,59) distribuidos en 4 grupos de 25 pacientes (infeccion viral, bacteriana localizada, bacteriana invasiva y grupo control). Los valores medios de procalcitonina y PCR en infecciones invasivas (procalcitonina, 14,45 ng/ml [DE, 27,95]; PCR, 95,10 mg/l [DE, 33,04]) fueron significativamente superiores a las no invasivas (procalcitonina, 0,27 ng/ml [DE, 0,19]; PCR, 25,67 mg/l [DE, 33,04]) pero la rentabilidad diagnostica de procalcitonina fue mayor. El area bajo la curva para procalcitonina fue de 0,95 (DE, 0,03), superior a la obtenida para PCR (0,81 [DE, 0,05]) (p 0,4 ng/ml (sensibilidad 95,5 %, especificidad 86,4 %) y para PCR en > 42,9 mg/l con sensibilidad 75 % y especificidad 81,8 %. En los lactantes con fiebre inferior a 12 h (n = 30), el area bajo la curva para procalcitonina ha sido 0,90 (DE, 0,06), tambien superior a la PCR (0,64 [DE, 0,11]) (p 0,4 ng/ml (sensibilidad, 90 %; especificidad, 94 %) y para PCR es > 26,6 mg/l (sensibilidad, 60 %; especificidad, 77,8 %). Conclusion La procalcitonina es un marcador de mayor rentabilidad diagnostica que la PCR en la deteccion de infeccion bacteriana invasiva en el lactante febril incluso de forma precozen evoluciones inferiores a 12 h.

Perfil de los adolescentes que acuden a urgencias por intoxicación enólica aguda

Introduction In recent years, the prevalence of Acute Alcohol Intoxication (AAI) in adolescents has increased. One of its impacts had been the increase in consultations in the Emergency Services (ES). The objective of this study is to assess the psychosocial profile of adolescents who consult for AAI and study their personal, family and social functioning.INTRODUCTION In recent years, the prevalence of Acute Alcohol Intoxication (AAI) in adolescents has increased. One of its impacts had been the increase in consultations in the Emergency Services (ES). The objective of this study is to assess the psychosocial profile of adolescents who consult for AAI and study their personal, family and social functioning. METHODS 104 families of adolescents who attended for AAI in ES and 104 controls, matched by age and sex, were interviewed by telephone to obtain sociodemographic, clinical, academic and family functioning data. RESULTS 72% of the adolescents who were attended for AAI were under 16 years old. Academic data showed that 37.7% had repeated a school year, 20% had truancy and 19.6% abandoned their basic studies. 9,8% were in psychiatric treatment. Only 11.4% of patients were referred to specialist service. There were no significant differences between in any of the clinical variables between the study and control group. CONCLUSIONS This study provides new information on the characteristics of this population and provides guidance on the need to develop protocols for working in the ES that includes not only biochemical/ toxicological parameters but also includes the assessment of psychosocial parameters.

El niño febril. Resultados de un estudio multicéntrico

Objetivos Establecer el valor pronostico de los parametros clinicosy analiticos recogidos en un protocolo de estudio multicentricosobre el nino febril (0 a 36 meses) visitado enservicios de urgencias hospitalarios. Conocer la etiologiacausante de infecciones bacterianas potencialmente gravesen nuestro medio en este grupo de pacientes. Pacientes y metodos Se llevo a cabo el estudio prospectivo de los ninos de0 a 36 meses con fiebre mediante el cumplimiento de unprotocolo clinico y analitico que se aplico a ninos que acudierana los servicios de urgencias de los hospitales participantesy cumplieran los criterios de inclusion. Resultados Se recogieron un total de 937 casos de los cuales se excluyeron 43 por no haberse realizado un hemocultivo y 151 por no haberse practicado el obligado control hastaque quedaron afebriles o no tener un diagnostico final. Por ello, el tamano de la muestra fue de 743 pacientes. La valoracion clinica es fundamental para distinguir alos pacientes afectados de enfermedad bacteriana potencialmente grave. Entre los parametros analiticos la leucocitosis(> 15.000 leucocitos), leucopenia ( Conclusiones La experiencia del pediatra apoyada en parametros clinicosy analiticos son los argumentos mas solidos paradetectar ninos febriles (0 a 36 meses) con enfermedad bacteriana potencialmente grave.

Celulitis orbitaria y periorbitaria. Revisión de 107 casos

Objetivos Revisar la epidemiologia, manifestaciones clinicas, manejo y complicaciones de las celulitis periorbitarias y orbitarias. Conocer la utilidad de las pruebas de imagen en la deteccion de dichas complicaciones Material y metodos Estudio retrospectivo de los pacientes pediatricos afectos de celulitis periorbitaria u orbitaria ingresados desde enero de 1991 hasta enero de 1999 Resultados Se incluyeron 107 pacientes, con edad de maxima incidencia durante el segundo ano de vida, sin predominio significativo en ninguno de los dos sexos y con mayor incidencia en invierno En 68 pacientes (63,6%) se identifico una sinusitis como causa de la celulitis. Los germenes mas frecuentemente aislados fueron Staphylococcus aureus, Streptococcus pneumoniae y Streptococcus pyogenes. Mediante tomografia computarizada (TC) se detecto afectacion retrosep-tal en 36 pacientes, con 23 abscesos subperiosticos, 3 abscesos orbitarios y tres complicaciones intracraneales El tratamiento instaurado al ingreso fue monoterapia antibiotica (cefotaxima, cefuroxima o amoxicilina-clavula-nico) en el 69 % de los casos y politerapia en le 31 % de los pacientes. El 8,4% requirio cirugia Conclusiones La celulitis orbitaria es un proceso potencialmente grave y relativamente frecuente en la infancia. Para determinar el pronostico es muy importante la prontitud con que se determine y la extension de la afectacion mediante pruebas de imagen, que determinaran la necesidad o no de drenaje quirurgico

Calidad de la prescripción antibiótica en un servicio de urgencias pediátrico hospitalario

INTRODUCTION Adequate antibiotic prescribing in Paediatric Emergency Departments (PEDs) is a necessity due to the high number of patients consulting for infectious diseases. The aim of this study was to evaluate the antibiotic prescription quality in a PED. MATERIAL AND METHODS Retrospective study of patients attending a PED and diagnosed with acute otitis media, pharyngotonsillitis or community-acquired pneumonia during 2008. A random sample of 100 cases for each disease was selected. The parameters employed for assessing the prescribing quality were: illness subject to being treated with antibiotics, adequate antibiotic, dosage, interval of administration and length of treatment. An error in any of these parameters was considered an inappropriate prescription. The appropriateness of the antibiotic prescriptions was assessed based on the recommendations described on our hospital protocols. RESULTS Antibiotics were prescribed to 219 patients (73%). Therapy was considered to be inappropriate in 67 children (22.3%). Unnecessary treatment was indicated in 15 cases (6.8%) and in 4 patients (2%) the antibiotic selected was incorrect. Antibiotic was not prescribed to one patient subject to being treated (1.2%). The treatment length was wrong in 22 cases (11.5%), inappropriately short in all of them, the interval of administration in 20 (10.1%) and dosage in 13 (6.5%). CONCLUSIONS The use of antibiotics was appropriate for the diseases analysed, particularly as regards to the indication and antibiotic selection. The length of the treatment was the aspect found to be most deficient. Some important measures should be undertaken in order to improve antibiotic prescription quality.

Intoxicaciones voluntarias como intento de suicidio

Antecedentes La intoxicacion voluntaria como intento de suicidio es actualmente un problema importante entre la poblacion adolescente. La tentativa de suicidio es la urgencia psiquiatrica mas frecuente en la adolescencia. Presentamos nuestra experiencia sobre intoxicaciones voluntarias durante un periodo de 2 anos. Material y metodos Estudio retrospectivo y descriptivo de los pacientes ingresados por intoxicaciones voluntarias desde enero de 1996 hasta diciembre de 1997. Se analizan: sexo, edad y hora de la intoxicacion, antecedentes de habitos toxicos, controles psiquiatricos o intoxicaciones previas, tipo y obtencion del toxico utilizado, sintomatologia presentada en el momento de acudir a urgencias, actitud terapeutica y exploraciones complementarias mas utilizadas, y dias de estancia hospitalaria. Resultados Durante el periodo de estudio ingresaron 46 pacientes. La edad mediana fue de 15,6 anos, siendo mas frecuente en el sexo femenino (40 casos) (87%). Un 60,9% (28 casos) habia sido controlado previamente en algun servicio de psiquiatria. El toxico utilizado fue de naturaleza farmacologica, y es obtenido en 38 pacientes (82,6%) del botiquin del hogar. En 22 casos (47,8%) se trata de intoxicacion multiple. El 13% (6 pacientes) requirio hospitalizacion en cuidados intensivos. La duracion media de la estancia hospitalaria fue de 3 dias. Comentarios Las intoxicaciones voluntarias como intento de suicidio representan un problema importante entre la poblacion adolescente, y sobre todo entre las adolescentes de sexo femenino. La identificacion de la poblacion de riesgo seria la mejor medida preventiva, constituida por adolescentes, de sexo femenino en su mayoria, con depresion, trastornos de la conducta alimentaria o tentativas de suicidio anteriores.

Registro de traumatismos craneoencefálicos leves: estudio multicéntrico de la Sociedad Española de Urgencias Pediátricas

OBJECTIVE To determine management practices of minor head trauma in children evaluated at Spanish Hospital Emergency Departments and to determine patient variables associated with intracranial injury. METHODS Multicenter and prospective study during 18 months in 9 hospitals in Spain. Patients up to the age of 18 years with minor head trauma (Glasgow Coma Scale score higher than or equal to 13 on admission), treated in Emergency Departments and with a maximum onset of 72h since the traumatism, were included in the study. RESULTS A total of 1070 patients were studied with a median age of 2.4 years (p25-75 0.9-6.4 years); 61.2% were male. The median time between head trauma and medical consultation was 1 hour (p25-75 0.6-2.5h). Skull X-rays were performed on 64.5% of the children and a head CT scan on 9%; 91.4% of X-ray and 84.4% of CT were normal. The prevalence of intracranial injury was 1.4% (95% CI: 0.8-2.3). Twenty-five point three percent of the patients were admitted; 4 (3.7%) required neurosurgical intervention during admission. None of the patients died. Multiple logistic regression analysis identified loss of consciousness (OR 4.2, 95% CI: 1.1-17; P=0.045), neurological deterioration (OR 8.8, 95% CI: 2.1-37.6; P=0.003) and cephalhaematoma (OR 14.6, 95% CI: 4.9-44; P <0.001) as independent predictors of intracranial injury. CONCLUSIONS The combination of clinical parameters allows selection of patients with minor head trauma who need complementary explorations. In consequence, the routine use of skull X-ray in their initial evaluation is unnecessary.