Daniele Donà

Burden of acute otitis media in primary care pediatrics in Italy: a secondary data analysis from the Pedianet database

BackgroundThe incidence of acute otitis media (AOM) vary from country to country. Geographical variations together with differences in study designs, reporting and settings play a role. We assessed the incidence of AOM in Italian children seen by primary care paediatricians (PCPs), and described the methods used to diagnose the disease.MethodsThis secondary data analysis from the Pedianet database considered children aged 0 – 6 years between 01/2003 and 12/2007. The AOM episodes were identified and validated by means of patient diaries. Incidence rates/100 person-years (PY) were calculated for total AOM and for single or recurrent AOM.ResultsThe 92,373 children (52.1% males) were followed up for a total of 227,361 PY: 23,039 (24.9%) presented 38,241 episodes of AOM (94.6% single episodes and 5.4% recurrent episodes). The total incidence rate of AOM in the 5-year period was 16.8 episodes per 100 PY (95% CI: 16.7-16.9), including single AOM (15.9 episodes per 100 PY; 95% CI: 15.7-16.1) and recurrent AOM (0.9 episodes per 100 PY; 95% CI: 0.9-0.9). There was a slight and continuously negative trend decrease over time (annual percent change −4.6%; 95%CI: -5.3, -3.9%). The AOM incidence rate varied with age, peaking in children aged 3 to 4 years (22.2 episodes per 100 PY; 95% CI 21.8-22.7). The vast majority of the AOM episodes (36,842/38,241, 96.3%) were diagnosed using a static otoscope; a pneumatic otoscope was used in only 3.7%.ConclusionsOur data fill a gap in our knowledge of the incidence of AOM in Italy, and indicate that AOM represents a considerable burden for the Italian PCP system. Educational programmes concerning the diagnosis of AOM are needed, as are further studies to monitor the incidence in relation to the introduction of wider pneumococcal conjugate vaccines.

Antibiotic Prescriptions and Prophylaxis in Italian Children. Is It Time to Change? Data from the ARPEC Project

Background Antimicrobials are the most commonly prescribed drugs. Many studies have evaluated antibiotic prescriptions in the paediatric outpatient but few studies describing the real antibiotic consumption in Italian children’s hospitals have been published. Point-prevalence survey (PPS) has been shown to be a simple, feasible and reliable standardized method for antimicrobials surveillance in children and neonates admitted to the hospital. In this paper, we presented data from a PPS on antimicrobial prescriptions carried out in 7 large Italian paediatric institutions. Methods A 1-day PPS on antibiotic use in hospitalized neonates and children was performed in Italy between October and December 2012 as part of the Antibiotic Resistance and Prescribing in European Children project (ARPEC). Seven institutions in seven Italian cities were involved. The survey included all admitted patients less than 18 years of age present in the ward at 8:00 am on the day of the survey, who had at least one on-going antibiotic prescription. For all patients data about age, weight, underlying disease, antimicrobial agent, dose and indication for treatment were collected. Results The PPS was performed in 61 wards within 7 Italian institutions. A total of 899 patients were eligible and 349 (38.9%) had an on-going prescription for one or more antibiotics, with variable rates among the hospitals (25.7% - 53.8%). We describe antibiotic prescriptions separately in neonates (<30 days old) and children (> = 30 days to <18 years old). In the neonatal cohort, 62.8% received antibiotics for prophylaxis and only 37.2% on those on antibiotics were treated for infection. Penicillins and aminoglycosides were the most prescribed antibiotic classes. In the paediatric cohort, 64.4% of patients were receiving antibiotics for treatment of infections and 35.5% for prophylaxis. Third generation cephalosporins and penicillin plus inhibitors were the top two antibiotic classes. The main reason for prescribing antibiotic therapy in children was lower respiratory tract infections (LRTI), followed by febrile neutropenia/fever in oncologic patients, while, in neonates, sepsis was the most common indication for treatment. Focusing on prescriptions for LRTI, 43.3% of patients were treated with 3rd generation cephalosporins, followed by macrolides (26.9%), quinolones (16.4%) and carbapenems (14.9%) and 50.1% of LRTI cases were receiving more than one antibiotic. For neutropenic fever/fever in oncologic patients, the preferred antibiotics were penicillins with inhibitors (47.8%), followed by carbapenems (34.8%), aminoglycosides (26.1%) and glycopeptides (26.1%). Overall, the 60.9% of patients were treated with a combination therapy. Conclusions Our study provides insight on the Italian situation in terms of antibiotic prescriptions in hospitalized neonates and children. An over-use of third generation cephalosporins both for prophylaxis and treatment was the most worrisome finding. A misuse and abuse of carbapenems and quinolones was also noted. Antibiotic stewardship programs should immediately identify feasible targets to monitor and modify the prescription patterns in children’s hospital, also considering the continuous and alarming emergence of MDR bacteria.

Epidemiology of Frequently Occurring Skin Diseases in Italian Children from 2006 to 2012: A Retrospective, Population-Based Study

Recent estimates indicate an increase in the prevalence of skin diseases in children. Few large epidemiologic studies have examined prevalence trends in Europe. This study evaluated the incidence and prevalence of frequently occurring pediatric skin diseases (PSDs) in Italy as seen by family pediatricians (FPs).

Update on antiretroviral therapy in paediatrics

This review provides an update on the most relevant issues concerning the current management of HIV infection in infants and children. Tremendous progress has been made over the last few years to diagnose and treat infants and children with HIV infection, yet much remains to be done. Every day there are nearly 1150 new infections in children under 15 years of age, more than 90% of them occurring in the developing world and most being the result of transmission from mother-to-child (WHO 2008). The comprehensive approach to preventing mother-to-child transmission (MTCT) has clearly reduced the number of children acquiring the infection in Western countries; while a further reduction of mother-to-child transmission should be aimed for personalized setting, specific intervention needs to be put in place and new efforts are now required in order to optimise treatment and care in HIV-infected children. The prompt initiation of treatment and a careful selection of first-line regimen, which considers potency as well as tolerability remain central. In addition, occurrence and prevention of opportunistic infections, adherence as well as long-term psychosocial consequences are becoming more and more relevant in the era of effective antiretroviral therapy. This article forms part of a special issue of Antiviral Research marking the 25th anniversary of Antiretroviral Drug Discovery and Development, vol. 85, issue 1, 2010.

Community-Acquired Rotavirus Gastroenteritis Compared with Adenovirus and Norovirus Gastroenteritis in Italian Children: A Pedianet Study.

Background. Rotavirus (RV) is the commonest pathogen in the hospital and primary care settings, followed by Adenovirus (AV) and Norovirus (NV). Only few studies that assess the burden of RV gastroenteritis at the community level have been carried out. Objectives. To estimate incidence, disease characteristics, seasonal distribution, and working days lost by parents of RV, AV, and NV gastroenteritis leading to a family pediatrician (FP) visit among children < 5 years. Methods. 12-month, observational, prospective, FP-based study has been carried out using Pedianet database. Results. RVGE incidence was 1.04 per 100 person-years with the highest incidence in the first 2 years of life. Incidences of AVGEs (1.74) and NVGEs (1.51) were slightly higher with similar characteristics regarding age distribution and symptoms. Risk of hospitalisation, access to emergency room (ER), and workdays lost from parents were not significantly different in RVGEs compared to the other viral infections. Conclusions. Features of RVGE in terms of hospitalisation length and indirect cost are lower than those reported in previous studies. Results of the present study reflect the large variability of data present in the literature. This observation underlines the utility of primary care networks for AGE surveillance and further studies on community-acquired gastroenteritis in children.

Treatment of Community-Acquired Pneumonia: Are All Countries Treating Children in the Same Way? A Literature Review

Background Pneumonia represents an important threat to childrens health in both developed and developing countries. In the last 10 years, many national and international guidelines on the treatment of pediatric CAP have been published, in order to optimize the prescription of antibiotics and limit their cost and side effects. However, the practical implementation of these guidelines is still limited. Main Text We analyzed the current recommendations for the therapy of pediatric community-acquired pneumonia (CAP) that all converge on the identification of aminopenicillins and beta-lactams as the optimal treatment for CAP. We also conducted a review of the current literature on antibiotic regimens used for pediatric CAP to identify the current state of guidelines implementation in different settings. We selected 37 studies published from 2010 to 2016, including both retrospective and prospective studies, mainly cross-sectional and hospital based. The results show a global heterogeneity in the antibiotics prescription for pediatric CAP, with application of guidelines varying from 0% to more than 91% and with important differences even within the same country. Conclusions Our review has demonstrated that the implementation of the guidelines is still limited but also that achieving the optimal prescription is possible and can be done in both developed and developing countries.

Antibiotics Prescriptions in the Neonatal Intensive Care Unit: How to Overcome Everyday Challenges

Abstract Antimicrobial prescriptions in neonatal intensive care units (NICUs) represent a point of concern for the emergence of MDROs and for morbidity associated with prolonged antibiotic exposure (e.g., invasive candidiasis, necrotizing enterocolitis, and late‐onset sepsis). Antimicrobial stewardship programs (ASPs) have shown to be a valuable tool for the prevention of resistance with the goals of optimizing clinical outcomes while decreasing unnecessary prescribing. The most frequent ASP strategies include the correct collection and interpretation of microbiological specimens, prescription of the narrowest‐spectrum antibiotic appropriate for a particular case, and de‐escalation or discontinuation of therapy in defined situations. A robust ASP requires everyday multidisciplinary collaboration between ID physicians, neonatologist, clinical pharmacists, clinical microbiologists, infection control professionals, hospital epidemiologists, and information services specialists. Education and clinical pathways (e.g., sepsis or surgical prophylaxis pathways) are an excellent starting point if followed by proactive interventions such as prospective audits and feedback and formulary restriction with prior antimicrobial authorization. The current review outlines the problems faced in NICU antimicrobial prescribing and presents various solutions from the literature.

Prevention of Invasive Candidiasis in Premature Neonates: Administering Fluconazole or Not?

Purpose of the ReviewFluconazole prophylaxis (FP) for invasive candidiasis (IC) in preterm newborns is still a debated topic. In this review, we describe the most important papers on the topic, and we discuss pros and cons of the use FP in newborns according to these paper’s findings.Recent FindingsSince 2001, several studies have been published on the use of FP to prevent IC. While most of them agree on the effectiveness of FP in reducing IC, especially in NICUs with high IC rates, the lack of evidence of decrease in overall mortality, and the risks associated with fluconazole administration both concerning neurodevelopmental impairment and the increase in Candida resistances still pose great concern against the universal implementation of FP.SummaryA local risk-based selection strategy could represent the best choice to optimize the benefits of FP and minimize the potential long-term toxicity and the development of resistant pathogens.

Profilo lipidico e terapia antiretrovirale in una coorte di bambini, adolescenti e giovani adulti con infezione da HIV a trasmissione verticale.@@@Lipid profile and antiretroviral therapy in a cohort of children, adolescents and young adults infected with HIV by vertical transmission.

DOI: 10.19198/JHA31435 Riassunto Con l’introduzione della terapia antiretrovirale combinata (cART), l’infezione da HIV è diventata una patologia cronica, associata ad aterosclerosi accelerata e aumentato rischio di eventi cardiovascolari precoci. Numerosi studi, svolti sia nella popolazione adulta sia in quella pediatrica, hanno identificato l’origine multifattoriale di questo aumentato rischio cardiovascolare: l’effetto diretto del virus, l’infiammazione cronica e la prolungata esposizione alla terapia antiretrovirale concorrono infatti, insieme ai fattori di rischio classici, a determinare un’alterazione del profilo lipidico in senso aterosclerotico. Il nostro lavoro è uno studio osservazionale descrittivo trasversale, condotto su 76 pazienti seguiti presso l’Ambulatorio di Malattie infettive pediatriche dell’Azienda Ospedaliera di Padova. La popolazione comprende 35 maschi e 41 femmine, con range d’età 6-34 anni ed età media 21.1 anni; tutti i pazienti sono affetti da infezione da HIV acquisita per via verticale e tutti eccetto uno sono in cART. Il nostro scopo principale è stato indagare la prevalenza di alterazioni del profilo lipidico e la loro relazione con il tipo di terapia assunta e con lo stato viro-immunologico e infiammatorio. Lo studio ha evidenziato una quota elevata (57.9%) di pazienti con uno o più parametri lipidici alterati tra colesterolo totale, LDL, HDL e trigliceridi; per quanto riguarda la relazione tra alterazioni del profilo lipidico e terapia antiretrovirale, non abbiamo però rilevato associazioni significative. Quella dei pazienti pediatrici e giovani adulti con infezione verticale da HIV è quindi una popolazione ad elevato rischio di aterosclerosi precoce ed eventi cardiovascolari; la prevenzione è perciò fondamentale, sia a livello primario, sia a livello di screening e diagnosi precoce della patologia cardiovascolare. Abstract Following highly active antiretroviral therapy (HAART) introduction, HIV infection has become a chronic disease, characterized by premature atherosclerosis and increased incidence of cardiovascular events. Many studies, conducted both on adults and children, have shown that multiple factors are associated with this increased cardiovascular risk; direct viral effect, chronic inflammation, long lasting antiretroviral exposition and general cardiovascular risk factors contribute to the developement of dyslipidemia and consequently to increased cardiovascular risk. Our cross-sectional study has been conducted on 76 patients followed at the outpatient clinic for pediatric infectious diseases of Padua Hospital. The population included 35 boys and 41 girls, aged 6-34 years old (mean age 21.1 years); all patients have a perinatally-acquired HIV infection and 75 of them are on HAART. The primary aim of this study was to investigate the prevalence of lipid abnormalities and their relation with HAART regimen and with biomarkers of viro-immunological state and inflammation. We found a high prevalence of dyslipidemia among our patients (57.9%), with increased total cholesterol, LDL-cholesterol and triglycerides and low LDL-cholesterol. We did not find any significant difference in frequency of lipid profile alterations between patients treated with HAART regimens including protease inhibitors and patients treated with other regimes. Children and young adults with vertically-acquired HIV infection are exposed to premature atherosclerosis and cardiovascular events risk. Prevention is therefore very important, both by education and screening for early diagnosis of cardiovascular disease.

An unexpected fever post serogroup B meningococcal sepsis

This case report describes an invasive meningococcal group B infection followed by the development of Kawasaki disease (KD) complicated by macrophage activation syndrome (MAS) in a 2-year-old child. The presented case indicates the possible etiologic relationship between meningococcal sepsis and KD as support of bacterial toxin induced theory. It’s important to maintain a high grade of suspicious for KD in every relapse of fever also during convalescence phase of severe infection. Usually, initial treatment with intravenous immunoglobulin is sufficient to control the disease; but, in case of refractory KD complicated by MAS, corticosteroid therapy represents a good option inducing prompt fever resolution and clinical improvement.