Eduardo G. Pérez-Yarza

Viruses in community-acquired pneumonia in children aged less than 3 years old: High rate of viral coinfection.

The occurrence of viral coinfections in childhood pneumonia has received little attention, probably because suitable detection methods have been lacking. Between November 2004 and October 2006, the presence of 14 respiratory viruses in children aged less than 3 years old with community‐acquired pneumonia were investigated using molecular or immunochromatographic techniques and/or viral culture. A total of 315 children (338 episodes) were included, and hospitalization was required in 178 episodes. At least one virus was detected in 66.9% of the episodes and simultaneous detection of two or more viruses was frequent (27% of the episodes with viral detection). The most frequently detected virus was respiratory syncytial virus (n = 67: 33 subgroup A, 33 subgroup B, 1 not typed), followed by human bocavirus (n = 48), rhinovirus (n = 46), human metapneumovirus (n = 39: 13 genotype A2, 8 B1, 5 B2, 1 A1, 12 not genotyped) and parainfluenza viruses (n = 38: 1 type 1, 3 type 2, 22 type 3, 11 type 4 and 1 not typed). The 14 viruses investigated were found in viral coinfections, which were more frequent in children aged less than 12 months. Except for adenovirus, the incidence of which was low, the percentage of viral coinfection ranged between 28.2% and 68.8%. Children with viral coinfection more frequently required hospital admission than those with single viral infection. It is concluded that viral coinfections are frequent in children aged less than 3 years old with community‐acquired pneumonia and can be a poor prognostic factor. J. Med. Virol. 80:1843–1849, 2008.

Human Bocavirus, a Respiratory and Enteric Virus

In Spain, human bocavirus (HBoV) was detected in 48 (9.1%) of 527 children with gastroenteritis at similar frequency as for children with respiratory illness (40/520, 7.7%). Fecal excretion adds new concern about the transmission of HBoV. To our knowledge, this report is the first to document HBoV in human feces.

The association between respiratory syncytial virus infection and the development of childhood asthma: a systematic review of the literature.

Background: The relation between early respiratory syncytial virus (RSV) infection and later emergence of episodes of wheezing/asthma remains a subject of debate. We carried out a systematic review of studies of the association between RSV infection in the first 36 months of life and the subsequent development of asthma/bronchial hyperreactivity. Methods: A literature search for original studies on RSV respiratory infection published in English or Spanish over the last 21 years was conducted in the bibliographic databases Medline, Embase, and Índice Médico Español, and in the Cochrane library. Articles were included if they described original studies of confirmed RSV infection in children under 3 years of age, and had defined outcome variables. The methodologic quality of articles included in the review was evaluated according to the Hadorn criteria. Results: The review included 12 original articles that respond to the research question. The studies evaluated showed that RSV lower respiratory tract infection is associated with an increased risk for subsequent development of asthma/recurrent wheezing, and that this association becomes progressively smaller with increasing age. Conclusion: On the basis of this systematic review of the literature, it can be concluded that a significant association exists between RSV infection in childhood and the long-term development of subsequent episodes of recurrent wheezing or asthma. However, the methodologic quality of the articles evaluated is limited, and hence additional studies are needed, ideally, with specific therapeutic interventions aimed at reducing RSV replication.

Improving anaphylaxis management in a pediatric emergency department

To cite this article: Arroabarren E, Lasa EM, Olaciregui I, Sarasqueta C, Muñoz JA, Pérez‐Yarza EG. Improving anaphylaxis management in a pediatric emergency department. Pediatric Allergy Immunology 2011; 22: 708–714.

Urokinase versus VATS for treatment of empyema: a randomized multicenter clinical trial.

BACKGROUND AND OBJECTIVE: Parapneumonic empyema (PPE) is a frequent complication of acute bacterial pneumonia in children. There is limited evidence regarding the optimal treatment of this condition. The aim of this study was to compare the efficacy of drainage plus urokinase versus video-assisted thoracoscopic surgery in the treatment of PPE in childhood. METHODS: This prospective, randomized, multicenter clinical trial enrolled patients aged <15 years and hospitalized with septated PPE. Study patients were randomized to receive urokinase or thoracoscopy. The main outcome variable was the length of hospital stay after treatment. The secondary outcomes were total length of hospital stay, number of days with the chest drain, number of days with fever, and treatment failures. The trial was approved by the ethics committees of all the participating hospitals. RESULTS: A total of 103 patients were randomized to treatment and analyzed; 53 were treated with thoracoscopy and 50 with urokinase. There were no differences in demographic characteristics or in the main baseline characteristics between the 2 groups. No statistically significant differences were found between thoracoscopy and urokinase in the median postoperative stay (10 vs 9 days), median hospital stay (14 vs 13 days), or days febrile after treatment (4 vs 6 days). A second intervention was required in 15% of children in the thoracoscopy group versus 10% in the urokinase group (P = .47). CONCLUSIONS: Drainage plus urokinase instillation is as effective as video-assisted thoracoscopic surgery as first-line treatment of septated PPE in children.

Características clínicas de los niños hospitalizados por infección por virus Influenza

Antecedentes Las manifestaciones clinicas de la gripe son bastante inespecificas y similares a otras infecciones virales, a procesos respiratorios de otra etiologia e incluso a cuadros septicos en lactantes. Existen pocos estudios sobre las caracteristicas clinicas de la infeccion por virus Influenza en ninos hospitalizados. Objetivo Evaluar las caracteristicas clinicas de los ninos hospitalizados por infeccion por virus Influenza en cuatro ondas epidemicas consecutivas (2000-2004). Material y metodos Estudio retrospectivo por revision de historias clinicas de los ninos hospitalizados por infeccion confirmada por virus Influenza A y B, mediante cultivo celular y reaccion en cadena de la polimerasa. Se registraron las variables:sexo, edad, clinica al ingreso, exploraciones complementarias,diagnostico y evolucion posterior. Resultados Fueron hospitalizados 84 ninos, 74 casos debidos a infeccion por virus Influenza AH3, 5 casos por virus Influenza AH1 y cinco por Influenza B. El 42,8% fueron menores de 6 meses. El cuadro clinico principal fue fiebre (75 casos), tos (56 casos), afectacion otorrinolaringologica (53 casos). Los diagnosticos mas frecuentes que motivaron el ingreso fueron sindrome febril (75 casos), bronquiolitis (19 casos), neumonia (13 casos) y bronquitis (8 casos). En 21 casos se objetivo coinfeccion viral o bacteriana,siendo la asociacion con virus respiratorio sincitial la coinfeccion mas frecuente (10 casos). Se han observado pocas diferencias entre los diferentes grupos de edad, excepto para neumonia y fiebre prolongada (mas frecuentes en mayores de 6 meses) y linfocitosis (en menores de 6 meses). El cuadro febril agudo en menores de 6 meses ha originado mayor numero de exploraciones complementarias en los de menor edad. Solo en tres ninos se encontraron factores de riesgo para hospitalizacion,todos ellos mayores de 6 meses. Todos los casos evolucionaron favorablemente. Conclusiones La infeccion por virus Influenza en los ninos que estan hospitalizados predomina en lactantes sanos, con fiebre y signos y sintomas respiratorios poco especificos, similares a otros cuadros infecciosos. Es necesario aplicar tecnicas diagnosticas microbiologicas especificas para el diagnostico precoz. Los lactantes sanos y menores de 24 meses constituyen el grupo de mayor riesgo para la hospitalizacion por infeccion por virus Influenza.

Prognostic score in acute meningococcemia

A prognostic score for children with acute meningococcemia is proposed. We reviewed 176 consecutive patients with acute meningococcemia with ten fatalities admitted to our pediatric ICU in the last 3 yr. The score was obtained from patients in shock, using a stepwise linear discriminant analysis of 18 clinical and laboratory variables on admission. Nine variables showed a significant discriminant power in predicting survival and death: coma, base excess, platelets, glucose, temperature, WBC, sex, purpura, and CSF. The score predicted survival in 100% and death in 91%. The predictive values were significantly better than evaluation by the frequencies of the usual clinical and laboratory variables.

Social, economic, and health impact of the respiratory syncytial virus: a systematic search

BackgroundBronchiolitis caused by the respiratory syncytial virus (RSV) and its related complications are common in infants born prematurely, with severe congenital heart disease, or bronchopulmonary dysplasia, as well as in immunosuppressed infants. There is a rich literature on the different aspects of RSV infection with a focus, for the most part, on specific risk populations. However, there is a need for a systematic global analysis of the impact of RSV infection in terms of use of resources and health impact on both children and adults. With this aim, we performed a systematic search of scientific evidence on the social, economic, and health impact of RSV infection.MethodsA systematic search of the following databases was performed: MEDLINE, EMBASE, Spanish Medical Index, MEDES-MEDicina in Spanish, Cochrane Plus Library, and Google without time limits. We selected 421 abstracts based on the 6,598 articles identified. From these abstracts, 4 RSV experts selected the most relevant articles. They selected 65 articles. After reading the full articles, 23 of their references were also selected. Finally, one more article found through a literature information alert system was included.ResultsThe information collected was summarized and organized into the following topics: 1. Impact on health (infections and respiratory complications, mid- to long-term lung function decline, recurrent wheezing, asthma, other complications such as otitis and rhino-conjunctivitis, and mortality; 2. Impact on resources (visits to primary care and specialists offices, emergency room visits, hospital admissions, ICU admissions, diagnostic tests, and treatments); 3. Impact on costs (direct and indirect costs); 4. Impact on quality of life; and 5. Strategies to reduce the impact (interventions on social and hygienic factors and prophylactic treatments).ConclusionsWe concluded that 1. The health impact of RSV infection is relevant and goes beyond the acute episode phase; 2. The health impact of RSV infection on children is much better documented than the impact on adults; 3. Further research is needed on mid- and long-term impact of RSV infection on the adult population, especially those at high-risk; 4. There is a need for interventions aimed at reducing the impact of RSV infection by targeting health education, information, and prophylaxis in high-risk populations.

Dynamics of Streptococcus pneumoniae Serotypes Causing Acute Otitis Media Isolated from Children with Spontaneous Middle-Ear Drainage over a 12-Year Period (1999–2010) in a Region of Northern Spain

The aim of this study was to determine the serotype and clonal distribution of pneumococci causing acute otitis media (AOM) and their relationship with recurrences and mixed infections with other microorganisms under the influence of the 7-valent pneumococcal conjugate vaccine (PCV7). To do this, all pneumococcal isolates collected from the spontaneous middle-ear drainage of children <5 years old diagnosed of AOM by their pediatrician or their general practitioner from 1999 to 2010 were phenotypically characterized and the most frequent serotypes were genotyped. In the 12-year study, 818 episodes of pneumococcal AOM were detected, mostly (70.5%) in children younger than 2 years old. In 262 episodes (32%), the pneumococci were isolated with another bacterium, mainly (n = 214) Haemophilus influenzae. Mixed infections were similar in children under or over 2 years old. The most frequent serotypes were 19A (n = 227, 27.8%), 3 (n = 92, 11.2%) and 19F (n = 74, 9%). Serotypes included in the PCV7 sharply decreased from 62.4% in the pre-vaccination (1999–2001) to 2.2% in the late post-vaccination period (2008–2010). Serotype diversity steadily increased after the introduction of the PCV7 but decreased from 2008–2010 due to the predominant role of serotype 19A isolates, mostly ST276 and ST320. The prevalence of serotype 3 doubled from 6.1% (20/326) in 1999–2004 to 14.6% (72/492) in 2005–2010. Relapses mainly occurred in male infants infected with isolates with diminished antimicrobial susceptibility. Reinfections caused by isolates with the same serotype but different genotype were frequent, highlighting the need for genetic studies to differentiate among similar strains. In conclusion, the main change in pneumococcal AOM observed after the introduction of the PCV7 was the sharp decrease in vaccine serotypes. Also notable was the high burden of serotype 19A in total pneumococcal AOM before and especially after the introduction of the PCV7, as well as in relapses and reinfections.

Óxido nítrico exhalado en niños: un indicador no invasivo de la inflamación de las vías aéreas

En este articulo se presenta una revision academica sobre la aplicabilidad de la medida de la fraccion exhalada de oxido nitrico (FE NO ) en ninos. De acuerdo con las normas conjuntas de la American Thoracic Society/European Respiratory Society, se describen los metodos de medida on-line en ninos colaboradores y no colaboradores, los registros off-line sin control de flujo de exhalacion y con control de flujo de exhalacion mediante restrictor de flujo dinamico, y el registro off-line a respiracion corriente en ninos no colaboradores. Se revisan los valores de normalidad, fundamentalmente con los analizadores de la FE NO por quimioluminiscencia, mediante registro on-line de una unica respiracion (media geometrica: 9,7 ppb –partes por mil millones–; limite superior del intervalo de confianza del 95%: 25,2 ppb). Los valores de la FE NO superiores a 17 ppb aportan un 81% de sensibilidad y un 80% de especificidad para predecir asma de fenotipo eosinofilico. Se analiza la respuesta de la FE NO al tratamiento antiinflamatorio y al seguimiento del asma. Por ultimo, se comparan los resultados entre los analizadores por quimioluminiscencia y los electroquimicos, portatiles. Estos ultimos ofrecen la posibilidad, en ninos mayores de 5 anos, de un seguimiento adecuado y universal del oxido nitrico exhalado como indicador emergente de la inflamacion eosinofilica en la enfermedad asmatica, de modo que facilitan el diagnostico, el control evolutivo y el seguimiento terapeutico.