Elisa Bartolini

Community-Acquired Bacteremic Pneumococcal Pneumonia in Children: Diagnosis and Serotyping by Real-Time Polymerase Chain Reaction Using Blood Samples

BACKGROUND The aim of this study was to use real-time polymerase chain reaction (RT-PCR) on blood samples to diagnose and serotype pneumococcal infection in a large cohort of Italian children hospitalized for community-acquired pneumonia. METHODS We conducted an observational study from April 2007 through June 2009 of children aged 0-16 years with a diagnosis of community-acquired pneumonia admitted to 83 pediatric hospitals in Italy. RESULTS Seven hundred fifty-three children were studied. RT-PCR found pneumococcal infection in 80 (10.6%) of 753 patients. In 292 patients, culture and RT-PCR were simultaneously performed. Streptococcus pneumoniae was identified in 47 of 292 patients; 45 (15.4%) tested positive by RT-PCR and 11 (3.8%) tested positive by culture. RT-PCR was significantly more sensitive than culture in revealing bacteremic pneumonia (odds ratio, 30.6; 95% confidence interval, 5.8-97.5; P<.001). Complicated pneumonia was found in 162 (21.5%) of 753 children; 152 (93.8%) of these 162 had parapneumonic effusion, and 51 (33.6%) had empyema. Children with complicated pneumonia were significantly older. Pneumococcal bacteremia was found by RT-PCR to occur significantly more frequently in children with complications (38 [23.5%] of 162) than in children with uncomplicated pneumonia (44 [7.4%] of 591; odds ratio, 3.8; 95% confidence interval, 2.30-6.30; P<.001). RT-PCR allowed serotyping from blood in 92.5% of patients. More than two-thirds of the pneumonia cases were due to nonpneumococcal conjugate vaccine 7 serotypes. Serotype 1 was the most frequent serotype (26 [32.5%] of 80) and was significantly associated with complications (50.0% in patients with complicated pneumonia vs 18.2% in patients with uncomplicated pneumonia; odds ratio, 4.5, 95% confidence interval, 1.48-14.03; P=.005) and older age. Serotype 19A was second in frequency (15.0%) and was significantly associated with younger age. CONCLUSIONS RT-PCR allows diagnosis and serotyping of pneumococcal bacteremic community-acquired pneumonia in children and is an important tool for evaluating serotype distribution in culture-negative samples.

Comparison of the effect of antibiotic treatment on the possibility of diagnosing invasive pneumococcal disease by culture or molecular methods: A prospective, observational study of children and adolescents with proven pneumococcal infection

BACKGROUND Detection of Streptococcus pneumoniae in culture specimens in invasive pneumococcal disease (IPD) may be hampered by antibiotic treatment administered before hospital admission. Realtime polymerase chain reaction (RT-PCR) assays do not require viable bacteria and are therefore less influenced by antimicrobial therapy. It is not known how long results of culture or molecular tests remain positive after antibiotic therapy is begun. OBJECTIVE The goal of the current study was to assess, in a pediatric population with a diagnosis of IPD confirmed by laboratory tests (culture and/or RT-PCR assay), the relationship between use of antibiotic therapy before hospital admission and the result of diagnostic methods (culture or molecular techniques) after admission. METHODS This prospective, observational study was conducted from April 2006 through March 2009. All children and adolescents aged 0 to 16 years, admitted to the hospital with a diagnosis of IPD confirmed by culture and/or molecular methods, were included in the study. Previous antibiotic treatment (drug, duration of therapy) was recorded. Primers and probes designed from the pneumococcal autolysin gene (lytA) were used in an RT-PCR assay for detection of S pneumoniae. Antibiotic tolerability, permanent sequelae (after a 6-month follow-up), and deaths were recorded. RESULTS Eighty-three patients (50 males, 33 females; 80 white, 3 Asian; mean age, 4.6 years; median age, 4.0 years; age range, 10 days-16 years) were included in the study. Fifty-four patients presented with pneumonia, 26 with meningitis/sepsis (meningitis, 19; sepsis, 7), and 3 with arthritis. Results of RT-PCR assays were positive in all 83 patients (100.0%), and 28 of the 83 patients (33.7%) also had culture-positive findings. Forty-two of the 83 patients (50.6%) had received antibiotic treatment before hospital admission, and 41 (49.4%) had not received antibiotics. Results of cultures were positive in 9 of the 42 patients with IPD (21.4%) who had received antibiotic treatment and in 19 of the 41 patients with IPD (46.3%) who had not received antibiotics (odds ratio, 3.2; 95% CI, 1.1-9.3; P = 0.03). Molecular methods appeared more sensitive than culture in any type of disease studied but particularly in patients with pneumonia, in whom the difference was statistically significant (P = 0.043). The mean length of antibiotic therapy was 1.4 days (median, 1 day; SD, 0.53 day; range, 1-2 days) for culture-confirmed cases and 4.5 days (median, 4 days; SD, 3.08 days; range, 1-15 days) for cases confirmed by RT-PCR assay (P = 0.002). No adverse reactions to the antibiotics used during home or hospital treatment were found. Two patients with meningitis suffered permanent, severe neurologic sequelae, and 1 girl died of sepsis 3 days after hospital admission. No permanent sequelae were recorded in patients with pneumonia or arthritis. CONCLUSION In these children and adolescents with IPD, the molecular methods used appeared to be more sensitive than culture in any IPD patient, with a higher statistical significance in patients previously treated with antibiotics and in patients with pneumonia.

Thyroid function and anti-thyroid autoantibodies in untreated children with vertically acquired chronic hepatitis C virus infection

Objective  The reported data on thyroid function and anti‐thyroid autoantibodies in adults with untreated hepatitis C virus (HCV) infection are controversial. Data are scarce for HCV‐infected children, and only in those treated with interferon‐α (IFN‐α). We investigated thyroid function and anti‐thyroid autoantibodies in a cohort of untreated children with vertically acquired, chronic, HCV infection.

Comparative Analysis of rs12979860 SNP of the IFNL3 Gene in Children with Hepatitis C and Ethnic Matched Controls Using 1000 Genomes Project Data

The rs12979860 single nucleotide polymorphism located on chromosome 19q13.13 near the interferon L3 gene (formerly and commonly known as interleukin 28B gene) has been associated in adults with both spontaneous and treatment induced clearance of hepatitis C virus. Although the exact mechanism of these associations remains unclear, it suggests that variation in genes involved in the immune response against the virus favours viral clearance. Limited and preliminary data are available on this issue in children. The aim of the present study was to evaluate, in a representative cohort of children with perinatal infection, the potential association between rs12979860 single nucleotide polymorphism and the outcome of hepatitis C virus infection. Alleles and genotypes frequencies were evaluated in 30 children who spontaneously cleared the virus and in 147 children with persistent infection and were compared with a population sample of ethnically matched controls with unknown hepatitis C status obtained using the 1000 Genomes Project data. The C allele and the C/C genotype showed greater frequencies in the clearance group (76.7% and 56.7%, respectively) when compared with both children with viral persistence (C allele 56.5%, p = 0.004; C/C genotype 32.7%, p = 0.02) and with the ethnically matched individuals (C allele 59.7%, p = 0.02; C/C genotype 34.7%, p = 0.03). Children with the C/C genotype were 2 times more likely to clear hepatitis C virus relative to children with the C/T and T/T genotypes combined (odds ratio: 2.7; 90% confidence intervals: 1.3–5.8). The present study provides the evidence that the rs12979860 single nucleotide polymorphism influences the natural history of hepatitis C virus in children.

Autoimmunity and Extrahepatic Manifestations in Treatment-Naïve Children with Chronic Hepatitis C Virus Infection

Hepatitis C virus (HCV) infection has been associated with autoimmunity and extrahepatic manifestations in adults. Few data are available on these topics in children. Nonorgan specific auto-antibodies development is part of the natural course of chronic hepatitis C in children. Smooth muscle autoantibody is the most common autoantibody found, while liver-kidney microsomal type-1 antibody positivity is the most peculiar autoimmune feature of children with HCV infection. The clinical significance of non-organ specific autoantibodies in the course of paediatric chronic hepatitis C is still debated. Autoantibody positivity can be considered neutral for most patients, while it can be associated with negative connotations for others, especially those positive for liver-kidney microsomal type-1 autoantibody. Subclinical hypothyroidism but not autoimmune thyroiditis has been demonstrated in HCV infection in children, while only few cases of HCV-associated membranoproliferative glomerulonephritis have been described. Single reports are available in the literature reporting the anecdotal association between chronic hepatitis C and other extrahepatic manifestations such as myopathy and opsoclonus-myoclonus syndrome. Despite the low incidence of extrahepatic manifestations of chronic hepatitis C in children, overall, available data suggest a careful monitoring.

Interleukin 28B rs12979860 single-nucleotide polymorphism predicts spontaneous clearance of hepatitis C virus in children.

Objective: Recent genome-wide association studies performed in adults correlated single-nucleotide polymorphisms (SNPs rs12979860 and rs8099917) located on chromosome 19, upstream of the interleukin 28B gene, with spontaneous clearance of hepatitis C virus and with response to treatment with paginated interferon and ribavirin. The aim of the present collaborative study was to evaluate the rs12979860 SNP in a large cohort of Italian children with perinatal acquisition of hepatitis C. Methods: Children were prospectively enrolled in 2 Italian centers. The interleukin 28B rs12979860 SNP was studied according to the diagnosis of chronic infection or spontaneous clearance. Results: One hundred thirty children (86.7%) with chronic infection and 23 (13.3%) with spontaneous clearance of the virus were enrolled. Overall, the interleukin 28B C/C and C/T-T/T genotypes were found in 57 (37.3%) and 96 (62.7%) children, respectively. The proportion of C/C genotype was higher among children who cleared infection (14/23; 60.9%) compared with children with chronic infection (43/130; 33.1%; P = 0.01; odds ratio 3.15; 90% confidence intervals 1.34–7.53). Conclusions: The present study showed that, as already demonstrated in adults, children with the rs12979860 C/C SNP of the interleukin 28B gene have a higher probability of spontaneous clearance of hepatitis C virus.

Intrafamilial transmission of hepatitis C virus: Infection of the father predicts the risk of perinatal transmission

The aims of the present study were to evaluate in a cohort of mothers infected with hepatitis C virus (HCV) the prevalence of HCV infection of their sexual partners, the influence of infection of the partners on perinatal transmission, and whether this influence is mediated by other well known risk factors for perinatal transmission. Forty‐nine consecutive mothers infected with HCV who transmitted infection to their offspring and, as a control group, 557 consecutive mothers infected with HCV who did not transmit infection, together with their children and the fathers of the children who were also the sexual partners of the mothers were evaluated. History of intravenous drug use was significantly more frequent in women with partners infected with HCV than in women with partners not infected [115/180 (63.9%) vs. 87/401 (21.7%); relative risk (RR): 6.38, 95% confidence intervals (CI): 4.34–9.39, P < 10−3]. HCV infection was more frequent in the partners of mothers who transmitted perinatally HCV [23/49 (46.9%) vs. 174/557 (31.2%); RR: 1.95, 95%CI: 1.08–3.51, P = 0.03]. Multivariate analysis demonstrated that paternal HCV infection is not a risk factor per se for perinatal HCV transmission, but its role is dependent on maternal intravenous drug use [adjusted RR: 1.23 (95%CI: 0.44–3.39, P = 0.6)]. In conclusion, the present study shows that partners of mothers infected with HCV with a history of intravenous drug use were at a higher risk of HCV infection. HCV infection of the father seems to be associated with perinatal transmission but this relationship is dependent on maternal history of intravenous drug use. J. Med. Virol. 80:1907–1911, 2008.

Chronic hepatitis C virus infection in children and adolescents: Epidemiology, natural history, and assessment of the safety and efficacy of combination therapy

Hepatitis C virus (HCV) is the most common cause of chronic liver disease of infectious etiology in children. Most of the children infected with HCV are asymptomatic, and only a few of them develop signs and symptoms of end-stage liver disease early in life. It is not possible to predict either in which patients HCV infection will have a bad outcome or the critical time in early adulthood when disease progression will accelerate. The experiences with therapy in children with chronic hepatitis C are based on earlier and continuing data from adult trials. The currently recommended treatment for chronic HCV infection in adults is the combination of peginterferon-á and ribavirin. The choice of this regimen is based on the results of randomized clinical trials that demonstrated the superiority of this combination treatment over standard interferon-á and ribavirin. Recently, results of pivotal, multicenter, interventional open-label studies on combined treatment with peginterferon-á and ribavirin in children have been published, and the US Food and Drug Administration and the European Medicines Agency have approved the combination therapy in those older than 3 years. The aim of this review is to evaluate critically the available data regarding the safety and efficacy of combination treatment with peginterferon-á and ribavirin in children.

Incidence and clinical significance of reactive thrombocytosis in children aged 1 to 24 months, hospitalized for community-acquired infections.

The aims of this study were to identify demographic, clinical and laboratory characteristics associated with reactive thrombocytosis useful for clinical management and to evaluate potential complications of this condition in a cohort of children selected for they young age as at high risk of reactive thrombocytosis. Retrospective analysis of medical records of 239 children among 902 aged 1–24 months, hospitalized during a 12-month period, and discharged with a diagnosis of infectious disease was performed. One hundred and nineteen children out of 239 (49.8%) presented thrombocytosis (>500 platelets × 109/L; normal range 150–499 × 109/L), 81/119 (68%) on admission. The incidences of thrombocytosis or extreme thrombocytosis (>1,000 × 109/L) were 13.2% (119/902) and 0.8% (7/902). Thrombocytotic children had higher counts of white blood cells and had been treated more frequently with steroids (36/82, 43.9% vs. 5/53, 9.4%; p = 5 × 10−5; relative risk 7.51, 95% confidence intervals 2.71–20.82). No significant difference was found in relation to sex, age, fever, C reactive protein level, diagnoses and antibiotic therapy. Two out of 239 (0.8%) enrolled children, both thrombocytotic and with other acquired risk factors, developed thrombosis. In conclusion, reactive thrombocytosis in children aged 1 up to 24 months is frequent and unrelated to markers of disease activity or degree of inflammation.

Hepatitis C in Children Co-infected With Human Immunodeficiency Virus.

Objectives: The objective of this systematic review was to summarize evidence regarding hepatitis C in hepatitis C virus/human immunodeficiency virus (HCV/HIV)–co-infected children focusing on mother-to-child transmission, clinical and laboratory features, outcome, and therapies. Methods: A literature search was performed using multiple keywords and standardized terminology in MEDLINE, EMBASE, and Cochrane databases dating back to their inception up to April 1, 2015, using the following terms hepatitis C virus, HIV, and child. Results: Fifty-five of 367 publications were selected for inclusion. In co-infected children, HIV impacted all the different aspects of HCV infection. Maternal HIV infection increased the risk of vertical transmission of hepatitis C. Children with HCV/HIV co-infection presented a lower rate of spontaneous clearance of HCV, were more commonly HCV viraemic, and had higher values of alanine aminotransferase when compared with HCV-monoinfected children. No relevant difference was reported between monoinfection and co-infection with regard to clinical findings. Although the data on the outcome of hepatitis C in the context of co-infection were limited, they were highly suggestive of a more severe outcome in terms of fibrosis in co-infected children. No pediatric data were available on the role of antiretroviral therapy as a cofactor of liver injury in HCV/HIV co-infection. The efficacy of pegylated interferon-&agr; and ribavirin in children with HCV/HIV co-infection was lower than in monoinfected children. Conclusions: The effect of HIV co-infection on HCV-related disease was clear with most studies indicating that HIV accelerates HCV progression and reduces the efficacy of the available anti-HCV therapies.