F. Dubos

Bronchiolite aiguë du nourrisson

Resume La bronchiolite aigue est linfection respiratoire basse la plus frequente chez le nourrisson. Elle survient chaque hiver par epidemies, et lagent viral le plus frequent est le virus respiratoire syncytial (VRS). Les symptomes restent le plus souvent moderes, permettant le maintien a domicile, et evoluent favorablement en quelques jours. Toutefois, la gravite de la detresse respiratoire, notamment chez les enfants a risque (antecedent de prematurite, de detresse respiratoire neonatale et de dysplasie bronchopulmonaire, âge inferieur a 3 mois, maladie chronique) peut justifier lhospitalisation. Le traitement reste essentiellement symptomatique (hydratation, desinfection rhinopharyngee, eventuellement oxygenotherapie), dans la mesure ou les bronchodilatateurs sont inconstamment efficaces, les corticoides inefficaces, et les antibiotiques habituellement inutiles. La kinesitherapie de drainage peut etre prescrite en cas dencombrement. Les espoirs se tournent maintenant vers les traitements preventifs, comme les immunoglobulines specifiques anti-VRS, deja disponibles pour certains enfants a risque de forme severe, et peut-etre dans lavenir un vaccin.

Antimicrobial treatment of urinary tract infections in children

Urinary tract infections are the most frequent documented bacterial infections in children. The antibiotic choices proposed in this manuscript are based on the guidelines published by the Pediatric Infectious Disease Group (GPIP) and the French-Language Infectious Disease Society (SPILF). Dipstick positive for leukocytes and/or nitrites must precede in most circumstances (excluding the newborns, neutropenic patients and those with sepsis), urine culture and antibiotic prescription. The proportion of extended-spectrum β-lactamase (ESBL) Escherichia coli strains has increased steadily in recent years, and the situations in which oral antibiotic switch is frequently not available are increasing. Cephalosporin resistance remains below 10% in most regions of France. However, there is no doubt that the proportion of resistant strains will increase in the coming years: the only uncertainly concerns the speed of this trend. With the aim of saving penems and promoting outpatient care, this guide proposes among the acceptable initial treatments for febrile urinary tract infections in infants, amikacin. This aminoglycoside remains active against the majority of ESBL strains and can be prescribed in once-daily dose allowing also ambulatory management of patients from pediatric emergency department.

Retrospective study of imported falciparum malaria in French paediatric intensive care units

Objective The World Health Organization (WHO) severity criteria for paediatric Plasmodium falciparum (Pf) malaria are based on studies in countries of endemic malaria. The relevance of these criteria for other countries remains unclear. We assessed the relevance of these criteria in an industrialised country. Design Retrospective case-control study. Setting Eight French university hospitals, from 2006 to 2012. Patients Children with Pf malaria admitted to paediatric intensive care units (cases: n=55) or paediatric emergency departments (controls: n=110). Main outcome measures Descriptive analysis of WHO severity criteria and major interventions (mechanical ventilation, blood transfusion, fluid challenge, treatment of cerebral oedema, renal replacement therapy). Thresholds were set by receiver operating characteristics curve analysis. Results Altered consciousness (71% vs 5%), shock (24% vs 1%), renal failure (20% vs 1%), anaemia <50u2005g/L (7% vs 2%), acidosis (38% vs 0%), bilirubin level >50u2005µmol/L (25% vs 8%) and parasitaemia >10% (30% vs 8%) were more frequent in cases (p<0.01). All these criteria were associated with major interventions (p<0.001). Respiratory distress (six cases), and hypoglycaemia (two cases) were infrequent. Thrombocytopenia <50u2005000/mm3 (46% vs 7%) and anaemia (haemoglobin concentration <70u2005g/L (41% vs 13%)) were more frequent in cases (p<0.0001). Conclusions The WHO severity criteria for paediatric Pf malaria are relevant for countries without endemic malaria. The infrequent but severe complications also provide a timely reminder of the morbidity and mortality associated with this condition worldwide. In non-endemic countries haemoglobin <70u2005g/L and platelet count <50u2005000/mm3 could be used as additional criteria to identify children needing high level of care.

Extended-spectrum β-lactamase-producing Enterobacteriaceae, national study of antimicrobial treatment for pediatric urinary tract infection

OBJECTIVEnTo evaluate clinical practices for ESBL-producing urinary tract infection (UTI) in France.nnnMETHODSnWe performed an observational, retrospective, cross-sectional, hospital-based study in 22 pediatric departments of university or secondary care hospitals. We collected data of the last five patients presenting with ESBL-producing UTI in 2012 and the physicians therapeutic approach to two case vignettes of acute non-septic ESBL-producing pyelonephritis (7-month-old girl) and cystitis (30-month-old girl). The adequacy of the therapeutic decision was analyzed by a panel of independent infectious disease experts.nnnRESULTSnA total of 80 case patients of ESBL-producing UTI were collected: 54 with acute pyelonephritis (mean age: 28 months, female: 66%), of whom 98% received an intravenous ESBL-adapted antibiotic treatment and 55% a two-drug antibiotic therapy. Carbapenems were used in 56% of cases and aminoglycosides in 36%. Of the 26 cystitis patients (mean age: 5 years, female: 73%), 85% were treated with antibiotics, including three intravenously (carbapenems=2). For the case vignettes, physicians (n=85) would have treated the pyelonephritis patient with carbapenems (76%) and/or aminoglycosides (68%); 71% would have used a two-drug antibiotic treatment. The cystitis patient would have been treated intravenously by 29% of physicians; 8% would have used a two-drug antibiotic treatment, 16% would have prescribed carbapenems, and 11% aminoglycosides. Antibiotic treatments were deemed appropriate in 37% of cases.nnnCONCLUSIONSnAntimicrobial treatment for ESBL-producing UTI greatly varies, and carbapenems are excessively prescribed. Specific guidelines for ESBL infections are required.

Antibiotic treatment of lower respiratory tract infections

Lower respiratory tract infections, i.e., bronchitis, bronchiolitis, and pneumonia, are the second leading cause of antibiotic prescriptions. The vast majority of these infections are due to viruses and are self-limited diseases: most patients recover spontaneously. These two facts explain that antibiotic prescriptions must be limited to some clinical situations for which the diagnosis has to be done early. The first message of this manuscript is to strengthen non-antibiotic prescriptions in many situations such as bronchitis and bronchiolitis. Implementation of pneumococcal conjugate vaccines (PCVs) has reduced the incidence of pneumonia and empyema, and induced a dramatic decrease in the proportion of pneumococcus in these diseases. However, pneumococcus remains probably the leading cause of bacterial pneumonia and empyema and the main target of antibiotic treatment. Furthermore, the implementation of PCVs has reduced resistance to antibiotics including penicillins and macrolides antibiotics, explaining the de-escalation proposed in the last few years, with the reduction of the use if third generation cephalosporins and vancomycin. The therapeutic choices proposed in this article follow the previous official guidelines in France. Serious infections represented by empyema and severe pneumonia remain therapeutic emergencies, most often warranting hospitalization and IV antibiotics.

SFP PC-80 – Critères de gravité du paludisme d’importation pédiatrique en France

Objectifs La severite du paludisme est appreciee par les criteres de gravite definis par l’OMS en 2000. Notre objectif etait d’evaluer leur pertinence et frequence chez l’enfant presentant un paludisme d’importation. Methodes Etude retrospective nationale, cas-temoin, comparant entre 2006 et 2012 des enfants admis en reanimation (REA, n=55) pour paludisme d’importation a une population controle (n=110) consultant aux Urgences pour paludisme. La severite etait appreciee par la realisation d’Actes Therapeutiques Majeurs (ATM) (remplissage vasculaire, transfusion, amines vasopressives, ventilation mecanique, traitement d’une HTIC). Resultats 62% des enfants admis en REA recevaient au moins 1 ATM, versus 10% des temoins (p 4% (58% vs 25% ; p Conclusion Les criteres de gravite de l’OMS semblent pertinents pour evaluer la severite du paludisme d’importation, toutefois des ajustements sont a envisager.