Javier Prego

Infecciones de piel y partes blandas en pacientes ambulatorios

Introduccion: En la ultima decada se ha informado a nivel mundial la emergencia de infecciones causadas por cepas de Staphylococcus aureus meticilino-resistente (SAMR) sin los factores de riesgo clasicos descritos para portar este germen, con un patron de susceptibilidad diferente a los antibioticos y adquirido en la comunidad. En nuestro pais las primeras comunicaciones de infecciones producidas por este germen fueron en el ano 2001 en ninos con infecciones de piel y partes blandas internados en el Centro Hospitalario Pereira Rossell (CHPR). Objetivo: 1) Analizar las caracteristicas clinicas y la etiologia de las infecciones de piel y partes blandas en pacientes ambulatorios; 2) Determinar en estas infecciones la prevalencia de Staphylococcus aureus meticilino-resistente adquirido en la comunidad (SAMR-com) y su sensibilidad a los antibioticos. Sujetos y Metodo: Se realizo un estudio descriptivo, prospectivo, de pacientes que consultaron en el Departamento de Emergencia Pediatrica del CHPR por infecciones de piel y partes blandas adquiridas en la comunidad, en el periodo 24 de marzo de 2004 al 31 de julio de 2004, tratados en forma ambulatoria y en los que se aislo una bacteria de las muestras obtenidas para estudio bacteriologico. Se incluyeron pacientes con impetigo, forunculo, absceso, celulitis a punto de partida cutaneo, panadizo y herida o quemadura sobreinfectada. Se analizaron datos demograficos, factores de riesgo para portar SAMR, caracteristicas clinicas de los pacientes y analisis bacteriologico de los resultados de las muestras obtenidas de acuerdo al informe realizado por el Laboratorio Central del CHPR, seccion Bacteriologia. Resultados: Se incluyeron 297 pacientes. Los diagnosticos clinicos realizados fueron: impetigo 122 (48,4%), forunculo 29 (11,5%), celulitis 19 (7,5%), absceso 30 (11,9%), panadizo ocho (3,2%), heridas o quemaduras infectadas seis (2,4%) y coexistencia de algunas de las anteriores 38 (15%). Se identifico Staphylococcus aureus (SA) en el 71,8% del total las infecciones, ya sea como unico germen o asociado a Streptococcus pyogenes, de los cuales el 47% correspondieron a SAMR-com. En las infecciones cutaneas profundas (forunculo, absceso y celulitis) se aislo SAMR-com en el 73% de las infecciones estafilofocicas, en tanto que en las infecciones superficiales (impetigo) estuvo presente en el 10%; diferencia estadisticamente significativa (p 0,10). En cuanto a la sensibilidad de SAMR-com a los antibioticos, no se informo de ningun caso de resistencia a vancomicina y trimetoprim-sulfametoxazol (TMP-SMX). Hubo un caso de resistencia a gentamicina. Ninguno tenia resistencia consititutiva a clindamicina y se observo resistencia inducible al grupo macrolidos, lincosaminas y streptograminas (MLS) en el 54%. Conclusiones: en las infecciones cutaneas superficiales el germen mas frecuente fue Streptococcus pyogenes, en tanto que en las infecciones mas profundas predomina SA. El germen mas frecuente, ya sea solo o asociado, en el total de las infecciones cutaneas es SA. La presencia de SAMR-com fue del 47% del total de las infecciones estafilococicas, en tanto que en las profundas fue mayor (73%), mientras que en las superficiales tiene poca frecuencia (10%). No se detecto resistencia de SAMR-com a vancomicina ni a TMP-SMX. Uno solo fue resistente a gentamicina y no se detecto resistencia constitutiva a clindamicina. La presencia de resistencia inducible al grupo MLS fue de 54%

International Epidemiological Differences in Acute Poisonings in Pediatric Emergency Departments

Background and Objective Identifying international differences in the epidemiology of acute poisonings in children may help in improving prevention. We sought to evaluate the international epidemiological differences in acute poisonings in children presenting to emergency departments (EDs) from 8 different global regions. Methods This was an international multicenter cross-sectional prospective study including children younger than 18 years with acute poisonings presenting to 105 EDs in 20 countries was conducted. Data collection started at each ED between January and September 2013, and continued for 1 year. Results During the study period, we registered 363,245 pediatric ED presentations, of which 1727 were for poisoning (0.47%; 95% confidence interval, 0.45%–0.50%), with a significant variation in incidence between the regions. Full data were obtained for 1688 presentations. Most poisonings (1361 [80.6%]) occurred at home with either ingestion (1504 [89.0%]) or inhalation of the toxin (126 [7.6%]). Nonintentional exposures accounted for 1157 poisonings (68.5%; mainly in South America and Eastern Mediterranean region), with therapeutic drugs (494 [42.7%]), household products (310 [26.8%]), and pesticides (59 [5.1%]) being the most common toxins. Suicide attempts accounted for 233 exposures (13.8%; mainly in the Western Pacific region and North America), with therapeutic drugs (214 [91.8%], mainly psychotropics and acetaminophen) being the most common toxins. Significant differences between regions were found in both types of poisonings. Recreational poisonings were more common in Europe and Western Pacific region. No patient died. Conclusions There are substantial epidemiological differences in acute poisonings among children in different countries and regions of the globe. International best practices need to be identified for prevention of acute poisonings in childhood.

Un quinquenio de experiencia (2005-2010) con infecciones por Salmonella spp en un centro nacional de referencia en pediatría

BACKGROUND Salmonella can cause asymptomatic infections, diarrhea, bacteremia and focal infections such as meningitis and osteomyelitis. AIM To describe clinical and microbiological aspects of infections by Salmonella spp. in children in a pediatric referral hospital: Centro Hospitalario Pereira Rossell, in Montevideo, Uruguay. MATERIALS AND METHODS Descriptive and retrospective study of 46 patients, from which Salmonella spp was isolated between January 1, 2005 and December 31, 2010. RESULTS Salmonella spp was isolated in 46 children younger than 15 years old. 18 were below 2 years old and 5 children below three months. 24% of the children had risk factors, such as HIV infection, oncological diseases and malnutrition; low birth weight and pneumonia were associated conditions. No deaths were reported. The serotypes more frequently found were: Typhimurium and Enteritidis. Most of the strains were susceptible to ampicillin and third generation of cephalosporins. DISCUSSION Diarrhea with blood was the predominant clinical presentation, and there were no outbreaks. Typhimurium and Enteritidis were the most common serotypes. Based on the profiles of susceptibility antimicrobial, we could maintain the same recommendations until the moment suggested. CONCLUSIONS we must consider the Salmonella infection in febrile children under risk of an invasive bacterial disease, with or without focal infection.

International Variability in Gastrointestinal Decontamination With Acute Poisonings

This was an international, multicenter, cross-sectional prospective study of acute pediatric poisonings to assess the variation and appropriateness of GID in the ED. BACKGROUND AND OBJECTIVES: Identifying international differences in the management of acute pediatric poisonings may help improve the quality of care. The objective of this study was to assess the international variation and appropriateness of gastrointestinal decontamination (GID) procedures performed in children and adolescents who present with acute poisonings to emergency departments. METHODS: This was an international, multicenter, cross-sectional prospective study including children <18 years with poisoning exposures presenting to 105 emergency departments in 20 countries from 8 global regions belonging to the Pediatric Emergency Research Networks. Data collection started between January and September 2013 and continued for 1 year. The appropriateness of GID procedures performed was analyzed using the American Academy of Clinical Toxicology and the European Association of Poisons Centres and Clinical Toxicologists’ recommendations. Multivariate logistic regression was performed to identify independent risk factors for performing GID procedures. RESULTS: We included 1688 patients, 338 of whom (20.0%, 95% confidence interval 18.1%–22.0%) underwent the following GID procedures: activated charcoal (166, 49.1%), activated charcoal and gastric lavage (122, 36.1%), gastric lavage (47, 13.9%), and ipecac (3, 0.9%). In 155 (45.8%, 40.5%–51.2%), the GID procedure was considered appropriate, with significant differences between regions. Independent risk factors for GID procedures included age, toxin category, mechanism of poisoning, absence of symptoms, and the region where the intoxication occurred (P < .001). CONCLUSIONS: Globally, there are substantial differences in the use and appropriateness of GID procedures in the management of pediatric poisonings. International best practices need to be better implemented.