L. de Pontual

Inter-observer agreement between physicians, nurses, and respiratory therapists for respiratory clinical evaluation in bronchiolitis.

Care providers for children with bronchiolitis use various tools to evaluate respiratory status. The use of a single tool by different types of care provider requires a high level of inter‐observer agreement, an aspect rarely studied. This study, involving 82 physicians, nurses, and respiratory therapists aimed to evaluate inter‐observer agreement for clinical evaluations in children hospitalized for a first episode of bronchiolitis. Respiratory evaluation included three frequently reported parameters of respiratory status: respiratory rate, retraction signs, and wheezing. The frequency of concordance for observers from the same and from different care provider groups was assessed using a weighted kappa statistic and considering all possible combinations of care providers. We also calculated inter‐provider agreement as a function of patient age, regardless of care provider type. Overall inter‐observer agreement for all provider pairs was 93.1%, with a weighted kappa statistic of 0.72 (95% CI, 0.66–0.78), indicating substantial agreement, with no difference as a function of pair composition. Inter‐observer agreements for the various age groups ranged from 87% to 93%, with kappa scores ranging from 0.62 to 0.78. We conclude that a simple clinical evaluation for respiratory status assessment has a high level of inter‐observer agreement within and between physicians, nurses and respiratory therapists. Thus, once the validity of this test has been confirmed in a large population sample, it should be possible to use this test to monitor children hospitalized with bronchiolitis and as an endpoint in clinical trials. Pediatr Pulmonol. 2009; 44:754–762.

Survey of vaccination policies in French healthcare institutions

OBJECTIVE The survey was implemented to describe vaccination policies for healthcare professionals in French healthcare institutions. METHODS A cross-sectional survey based on questionnaires was sent to occupational physicians and chairpersons of hospital infection prevention and control committees (HIPC) of 38 institutions between November 2010 and January 2011. RESULTS Twenty-nine occupational physicians and 26 hospital infection prevention and control committees chairpersons (HIPC), from 30 institutions answered (response rate: 79%), 70% of the institutions were university hospitals. Overall, 76% of occupational physicians and 85% of HIPC chairpersons reported that information and awareness campaigns about vaccination recommendations for healthcare professionals were usually conducted in their establishment. Fifty-nine percent of occupational physicians and 31% of HIPC chairpersons reported that they were aware of the vaccine coverage rates of professionals in their institution. The occupational physicians reported that they suggested diphtheria, tetanus, polio, influenza, and acellular pertussis vaccination to all staff at their annual visit in 100%, 97%, and 62% of cases, respectively. Varicella and measles vaccinations were never suggested in 31% and 17% of cases, respectively. Among respondents, 55% of physicians reported that they had already managed a pertussis epidemic, and 42% a measles epidemic, and in both of these cases an awareness campaigns were usually conducted (93% and 96%). CONCLUSIONS The vaccine coverage rates of healthcare professionals in French healthcare institutions remain insufficiently documented and could be improved.

Outcomes of bacterial meningitis in children

OBJECTIVE Pediatricians are well aware of the immediate risks of bacterial meningitis in children. However, the long-term outcome of the disease has not been extensively studied. We aimed: (i) to evaluate the duration and quality of the long-term follow-up of children diagnosed with bacterial meningitis in a general pediatric department, (ii) to estimate the incidence of sequelae at the various stages of follow-up, and (iii) to compare our data with that of other studies. METHODS We conducted a retrospective study and included 34 children (3 months-15 years) who had been hospitalized for bacterial meningitis in the pediatric department of a University Hospital between January 1st, 2001 and December 31st, 2013. RESULTS Overall, 32% of patients presented with sequelae and 15% with seizures. Only one patient presented with hearing loss, but 23.5% of patients did not have any hearing test performed. Seven patients had a neuropsychological assessment performed and no severe neuropsychological sequela was observed in this group. The average follow-up duration increased during the study period (from 23 to 49months). The long-term follow-up modalities observed in other studies were highly variable. Assessing the incidence and severity of sequelae was therefore difficult. CONCLUSION A standardized follow-up should be implemented by way of a national surveillance network of children presenting with bacterial meningitis.

Cavité pulmonaire nécrosante due à une infection à Mycoplasme

Cette enfant de 4 ans avait été adressée au service des urgences pédiatriques pour une toux fébrile traı̂nante. Sans antécédent particulier, elle présentait une toux grasse évoluant depuis 1 mois. Elle était tout juste de retour d’un séjour de 2 mois au Maroc où elle avait reçu un traitement de 7 j par de l’amoxicilline (80 mg/kg/j). Une franche altération générale était notée avec de la fièvre, une perte d’appétit et un amaigrissement de 2 kg en 1 mois. À l’examen clinique, il n’y avait pas de signe de déshydratation, la fréquence respiratoire était de 25/min, il n’y avait pas de signe de lutte et l’auscultation pulmonaire était asymétrique avec une diminution du murmure vésiculaire à gauche, sans bruit surajouté. Il n’y avait pas de syndrome inflammatoire biologique (9500 leucocytes/mm3 dont 6700 polynucléaires neutrophiles/mm3 et 1800 lymphocytes/mm3; protéine C-réactive (CRP) = 4 mg/L et procalcitonine (PCT) = 0,07 ng/mL). La reprise de l’interrogatoire avait révélé que l’enfant avait été en contact étroit, lors de son séjour aux Maroc, avec une tante ayant une toux grasse chronique. Une radiographie thoracique (fig. 1) avait alors été réalisée, complétée d’une tomodensitométrie (TDM) thoracique avec injection (fig. 2).

Fer et prédisposition aux infections

Iron is essential for proper functioning of the host immune system as well as an essential nutrient for growth of various pathogens. Iron deficiency increases infection susceptibility, specially those due to intracellular pathogens. At the opposite, excess iron stores could increase the virulence of some pathogens. Hepcidin synthesis is increased during the acute inflammation phase; leading to decreased iron intestinal absorption and retention of the metal within macrophages. This is considered to result from a defense mechanism of the child to limit the availability of iron for extracellular pathogens. On the other hand, iron affect innate immune responses by influencing IFN-γ or NF-kB pathways in macrophages. Consequently, iron enhances host resistance to intracellular pathogens but excess iron may alter immune system.Resume Le fer est un nutriment essentiel aussi bien pour assurer un bon fonctionnement des cellules du systeme immunitaire que pour contribuer a la croissance et la virulence des micro-organismes. Si la carence martiale augmente la susceptibilite aux infections, notamment celles dues aux micro-organismes intracellulaires, les situations de surcharge en fer comme l’hemochromatose peuvent au contraire augmenter la virulence de certains germes. La synthese d’hepcidine est augmentee lors de la phase aigue de l’inflammation, entrainant ainsi une diminution de l’absorption intestinale de fer et sa captation par les macrophages. Il s’agit d’un mecanisme de defense de l’enfant ayant pour but de limiter l’avidite du fer pour les micro-organismes extra-cellulaires. A l’inverse le fer affecte le fonctionnement de la reponse innee en diminuant la production d’IFN-γ et de NF-kB par les macrophages. Au total, la carence en fer favorise la survenue de certaines infections, mais l’exces de fer peut alterer la reponse des cellules du systeme immunitaire.Iron is essential for proper functioning of the host immune system as well as an essential nutrient for growth of various pathogens. Iron deficiency increases infection susceptibility, specially those due to intracellular pathogens. At the opposite, excess iron stores could increase the virulence of some pathogens. Hepcidin synthesis is increased during the acute inflammation phase; leading to decreased iron intestinal absorption and retention of the metal within macrophages. This is considered to result from a defense mechanism of the child to limit the availability of iron for extracellular pathogens. On the other hand, iron affect innate immune responses by influencing IFN-γ or NF-kB pathways in macrophages. Consequently, iron enhances host resistance to intracellular pathogens but excess iron may alter immune system.

Impact of social deprivation on length of stay for common infectious diseases in two French university-affiliated general pediatric departments

BACKGROUND Adult deprived patients consume more healthcare resources than others, particularly in terms of increased length of stay (LOS) and costs. Very few pediatric studies have focused on LOS, although the effect of deprivation could be greater in children due to the vulnerability of this population. Our objective was to compare LOS between deprived and nondeprived children hospitalized for acute infectious diseases in two university-affiliated pediatric departments located in a low-income area of northern Paris. METHODS We performed a prospective observational multicenter study in two university-affiliated hospitals, Hôpital Robert-Debré and Hôpital Jean-Verdier. All the patients under 15 years of age admitted to the general pediatric department for pneumonia, bronchiolitis, gastroenteritis, or pyelonephritis between 20 October 2016 and 20 March 2017 were included. Deprivation was assessed with an individual questionnaire and score (EPICES). Endpoints included length of stay, costs, and readmission rates at 15 days in each quintile of deprivation. Multivariate regression assessed the association between deprivation and each endpoint. RESULTS A total of 556 patients were included in the study and 540 were analyzed. Sixty percent were boys and the mean age was 9 months±18. Bronchiolitis was the most frequent diagnosis (67.8%). Fifty-six percent of patients were considered to be deprived based on the EPICES questionnaire. Mean LOS was 4.6±3.5 days and we found no significant difference in LOS between the different deprivation quintiles (P=0.83). Multivariate regression did not show an association between LOS and deprivation. CONCLUSION There was no difference between deprived and nondeprived patients in terms of LOS. Deprivation may therefore impact hospitals in other ways such as admission rates. The impact of deprivation during hospitalization for chronic diseases should also be investigated.

Antimicrobial treatment of infrequent bacterial species isolated in children

This section summarizes the empirical antimicrobial treatment according to the less frequent bacterial species responsible for infection whether community-acquired or nosocomial. It specifies their role in diseases and the recommended antibiotics, taking into account their natural and most common acquired resistance and the pharmacokinetic-pharmacodynamic parameters. The advice of an infectious disease specialist or bacteriologist is recommended.

PostersPathologie infectieuseP-522 – Déficit en fraction terminale du complément révélé dès le premier épisode d'infection invasive à méningocoque

Resume La prevalence du deficit en proteine du complement dans la population generale est faible et son association avec un risque accru d’infection invasive a meningocoque est connue. La prise en charge de ces patients presentant des infections potentiellement severes ainsi que les indications de recherche d’un tel deficit ne sont pourtant pas consensuelles. Nous rapportons le cas d’un enfant de trois ans ayant consulte au service d’accueil des urgences pour une fievre au retour d’un sejour au Senegal. Les explorations realisees ont mis en evidence une meningococcemie et une meningite a meningocoque W. Le dosage des proteines du complement a revele un deficit en proteine C6 de la voie finale du complement de meme que chez la sœur jumelle asymptomatique. Les deux enfants ont recu le vaccin conjugue tetravalent A,C,Y,W et ont ete mis sous antibioprophylaxie au long cours. La survenue d’infections invasives a meningocoque a repetition ainsi que la mise en evidence de certains serogroupes ou genotypes de meningocoque constituent les indications a l’exploration du complement pour de nombreux auteurs. Nous proposons ici d’elargir ces indications pour une recherche d’un deficit en proteine du complement apres un premier episode d’infection a meningocoque. Ce depistage est simple, rapide et peu couteux par le dosage du CH50, C3, C4 et de l’AP50. L’arrivee du nouveau vaccin contre le meningocoque B participera a l’amelioration de la prise en charge de ces patients.

Infections bactériennes sévères et morts inattendues de l’enfant de moins de 4 ans : à propos de 3 observations

Infectious factors contribute to sudden infant death in about 1 case out of 3. We report 3 children less than 4-years-old who died suddenly of bacterial infection due to Neisseria meningitidis, Streptococcus pneumoniae, and Staphylococcus aureus. The bacteria were isolated from central and peripheral samples. A bacterial origin should be sought in all cases of sudden death in children. When a bacterial origin is confirmed, the question of immunodeficiency should be raised.

CL088 - Prédisposition génétique au neuroblastome

Le neuroblastome (NB) est une tumeur pediatrique maligne du systeme nerveux peripherique, caracterisee par une grande heterogeneite clinique, evolutive et genetique, le plus souvent sporadique. De rares formes familiales sont decrites, compatibles avec une transmission dominante. Par ailleurs, des tumeurs neuroblastiques sont observees chez des patients porteurs d’autres anomalies de la crete neurale, comme la maladie de Hirschprung, le syndrome d’Ondine. Nous avons identifie le gene PHOX2B comme premier gene de predisposition au NB. En effet, des mutations constitutionnelles de ce gene ont ete caracterisees dans des formes familiales de NB ainsi que chez des patients presentant une association NB/maladie de Hirschsprung. Recemment, notre groupe et d’autres equipes ont identifie le gene ALK, (Anaplastic Lymphoma Kinase), comme gene de predisposition au NB. Ce gene code pour un recepteur transmembranaire a activite tyrosine kinase. Des mutations somatiques du gene ALK ont par ailleurs ete caracterisees dans des tumeurs sporadiques. L’identification de mutations constitutionnelles des genes PHOX2B et ALK va permettre d’ameliorer la prise en charge des familles a risque en proposant une surveillance adaptee aux enfants porteurs d’une mutation.