Mathie Lorrot

Isolation of Kingella kingae in the oropharynx during K. kingae arthritis in children

Kingella kingae arthritis in children is now mainly diagnosed by PCR, which has surpassed conventional culture of joint fluid. As oropharynx colonization is the first step of Kingella kingae invasion, we prospectively investigated the possibility of cultivating it from throat swabs, in children hospitalized for K. kingae arthritis. Throat culture was 5.6-fold more sensitive than joint fluid cultures in isolating K. kingae (66.7% vs. 11.9% respectively, p <0.001) and may be used to perform antibiotic susceptibility testing.

Aetiology of arthritis in hospitalised children: an observational study

Background and objective Arthritis in children has many causes and includes septic and viral arthritis, reactive arthritis and juvenile idiopathic arthritis (JIA). We aimed to describe the different types of arthritis among children hospitalised for a first episode of arthritis. Design Retrospective, descriptive case series study. Setting A French tertiary care centre. Patients Children under 16 years of age hospitalised for an arthritis episode between 1 January 2008 and 31 December 2009. Main outcome measures Demographic and clinical features were compared with χ2 or Fishers exact tests and non-parametric tests. Results 173 children were hospitalised for a first episode of arthritis during the study period, with a male/female ratio of 1.14. The most frequent cause of hospitalisation was septic arthritis (43.4% of cases, 69.3% of which were due to Kingella kingae and 10.7% to Staphylococcus aureus). JIA was responsible for 8.1% of cases and arthritis without any definitive diagnosis for 40.4%. Median age at diagnosis was 2.7 years (IQR 0.3–14.6) and was lower in the septic arthritis group (1.5 years; 1.1–3.4) than in the JIA group (4.7 years; 2.5–10.9) (p<0.01). Septic arthritis involved a single joint in 97.3% of cases, while JIA involved four joints in 14.3% of cases and two to four joints in 28.6% of cases (p<0.01). Conclusions Septic arthritis was the most frequent cause of arthritis in hospitalised children. Despite the increasing application of microbiological molecular methods to synovial fluid analysis, further measures are required to improve the diagnosis of arthritis of unknown cause.

Morbidity among child travellers with sickle-cell disease visiting tropical areas: an observational study in a French tertiary care centre

Objective To examine morbidity among children with sickle-cell disease (SCD) during and after travel to a tropical area. Design Observational study. Setting Tertiary care children; Robert Debré Hospital, Paris, France. Population Children with SCD younger than 18 years old and managed in the SCD referral centre at the Robert Debré Hospital who travelled to a tropical or subtropical area between 1 June 2009 and 31 December 2009. Main outcome To assess morbidity, we used the number of clinical events requiring medical consultation during the trip as the primary outcome and the number of hospitalisations required after returning as the secondary outcome. Results Thirty-nine children were included. The median age was 7.8 years (4.3–11.7 years). All of the children and their parents attended a pretravel visit focusing on the prevention of travel-related diseases. Twelve children (30%) consulted a physician while they were abroad. Thirteen children (33%) were hospitalised, and 23 children (59%) consulted a physician while they were abroad or within 3 months after returning to France. Considering the 3 months before and after travel, the number of children hospitalised after travel (n=12, 30.7%) was significantly higher than the number hospitalised before (n=4, 10.2%; p=0.01). One child was hospitalised for multifocal osteoarthritis as a complication of Salmonella enterica septicaemia of gastrointestinal origin. Conclusions Travels to tropical areas are associated with high morbidity in children with SCD. Salmonella infection is a particularly significant threat, and empirical antibiotic therapy should be prescribed routinely for travellers diarrhoea in this population.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011-12 and 2012-13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

Arthritis in children: comparison of clinical and biological characteristics of septic arthritis and juvenile idiopathic arthritis

Aim Childhood arthritis arises from several causes. The aim of this observational study is to compare the clinical and biological features and short-term outcome of different types of arthritis because they have different treatment and prognoses. Methods Children <16 years of age hospitalised in a French tertiary care centre for a first episode of arthritis lasting for less than 6 weeks who underwent joint aspiration were retrospectively included. We performed non-parametrical tests to compare groups (septic arthritis (SA), juvenile idiopathic arthritis (JIA) and arthritis with no definitive diagnosis). The time before apyrexia or C reactive protein (CRP) <10 mg/L was analysed using the Kaplan-Meier method. Results We studied 125 children with a sex ratio (M/F) of 1.1 and a median age of 2.2 years (range 0.3 to 14.6). SA was associated with a lower age at onset (1.5 years, IQR 1.2–3.0 vs 3.6 years, IQR 2.2–5.6), shorter duration of symptoms before diagnosis (2 days, IQR 1–4 vs 7 days, IQR 1–19) and higher synovial white blood cell count (147 cells ×103/mm3, IQR 71–227, vs 51 cells ×103/mm3, IQR 12–113), than JIA. Apyrexia occurred later in children with JIA (40% after 2 days, 95% CI 17% to 75%) than children with SA (82%, 95% CI 68% to 92%), as did CRP<10 mg/L (18% at 7 days, 95% CI 6.3% to 29.6% vs 82.1%, 95% CI 76.1% to 89.7%, p=0.01). Conclusions There were no sufficiently reliable predictors for differentiating between SA and JIA at onset. The outcomes were different; JIA should be considered in cases of poor disease evolution after antibiotic treatment and joint aspiration.

A comparison of antibiotic use in three specialist paediatric hospitals in France, Latvia and the UK

Objectives This article analyses antimicrobial use in three tertiary-care paediatric hospitals with the aim of improving antimicrobial stewardship in paediatric hospitals. Methods A point prevalence survey (PPS) was undertaken during November 2012 using validated and standardised ARPEC (Antibiotic Resistance and Prescribing in European Children) methodology. The data collected contributed to the ARPEC study. Results Antimicrobials were prescribed to 116 patients (48%) in Birmingham, 114 (38%) in Paris and 128 (37%) in Riga. Respiratory tract infections were the most common indications for antibiotic use in Riga, but in Birmingham and Paris antibiotics were used most for prophylaxis in case of medical problems. The most common age group of patients receiving antimicrobials across all three sites was children aged 1–5 years old: there were 41 (35%) children in this age group in Birmingham, 37 (32%) in Paris and 36 (28%) in Riga. The most common antimicrobial used for the treatment and prophylaxis of paediatric patients was co-trimoxazole in Birmingham and Paris and ceftriaxone in Riga. Antimicrobials were mainly used parenterally: there were 100 (55%) parenteral prescriptions in Birmingham, 122 (50%) in Paris and 111 (75%) in Riga. Conclusions The PPS identified differences in antimicrobial use in the three hospitals and problem areas requiring improvement: high use of third-generation cephalosporins for paediatric patients (especially in Riga) and predominant use of parenteral antibiotics. Further collaboration between pharmacists operating at each site is needed in order to improve antimicrobial stewardship initiatives.

Bone and joint infections in infants under three months of age

Studies on bone and joint infections (BJI) in infants under three months are rare. We described the clinical and paraclinical features and outcomes of infants hospitalised with BJI under three months of age.

When should clinicians suspect group A streptococcus empyema in children? A multicentre case–control study in French tertiary care centres

Background The incidence of invasive group A streptococcus (GAS) infections is increasing worldwide, whereas there has been a dramatic decrease in pneumococcal invasive diseases. Few data describing GAS pleural empyema in children are available. Objective To describe the clinical and microbiological features, management and outcome of GAS pleural empyema in children and compare them with those of pneumococcal empyema. Design, setting and patients Fifty children admitted for GAS pleural empyema between January 2006 and May 2013 to 8 hospitals participating in a national pneumonia survey were included in a descriptive study and matched by age and centre with 50 children with pneumococcal empyema. Results The median age of the children with GAS pleural empyema was 2 (range 0.1–7.6) years. Eighteen children (36%) had at least one risk factor for invasive GAS infection (corticosteroid use and/or current varicella). On admission, 37 patients (74%) had signs of circulatory failure, and 31 (62%) had a rash. GAS was isolated from 49/50 pleural fluid samples and from one blood culture. The commonest GAS genotype was emm1 (n=17/22). Two children died (4%). Children with GAS empyema presented more frequently with a rash (p<0.01), signs of circulatory failure (p=0.01) and respiratory disorders (p=0.02) and with low leucocyte levels (p=0.04) than children with pneumococcal empyema. Intensive care unit admissions (p<0.01), drainage procedures (p=0.04) and short-term complications (p=0.01) were also more frequent in patients with GAS empyema. Conclusions Pleural empyema following varicella or presenting with rash, signs of circulatory failure and leucopenia may be due to GAS. These features should prompt the addition to treatment of an antitoxin drug, such as clindamycin.

CL020 - Diversité génotypique des rotavirus aux urgences pédiatriques en France entre 2006 et 2009

Objectifs Suite a l’introduction de vaccins contre les rotavirus (RV) en France, la surveillance des gastroenterites aigues (GEA) a ete accrue afin d’evaluer la circulation des souches et detecter l’emergence de reassortants a risque epidemique. Materiels et Methodes Une etude prospective a ete menee de 2006 a 2009 chez des enfants diarrheiques de moins de 5 ans se presentant aux urgences pediatriques de 13 CHU. Les RV de 1947 selles positives ont ete genotypes par RT-PCR pour la determination de leurs genotypes G et P. Resultats Les genotypes G1 (61,7 %) et G9 (27,4 %) etaient predominants, suivis des G2 (6,5 %), G3 (4,0 %) et G4 (2,5 %) ; 93,4 % etaient P[8]. Les infections mixtes representaient 2,9 %, majoritairement des associations G1/G9. La distribution des genotypes etait geographiquement heterogene. 31 souches atypiques ont ete detectees dont plusieurs G8 et G12 (58,1 %). Conclusions Les souches G1P[8] et G9P[8] sont responsables de 86,4 % des GEA a RV. Diverses souches atypiques potentiellement a risque d’emergence circulent en France. La surveillance doit etre maintenue pour evaluer l’impact de la vaccination sur la distribution des souches et leur expression clinique, et detecter l’emergence de souches responsables de GEA severes et/ou ne repondant pas aux vaccins actuels.