Milena De Paulis

Severity of viral coinfection in hospitalized infants with respiratory syncytial virus infection

OBJECTIVE To compare the severity of single respiratory syncytial virus (RSV) infections with that of coinfections. METHODS A historical cohort was studied, including hospitalized infants with acute RSV infection. Nasopharyngeal aspirate samples were collected from all patients to detect eight respiratory viruses using molecular biology techniques. The following outcomes were analyzed: duration of hospitalization and of oxygen therapy, intensive care unit admission and need of mechanical ventilation. Results were adjusted for confounding factors (prematurity, age and breastfeeding). RESULTS A hundred and seventy six infants with bronchiolitis and/or pneumonia were included in the study. Their median age was 4.5 months. A hundred and twenty one had single RSV infection and 55 had coinfections (24 RSV + adenovirus, 16 RSV + human metapneumovirus and 15 other less frequent viral associations). The four severity outcomes under study were similar in the group with single RSV infection and in the coinfection groups, independently of what virus was associated with RSV. CONCLUSION Virus coinfections do not seem to affect the prognosis of hospitalized infants with acute RSV infection.

Fever without source: evaluation of a guideline

OBJECTIVE To evaluate the applicability of a standardized guideline for children up to 36 months of age with fever without source (FWS). METHODS Prospective cohort study involving children with FWS treated at the emergency department of Hospital Universitário, Universidade de São Paulo, São Paulo, Brazil, from June 2006 to May 2007. The guideline classifies the risk of serious bacterial infection (SBI) according to the presence or absence of toxemia, age, and temperature. Laboratory screening was based on risk assessment: complete blood count, blood culture, urinalysis, urine culture, and, if necessary, chest radiography, cerebrospinal fluid, and coproculture. RESULTS We studied 251 children and, of these, 215 were followed up until the final diagnosis. Toxemia was found in 20 children, and 195 were well-appearing (30 up to 3 months old and 165 from 3 to 36 months old). Among those children from 3 to 36 months without toxemia, 95 had axillary temperature > 39 degrees C. In 107 (49.8%) children, there was spontaneous resolution of fever; in 88 (40.9%), benign self-limited disease was identified; and in 20 (9.3%), there was SBI. Among the cases of SBI, we identified 16 urinary tract infections, three cases of pneumonia and one occult bacteremia. Of the 215 children, 129 (60%) received no antibiotics, and 86 received antibiotics at some point (45 empirically). Empirical antibiotic treatment was maintained for an average of 72 hours. CONCLUSION The guideline was shown to be appropriate to follow up these children using simple laboratory tests that can be carried out at most health facilities. The most frequent SBI in this sample was urinary tract infection.

Impacto do uso da prova rápida para estreptococo beta-hemolítico do grupo A no diagnóstico e tratamento da faringotonsilite aguda em pronto-socorro de Pediatria

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Febre sem sinais localizatórios: avaliação de um protocolo de atendimento

OBJECTIVE: To evaluate the applicability of a standardized guideline for children up to 36 months of age with fever without source (FWS). METHODS: Prospective cohort study involving children with FWS treated at the emergency department of Hospital Universitario, Universidade de Sao Paulo, Sao Paulo, Brazil, from June 2006 to May 2007. The guideline classifies the risk of serious bacterial infection (SBI) according to the presence or absence of toxemia, age, and temperature. Laboratory screening was based on risk assessment: complete blood count, blood culture, urinalysis, urine culture, and, if necessary, chest radiography, cerebrospinal fluid, and coproculture. RESULTS: We studied 251 children and, of these, 215 were followed up until the final diagnosis. Toxemia was found in 20 children, and 195 were well-appearing (30 up to 3 months old and 165 from 3 to 36 months old). Among those children from 3 to 36 months without toxemia, 95 had axillary temperature > 39 oC. In 107 (49.8%) children, there was spontaneous resolution of fever; in 88 (40.9%), benign self-limited disease was identified; and in 20 (9.3%), there was SBI. Among the cases of SBI, we identified 16 urinary tract infections, three cases of pneumonia and one occult bacteremia. Of the 215 children, 129 (60%) received no antibiotics, and 86 received antibiotics at some point (45 empirically). Empirical antibiotic treatment was maintained for an average of 72 hours. CONCLUSION: The guideline was shown to be appropriate to follow up these children using simple laboratory tests that can be carried out at most health facilities. The most frequent SBI in this sample was urinary tract infection.

Impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngotonsillitis in a pediatric emergency room.

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Infections Caused by HRSV A ON1 Are Predominant among Hospitalized Infants with Bronchiolitis in São Paulo City

Human respiratory syncytial virus is the main cause of respiratory infections in infants. Several HRSV genotypes have been described. Goals. To describe the main genotypes that caused infections in São Paulo (2013–2015) and to analyze their clinical/epidemiological features. Methods. 94 infants (0–6 months) with bronchiolitis were studied. Clinical/epidemiological information was collected; a search for 16 viruses in nasopharyngeal secretion (PCR-real-time and conventional, sequencing, and phylogenetic analyses) was performed. Results. The mean age was 2.4 m; 48% were male. The mean length of hospital stay was 4.4 d (14% in the Intensive Care Unit). The positive rate of respiratory virus was 98.9%; 73 cases (77.6%) were HRSV (76,7% HRSVA). HRSVA formed three clusters: ON1 (n = 34), NA1 (n = 1), and NA2 (n = 4). All HRSVB were found to cluster in the BA genotype (BA9-n = 10; BA10-n = 3). Clinical analyses showed no significant differences between the genotype AON1 and other genotypes. Conclusion. This study showed a high rate of HRSV detection in bronchiolitis. HRSVA ON1, which has recently been described in other countries and has not been identified in previous studies in the southeast region of Brazil, was predominant. The clinical characteristics of the infants that were infected with AON1 were similar to infants with infections by other genotypes.

Impacto del uso de la prueba rápida para estreptococos beta-hemolíticos del grupo A en el diagnóstico y tratamiento de la faringotonsilitis en emergencia de Pediatría

OBJETIVO: Evaluar el impacto de la realizacion de rutina de la prueba rapida para investigacion de estreptococos del grupo A en el diagnostico y tratamiento de la faringotonsilitis aguda en ninos. METODOS: Estudio prospectivo y observacional que conto con el uso de protocolo de investigacion establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atencion a ninos y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluacion critica, de los 650 pacientes estudiados, antimicrobianos serian prescritos a 389 individuos (59,8%) y, con el uso de la investigacion de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 ninos que no recibirian antibioticos por el cuadro clinico, 111 (42,5%) tuvieron investigacion de estreptococos del grupo A positiva. El diagnostico basado en el cuadro clinico presento sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnostico clinico de la faringotonsilitis estreptococica mostro baja sensibilidad y especificidad. El uso de rutina de la prueba rapida para investigacion de estreptococos permitio la reduccion del uso de antibioticos y la identificacion de un grupo de riesgo para las complicaciones de la infeccion estreptococica, pues el 42,5% de los pacientes con prueba rapida positiva no recibirian antibioticos si se llevara en consideracion solamente el diagnostico clinico.OBJECTIVE To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

Gravidade das coinfecções virais em lactentes hospitalizados com infecção por vírus sincicial respiratório

OBJECTIVE: To compare the severity of single respiratory syncytial virus (RSV) infections with that of coinfections. METHODS: A historical cohort was studied, including hospitalized infants with acute RSV infection. Nasopharyngeal aspirate samples were collected from all patients to detect eight respiratory viruses using molecular biology techniques. The following outcomes were analyzed: duration of hospitalization and of oxygen therapy, intensive care unit admission and need of mechanical ventilation. Results were adjusted for confounding factors (prematurity, age and breastfeeding). RESULTS: A hundred and seventy six infants with bronchiolitis and/or pneumonia were included in the study. Their median age was 4.5 months. A hundred and twenty one had single RSV infection and 55 had coinfections (24 RSV + adenovirus, 16 RSV + human metapneumovirus and 15 other less frequent viral associations). The four severity outcomes under study were similar in the group with single RSV infection and in the coinfection groups, independently of what virus was associated with RSV. CONCLUSION: Virus coinfections do not seem to affect the prognosis of hospitalized infants with acute RSV infection.