R. Piñeiro Pérez

Conocimiento sobre el uso de fármacos off-label en Pediatría. Resultados de una encuesta pediátrica nacional 2012-2013 (estudio OL-PED)

INTRODUCTION Off-label drug use is a common practice in paediatrics. The aim of the present study was to estimate the knowledge of Spaniard paediatricians on off-label use. MATERIAL AND METHODS Cross-sectional, multicentre, descriptive and national study from July 2012 to March 2013 using an on-line questionnaire on off-label use in children. An e-mail was sent to paediatricians who were members of the Spanish Association of Paediatrics (AEP) or its Regional or Paediatric Specialties Societies. RESULTS Out of 673 responses were received, 75.1% of Spanish paediatricians knew the meaning of off-label use, 61% of them prescribed medicines outside the conditions authorised in their Summary of Product Characteristics (SPC) and 47% knew of the importance of noting the off-label use in the medical record. However, just under half of paediatricians informed parents, and only 22% wrote it down in the medical record. CONCLUSIONS Most Spanish paediatricians do not meet current regulations regarding off-label use. This regulation demands: justifying the decisions when off-label use is needed, and to write down in the medical record that, at least an oral consent from the parents has been obtained. This study reveals a fact that Spanish paediatricians must change. Meanwhile, it is a priority to continue with the implementation of consensus and clinical guidelines, to obtain more data on the efficacy and safety of off-label drug use in children, and to incorporate them into the SPC.

Documento de Consenso de la Sociedad de Infectología Pediatrica y la Sociedad de Reumatología Pediatrica sobre el diagnóstico diferencial y el abordaje terapéutico de la fiebre recurrente

Recurrent fever is a relatively common problem during childhood. Diagnosis is often easy and related to mild viral infections. However a small proportion of these cases originate from an underlying non-infectious process that is generally difficult to diagnose. In this paper we describe the differential diagnosis of recurrent or periodic fever versus other processes, with especial attention to autoinflammatory disorders (AD). AD are alterations of innate immunity, and they have been recently classified as an immunodeficiency. Anyhow, since infections are not present, these processes are different to the classic primary immunodeficiency. An important part of AD is of known genetic aetiology. The symptoms originate from an underlying inflammatory process and can have different clinical expressions. One of the most relevant groups is the hereditary syndromes of periodic fever. This group of diseases associates recurrent fever and several clinical symptoms with a relative periodicity, separated by intervals free or almost free of symptoms. We include the diagnostic criteria for some processes as well as the characteristics that should, eventually, lead to a genetic study. Although treatment should be individualised, we also include some general recommendations.

Infecciones del tracto urinario: sensibilidad antimicrobiana y seguimiento clínico

The initial treatment of the urinary tract infections (UTI) is empirical and it is a priority to determine the antibiotic resistance of most common germs in a population. Furthermore, due to the suspicion of acute pyelonephritis the presence of renal scarring should be ruled out as this may lead to further complications. A retrospective longitudinal study was performed on all children under 14 years diagnosed with UTI from January 1 2009 to December 31 2009. The in vitro susceptibility to the most important urinary pathogens was analysed, along with the presence of scars, and a subsequent follow-up. The most frequently isolated bacteria were E. coli (80%), P. mirabilis (9.7%) and K. pneumoniae (4.2%). In the antibiogram, E coli showed a high sensitivity to fosfomycin (99.1%), cefotaxime (98.2%) cefuroxime (97.3%) and gentamicin (95.6%). The sensitivity obtained against amoxicillin-clavulanate was 83.2%, while that obtained against cotrimoxazole was 78.9%. Post-pyelonephritis scars were found in 19% of patients with febrile UTI, 17% out-patients and 20% of those admitted.

Exposición a tuberculosis multirresistente: estudio y seguimiento de nueve niños

A world increase in multidrug-resistant tuberculosis (MDR-TB) has been reported over the last few years. A larger number of diagnoses are being seen in Spain, due to the increase of immigration from high endemic TB countries. Articles published on this are anecdotal in children, and there is no clear directives for treatment of MDR-TB, or latent tuberculosis infection (ITBL) or on prophylaxis after exposure to active pulmonary MDR-TB. We present the initial management and progression of nine children after close contact exposure to an Ecuadorian woman diagnosed with active pulmonary TB, resistant to Isoniazid, Rifampicin and Pyrazinamide.

Artritis idiopática juvenil

Juvenile idiopathic arthritis (JIA) is a chronic disease defined by the International League of Associations for Rheumatology (ILAR) criteria as arthritis in one or more joints that begins before the 16th birthday, persists for at least 6 weeks, and excludes all other known conditions. It is the most common rheumatic disease in children and one of the more common chronic illnesses of childhood. The etiology and pathogenesis of JIA is not completely understood, but substantial evidence suggests that the pathogenesis is autoimmune. Outcome studies have underlined the importance of early diagnosis and early aggressive treatment in improving prognosis. Despite this situation, many children with JIA continue to have persistently active arthritis into adulthood. The modern treatment of JIA involves a range of specialists. In recent years, new biologic medications have added significantly to the management of children with JIA.

Documento de consenso sobre etiología, diagnóstico y tratamiento de la sinusitis

The Spanish National Consensus (Spanish Society of Pediatric Infectious Diseases, Spanish Association of Primary Care Pediatrics, Spanish Society of Pediatric Outpatient and Primary Care, Spanish Society of Otorhinolaryngology and Cervical-Facial Pathology) on Sinusitis is presented. Rhinosinusitis is a difficult to diagnose and often unrecognised disease. The document discusses the aetiology, the clinical signs and symptoms, and the diagnostic criteria. A proposal for treatment is made based on the epidemiological situation in our country. Oral amoxicillin is the treatment of choice (80mg/kg/day divided every 8hours). Alternative treatment is proposed in special cases and when amoxicillin is not sufficient. The main complications are reviewed.

Brote de 22 casos de sarampión autóctono en la zona norte de Madrid

After being virtually eradicated in Europe, thousands of cases of measles in the population of Spanish origin have appeared in the last 3 years. We describe the cases diagnosed in the north of Madrid between January and June 2011. A total of 22 cases are reported, 18 of them grouped in 2 outbreaks (2 nurseries). The primary attack rate was 29% in the main outbreak. All cases were in unvaccinated patients (median = 14 months). Genotype D4 was predominant (95%). There was a 45% complication rate and 45% were admitted to hospitals. The Public Health Service recommended isolating cases and vaccinating susceptible contacts in advance. Health Centres established a specific protocol to respond to suspected cases. The Measles vaccination has been brought forward from 15 to 12 months in Madrid. Measles is a re-emerging disease in Europe. The coordinated management between public health and health facilities is essential to limiting outbreaks.

Toxicidad de fármacos antirretrovirales en niños infectados por el virus de la inmunodeficiencia humana

Paediatric Human Immunodeficiency Virus infection (HIV) nowadays is a chronic disease with an excellent long term prognosis, but lifelong combined antiretroviral treatment is required. However, an improved quality of life in this population is limited by adverse drug effects. The highest risk of treatment toxicity is developing a complete metabolic syndrome including: Hyperlipemia, lipodystrophy, insulin resistance, lactic acidosis, osteopenia, hypertension, and specific system and organ toxicity, such as the kidney, liver, CNS or bone marrow. The risk of cardiovascular disease adult life and also definitive bone mass damage are the most significant metabolic costs that have to paid for increased survival. Most of these toxicities were able to be adequately treated but, pharmacological interferences, patient intolerance and the high number of drugs are the problems that limit the adherence to treatment, which is essential for a good therapeutical efficacy. In this article, we present four HIV paediatric patients who presented with almost the whole range of metabolic toxicities, and a practical overview of therapeutical management.

Retención urinaria secundaria a ciproheptadina

dio de los genes asociados con factores de virulencia del SARM-AC aislado, es probable su presencia dadas las manifestaciones clínicas descritas. La clindamicina, en combinación con un adecuado drenaje quirúrgico, ha sido usada con éxito en el tratamiento de infecciones cutáneas e invasivas por SARM-AC en niños, como ocurrió en el presente caso9. Sin embargo, hay que tener en cuenta la posibilidad de aparición de resistencias inducidas a la clindamicina en cepas resistentes a eritromicina de tipo ermB, que debe ser evaluada por el test de difusión de doble disco10. Como conclusión, este caso nos recuerda que debemos reforzar la vigilancia epidemiológica para detectar la posible emergencia de las cepas de SARM-AC en nuestro medio.

Vacunación frente a la encefalitis centroeuropea o encefalitis transmitida por garrapatas en niños viajeros

En mayo del año 2002 el Ministerio de Sanidad acreditó al Hospital Carlos III como centro de vacunación internacional, con dos consultas: consulta del niño y del adulto viajero. En la consulta pediátrica se evaluaron, sólo en el año 2007, 528 niños con edades comprendidas entre los 15 días y los 16 años. La mitad de los niños viajeros que acudieron a la consulta precisaron quimioprofilaxis antipalúdica y las vacunas más prescritas fueron contra la hepatitis A y la fiebre amarilla. Recientemente, ha surgido la alarma en los medios de comunicación sobre la indicación de vacunar frente a encefalitis centroeuropea a viajeros que van a zonas boscosas de Europa central esta primavera. El Servicio de Pediatría del Hospital Carlos III, como en años anteriores, recomienda: La vacuna frente a la encefalitis centroeuropea transmitida por garrapatas es una vacuna de virus inactivados cultivados en células de embrión de pollo. Se indica en los niños viajeros campistas a zonas boscosas del centro, norte y este de Europa en primavera y verano cuando el viaje tiene una duración superior a 3 semanas. La pauta son 3 dosis administradas con un intervalo de 1-3 meses entre la primera y la segunda (mínimo 15 días) y de 9-12 meses entre la segunda y la tercera. Existe, no obstante, una pauta acelerada: 0,7 y 21 días. En este caso la protección comienza a los 15 días de la segunda dosis. En niños de entre 1 y 11 años se administrará la dosis pediátrica (la mitad de la dosis de adultos) y en los mayores de 11 años, la dosis completa. Se recomienda un recuerdo cada 3-5 años si el niño se mantiene en zona de riesgo. La vacuna está comercializada como FSME-inmun inject. Júnior o Encepur Children dosis pediátrica (jeringa precargada de 0,25 ml) para niños menores de 11 años. Esta vacuna se administra únicamente en los centros de vacunación internacional autorizados por el Ministerio de Sanidad en cada comunidad autónoma. Los países con riesgo elevado de encefalitis centroeuropea son: Alemania, Austria, Bielorrusia, Croacia, Eslovaquia, Eslovenia, Finlandia, Hungría, Lituania, Polonia, Republica Checa, Rusia, Suecia, Suiza y Ucrania. Los países con riesgo bajo de encefalitis centroeuropea son Albania, Bosnia, China, Dinamarca (solo la isla de Bornholm), Francia, Grecia, Italia, Japón, Kazajstán, Moldavia, Mongolia, Noruega, Rumanía y Serbia1. Puede consultarse el mapa de distribución de los casos comunicados a la Organización Mundial de la Salud (OMS)2 (CDC Health Information for Internacional Travel 2008) disponible en http://www.isw-tbe.info/tbe.aspx.