Selma Lopes Betta Ragazzi

Infecção urinária comunitária: etiologia segundo idade e sexo

INTRODUCTION Choosing the antimicrobial agent for initial therapy of urinary tract infection (UTI) is usually empirical and should consider the prevalence of uropathogens in different age groups and gender. OBJECTIVE To establish prevalence rates of uropathogens in community-acquired UTI in relation to age and gender. METHODS Cross-sectional study conducted in the emergency department (ED) of a general hospital, from January to December, 2010, in patients younger than 15 years old who had clinical suspicion of UTI and collected quantitative urine culture. UTI was defined as urine culture with growth of a single agent > 100.000 colony forming units (cfu)/mL in a midstream collection or ≥ 50.000 cfu/mL in urethral catheterization. RESULTS There were 63.464 visits to ED. 2577 urine cultures were obtained, of whom 291 were positive for UTI (prevalence = 11.3% of clinical suspicion and 0.46% of visits), 212 cases (72.8%) in females, median age = 2.6 years. The predominant uropathogen was E. coli (76.6%), followed by Proteus mirabilis (10.3%) and Staphylococcus saprophyticus (4.1%). Among infants < 3 months, prevalence rates of E. coli were significantly lower (50% vs 78.4%; OR = 0.276; p = 0.006). Higher prevalences of Staphylococcus saprophyticus occurred among patients > 10 years (24.4% vs 0.4%; OR = 79.265; p < 0.0001). Proteus mirabilis was significantly more prevalent in boys than girls (24.0% vs 5.2%; OR = 5.786; p < 0.001). CONCLUSIONS E. coli was the most prevalent community-acquired uropathogen. Nevertheless, initial empiric antimicrobial treatment of UTI should consider the significant prevalence of other agents different from E. coli in infants < 3 months, the high prevalence of Staphylococcus saprophyticus in patients > 10 years and Proteus mirabilis in males.

Analysis of invasive pneumonia-causing strains of Streptococcus pneumoniae: serotypes and antimicrobial susceptibility

OBJECTIVES To identify the most common pneumococcal serotypes in children hospitalized with invasive pneumonia, correlate isolated serotypes with those included in conjugate vaccines, and ascertain the sensitivity of the isolated pneumococcal strains to penicillin and other antibiotics. METHODS From January 2003 to October 2008, a retrospective study of hospitalized children with a diagnosis of Streptococcus pneumoniae pneumonia was conducted at the university hospital of Universidade de São Paulo. Criteria for inclusion were: age greater than 29 days and less than 15 years, radiological and clinical diagnosis of pneumonia, and isolation of Streptococcus pneumoniae in blood cultures and/or pleural effusion. RESULTS The study included 107 children. The most common serotypes were 14 (36.5%), 1 (16%), 5 (14.6%), 6B (6.3%) and 3 (4.2%). The proportion of identified serotypes contained in the heptavalent, 10-valent and 13-valent conjugate vaccines was 53.1, 86.5, and 96.9%, respectively. Pneumococcal strains were sensitive to penicillin (minimum inhibitory concentration, MIC ≤ 2 µg/mL) in 100 cases (93.5%) and displayed intermediate resistance (MIC = 4 µg/mL) in 7 cases (6.5%). No strains were penicillin-resistant (MIC ≥ 8 µg/mL) according to the Clinical and Laboratory Standards Institute 2008 standards. Tested isolates were highly sensitive to vancomycin, rifampicin, ceftriaxone, clindamycin, erythromycin, and chloramphenicol. CONCLUSIONS Our results confirm a significant potential impact of conjugate vaccines, mainly 10-valent and 13-valent, on invasive pneumonia. Furthermore, susceptibility testing results show that penicillin is still the treatment of choice for invasive pneumonia in our setting.

Congenital and neonatal measles during an epidemic in São Paulo, Brazil in 1997.

During a measles outbreak, 2 mothers with measles gave birth at University Hospital in São Paulo City, Brazil. Blood, saliva and urine were collected from the mothers and newborns. Measles virus genome and IgM antibodies against measles were detected. In 1 infant, measles virus genome persisted in peripheral blood mononuclear cells for 157 days after birth.

High Frequency of Staphylococcus Saprophyticus Urinary Tract Infections Among Female Adolescents.

Staphylococcus saprophyticus is a rarely reported agent of urinary tract infection (UTI) in the pediatric population. In our retrospective 3-year study, S. saprophyticus comprised 24.5% of 106 isolates of UTIs in female adolescents 12–15 years of age who attended an emergency department. Clinicians should be aware of the high prevalence of this etiology when empirically treating UTIs in female adolescents.

Análise das cepas de Streptococcus pneumoniae causadores de pneumonia invasiva: sorotipos e sensibilidade aos antimicrobianos

OBJECTIVES: To identify the most common pneumococcal serotypes in children hospitalized with invasive pneumonia, correlate isolated serotypes with those included in conjugate vaccines, and ascertain the sensitivity of the isolated pneumococcal strains to penicillin and other antibiotics. METHODS: From January 2003 to October 2008, a retrospective study of hospitalized children with a diagnosis of Streptococcus pneumoniae pneumonia was conducted at the university hospital of Universidade de Sao Paulo. Criteria for inclusion were: age greater than 29 days and less than 15 years, radiological and clinical diagnosis of pneumonia, and isolation of Streptococcus pneumoniae in blood cultures and/or pleural effusion. RESULTS: The study included 107 children. The most common serotypes were 14 (36.5%), 1 (16%), 5 (14.6%), 6B (6.3%) and 3 (4.2%). The proportion of identified serotypes contained in the heptavalent, 10-valent and 13-valent conjugate vaccines was 53.1, 86.5, and 96.9%, respectively. Pneumococcal strains were sensitive to penicillin (minimum inhibitory concentration, MIC 8 µg/mL) according to the Clinical and Laboratory Standards Institute 2008 standards. Tested isolates were highly sensitive to vancomycin, rifampicin, ceftriaxone, clindamycin, erythromycin, and chloramphenicol. CONCLUSIONS: Our results confirm a significant potential impact of conjugate vaccines, mainly 10-valent and 13-valent, on invasive pneumonia. Furthermore, susceptibility testing results show that penicillin is still the treatment of choice for invasive pneumonia in our setting.

Treatment of pediatric outpatients with complicated urinary tract infections

In an open and prospective study involving outpatient children with complicated urinary tract infections (UTI), we evaluated the therapeutic efficacy of ceftriaxone administered intramuscularly, once-daily--50 to 70 mg/kg, during 8 to 10 days. Initially, the selected patients exhibited at least two of the following clinical criteria: age below 6 months, any degree of toxicity, fever, strong suspicion or proved abnormalities of their urinary tracts and lumbar pain in children older than 4 years. Significant bacteriuria was demonstrated by urine culture in 40 patients (21 boys, 19 girls), whose ages ranged from 15 days to 6 years 9 months (median 3 months). The radiological studies revealed vesicoureteral reflux in 6 patients, urethral posterior valve in 1, and neurogenic bladder in 4. The main causative agents were Escherichia coli isolated in 30 patients, Klebsiella (4) and Proteus (4). The treatment was found to be effective in 38 patients (95%). There was failure of treatment in 1 patient and a symptomatic reinfection in another one. It was concluded that children with complicated UTI could be treated alternatively by once daily ceftriaxone.

Otomastoiditis caused by Sphingomonas paucimobilis: case report and literature review

Sphingomonas paucimobilis is an aerobic Gram-negative bacillus that, although rare in humans, most commonly infects immunocompromised and hospitalized patients. Among the 59 pediatric cases of S. paucimobilis infection reported in the literature, the most common diagnosis involves isolated bacteremia. These cases are related to sporadic or epidemic infections. Death related to this infection occurred in only one case. The authors report a case of an 11-year-old boy with the diagnosis of Sphingomonas paucimobilis otomastoiditis and a thorough review of the literature on this infection in pediatrics. The patient presented a 20-day history of fever, otalgia, otorrhea, and progressive retroauricular swelling with protrusion of the left ear; despite 15 days of amoxicillin regimen. His past medical history included chronic bilateral otitis media, but no cause of immunosuppression was found. A brain computed tomography scan showed left otomastoiditis associated with a large circumscribed fluid collection with deep involvement of the soft tissues of the temporal region, including the subperiosteal space. Blood tests showed neutrophilia and elevated C-reactive protein. Surgical manipulation of the cited collection drained a large amount of a fetid purulent secretion. Ceftazidime and clindamycin were empirically initiated. The outcome was favorable, with fever defervescence and resolution of the scalp deformation. Culture of the drained secretion was positive for S. paucimobilis. Ciprofloxacin was scheduled for a further 10 days after discharge. The follow-up showed complete recovery. As far as we know, this is the first case of S. paucimobilis otomastoiditis, complicated with subperiosteal abscess in an immunocompetent child. The authors call attention to the increasing number of reports on S. paucimobilis infection over the years, and therefore to the importance of this pathogen, which was previously underestimated.

Complicated pneumococcal pneumonia in children at a university hospital in São Paulo (Brazil)

Physical examination, laboratory studies, radiographic data (including chest CT scan), abdominal ultrasound, diagnostic thoracentesis established the diagnostic: 1. S. pneumoniae: Pneumonia of the RUL and RLL, complicated with pleural empyema. 2. D-Hemolytic Uremic Syndrome (HUS) (mediated by neuraminidases) 3. Hypocomplement C3, C4. Differential diagnostic was difficult: sepsis with pleural pulmonary and renal determination, parenchymal malformations were discussed. The treatment included: fluid therapy with monitor electrolyte and hydration status, platelets transfusion, packed RBC, IV immunoglobulines, albumin replacement, plasma infusion, diuretics and IV antibiotics (doses adjusted for glomerular clearance) for 7 weeks: meropenem, ertapenem, zyvoxid, ciprofloxacin, clindamycin. She didn’t need dialysis, or mechanical ventilation. Pulmonary outcome was good, with total recovery; after 3 months chest CT was normal. Renal outcome was good, with no recurrence. We discuss the severity of lung damage with a lot of pneumatoceles, but without pneumothorax or chronic empyema – that progressively resolved with antibiotic therapy in a child of 2 years that was vaccinated. It is the first case in our experience that associates HUS. We couldn’t explain this evolution on a genetic deficiency of the immune system (normal IgG, IgM, IgA, normal MBL), except complement C3, C4 decreased during the acute episode. We couldn’t determine the pneumococcal serotype, but it is possible to be 19A, the most frequent serotype that determine empyema or SHU, according to the studies from North America and Australia, serotype that is not present in 10 valent vaccine.

Doença de Kawasaki: experiência clínica em hospital universitário

OBJETIVO: A doenca de Kawasaki e uma vasculite sistemica aguda de etiologia desconhecida. Seu diagnostico baseia-se em criterios clinicos. O objetivo deste estudo foi descrever os casos de pacientes com doenca de Kawasaki internados no Hospital Universitario da Universidade de Sao Paulo entre janeiro/2000 e junho/2008. METODOS: Dentre todos os pacientes internados na Enfermaria de Pediatria no periodo acima, foram selecionados aqueles cujo CID de alta foi doenca de Kawasaki. Realizou-se estudo descritivo por meio da analise dos prontuarios dessas criancas. RESULTADOS: Foram encontrados 18 casos. A media de internacoes foi de 2,1 casos/ano. A idade variou de tres meses a nove anos. A proporcao meninos:meninas foi 1:1,25. Receberam outros diagnosticos previos 17 pacientes, sendo escarlatina em 2/3 dos casos. O tempo de febre antes do diagnostico variou de cinco a 11 dias. Nove criancas apresentaram quatro sinais sugestivos de doenca de Kawasaki; oito apresentaram cinco sinais e uma apresentou dois sinais, o que foi considerado doenca de Kawasaki incompleta. Receberam gamaglobulina 15 criancas (entre o sexto e o decimo dias de evolucao) e 11 (73%) ficaram afebris apos infusao da medicacao. Os demais tiveram febre ate 24 horas apos a administracao. Todos os pacientes realizaram ecocardiograma e tres apresentaram aneurisma leve da coronaria. CONCLUSOES: A doenca de Kawasaki e habitualmente confundida com outras doencas, o que causa retardo no tratamento e aumento no risco de complicacoes cardiacas.

Infecção urinária em menores de 15 anos: etiologia e perfil de sensibilidade antimicrobiana em hospital geral de pediatria

OBJECTIVE: To describe the prevalence of the most frequent etiological agents of community acquired urinary tract infection in children under the age of 15 years, as well as to analyse the antimicrobial susceptibility patterns of the most prevalent pathogen, Escherichia coli. METHODS: Retrospective study conducted from urine cultures of a single bacterial species, at a concentration > 105 colonies forming units/mL. The children included in the study were treated in the Pediatric Emergency Care Unit of the University Hospital of the University of Sao Paulo from January, 2006 to December, 2007. In order to analyze Escherichia coli antimicrobial susceptibility patterns, cases with recurrent urinary tract infection and/or carriers of uropathy were excluded. RESULTS: Among 176 urinary tract infection patients, 133 (76%) were females. Children less than two years old presented the highest prevalence of urinary tract infection (84 cases; 48%). E. coli was the main agent (122 cultures - 69% of the total). There were high rates of E. coli antimicrobial susceptibility to second and third-generation cephalosporins (cefuroxime and ceftriaxone, 100%), aminoglycosides (amikacin, 100%, gentamicin, 96.4%), nalidixic acid (97.3%), nitrofurantoin (98.2%) and quinolones (ciprofloxacin and norfloxacin, 98.2%); moderate susceptibility to first-generation cephalosporin (cephalothin, 78.4%); low susceptibility to ampicillin (38.7%) and sufamethoxazole-trimethoprim (55%). CONCLUSIONS: E. coli remains the most prevalent bacterial pathogen of community acquired urinary tract infection. Given the low in vitro susceptibility of these bacteria to sulfamethoxazole-trimethoprim and ampicillin, these drugs should not be elected as the initial choice for treatment.