Yehuda Benguigui

Penicillin resistant pneumococcus and risk of treatment failure in pneumonia

Objective: To determine whether the presence of in vitro penicillin-resistant Streptococcus pneumoniae increases the risk of clinical failure in children hospitalised with severe pneumonia and treated with penicillin/ampicillin. Design: Multicentre, prospective, observational study. Setting: 12 tertiary-care centres in three countries in Latin America. Patients: 240 children aged 3–59 months, hospitalised with severe pneumonia and known in vitro susceptibility of S pneumoniae. Intervention: Patients were treated with intravenous penicillin/ampicillin after collection of blood and, when possible, pleural fluid for culture. The minimal inhibitory concentration (MIC) test was used to determine penicillin susceptibility of the pneumococcal strains isolated. Children were continuously monitored until discharge. Main outcome measures: The primary outcome was treatment failure (using clinical criteria). Results: Overall treatment failure was 21%. After allowing for different potential confounders, there was no evidence of association between treatment failure and in vitro resistance of S pneumoniae to penicillin according to the Clinical Laboratory Standards Institute (CLSI)/National Committee for Clinical Laboratory Standards (NCCLS) interpretative standards (adjRR = 1.03; 95%CI: 0.49–1.90 for resistant S pneumoniae). Conclusions: Intravenous penicillin/ampicillin remains the drug of choice for treating penicillin-resistant pneumococcal pneumonia in areas where the MIC does not exceed 2 μg/ml.

Childhood pneumonia: clinical aspects associated with hospitalization or death

OBJECTIVE To determine which available information at an Emergency Room (ER) consultation is associated with hospitalization or death among children with pneumonia. DESIGN Prospective cohort study. SETTING The ER of one university and one private hospital. MEASUREMENT Using stepwise logistic regression we analyzed factors that showed a univariate association. MAIN RESULTS Of 2,970 cases, the median age was 1.83 years (range 2 days to 14.5 yrs, mean 2.76 +/- 2.72 yrs); 25.8% were hospitalized and 0.8% died. Age (2-11 mos, OR 0.4 [0.2-0.6]; 12-59 mos, OR 0.2 [0.1-0.4]; > or = 5 yrs, OR 0.1 [0.08-0.3]), malnutrition (OR 2.0 [1.4-2.7]), underlying chronic illness (OR 1.4 [1.1-1.8]), tachypnea (OR 1.8 [1.4-2.4]), chest indrawing (OR 1.7 [1.4-2.2]), and somnolence (OR 1.8 [1.4-2.4]) were associated with hospitalization and age (2-11 mos, OR 0.3 [0.08-0.8]; > or = 12 mos, OR 0.06 [0.02-0.2]), malnutrition (OR 3.1 [1.2-7.7]) and underlying chronic illness (OR 4.3 [1.6-11.0]) were associated with death in the multivariate analysis. CONCLUSIONS Several clinical aspects may be used in assessing need for hospitalization (i.e. young age, malnutrition, underlying chronic illness, tachypnea, chest indrawing and somnolence) for children with pneumonia seen at the ER. Individual intrinsic factors such as age, malnutrition and underlying chronic illness were independently associated with death. Pneumonia should be considered a treatable disease and complete recovery can be achieved in the majority of the cases.

Acute respiratory infections control in the context of the IMCI strategy in the Americas

As infeccoes respiratorias agudas (IRA) sao importante causa de morbidade e mortalidade em menores de cinco anos. Importantes contrastes sao observados em relacao a isto nos diferentes paises das Americas, e tambem entre regioes ou estados de um mesmo pais. A morbidade esta associdada a varios fatores, especialmente com a situacao nutricional das pacientes e o tempo de aleitamento materno. Tambem as caracteristicas dos cuidados prestados a essas criancas durante a doenca sao essenciais, com destaque para a percepcao dos pais ou responsaveis em relacao a doenca, os cuidados que os mesmos prestam a crianca durante a doenca, a preocupacao em decidir e consultar os servicos de saude, a forma em que esses cuidados sao oferecidos pelos servicos de saude e em que as orientacoes sao cumpridas em casa. Especial preocupacao deve existir em relacao a resistencia bacteriana aos antibioticos, sendo um problema crescente na America, com uma media de 26,1% de resistencia do Streptococcus pneumoniae a penicilina. Os antibioticos sao frequentemente utilizados de forma irresponsavel com 70% das criancas com IRA recebendo-os desnecessariamente. Controlar as IRA tem-se tornado prioridade. Intervencoes preventivas como as atuais vacinas conjugadas para Haemophilus influenzae e Streptococcus pneumoniae, e o manejo padronizado de casos, como proposto pela estrategia Atencao Integrada a Doencas Prevalentes na Infância (AIDPI), aparecem como os mais importantes passos para este problema de Saude Publica.

Evaluación de dos métodos estandarizados de interpretación de radiografías de tórax en niños con neumonía

OBJECTIVE To evaluate the accuracy of World Health Organization (WHO) method of interpreting chest radiographs on identifying young children with bacterial pneumonia, and to compare its accuracy with other method. METHODS Chest radiographs from children aged under 5 years old hospitalized for pneumonia, with microbiological evidence of bacterial or viral infection, were evaluated by 3 observers blinded to other data (pediatrician [P], pulmonologist [N], radiologist [R]) according to WHO and Khamapirad scores. A WHO score=1 and a Khamapirad score >2 were selected as the thresholds suggesting bacterial pneumonia. The relationship between radiographic scores and etiology was evaluated using chi square. Sensitivity (Se), specificity (Sp), positive (PPV) and negative (NPV) predictive values for predicting bacterial pneumonia were calculated. Interobserver agreement (P vs. N vs. R) was calculated (kappa). RESULTS 108 chest radiographs were evaluated (87 viral, 21 bacterial). WHO score= 1 was associated with bacterial pneumonia (p <0.001; OR= 6.4; CI 95%= 1.629.7), achieving a Se= 85%, Sp= 51%, PPV= 30%, NPV= 93%. Khamapirad score >2, evaluated by P, was also associated with bacterial pneumonia (p <0.0008; OR= 6.31; CI 95%= 1.8-24.4), achieving a Se= 80%, Sp= 59%, PPV= 32% NPV= 92%. Interobserver agreement was slightly better using WHO score (P vs. N= 0.82, P vs. R= 0.69, N vs. R= 0.85) than Khamapirad score (P vs. N= 0.48, P vs. R= 0.69, N vs. R= 0.82). CONCLUSIONS Both methods showed similar accuracy in order to identify bacterial pneumonia. WHO score is simpler than Khamapirad score and showed a better interobserver agreement.

Integrated management of childhood illness (IMCI): an innovative vision for child health care

The Integrated Management of Childhood Illness (IMCI) strategy developed by the World Health Organization (WHO), Panamerican Health Organization (PAHO) and the United Nation Childrens Fund (UNICEF), joint experiences of previous frequent diseases programs in children, with prevention and health promotion activities. In this new approach the family, the community and health workers have a leading role in health condition of the child. The strategy aims a reduction in Infant Mortality Rate, specially in those regions and countries in which it is high. Pneumonia, diarrhea, malnutrition and other preventable diseases are the main causes of deaths in this settings. Health workers can early recognized danger signs of severe diseases, as well as they can evaluate and treat the most frequent health problems. By enhancing prevention and health promotion activities, as better conditions of life, giving an holistic vision of the child and his family, and not only looking for the symptom that motivate the consultation.

Empyema and bacteremic pneumococcal pneumonia in children under five years of age.

We compared bacteremic pneumococcal pneumonia (BPP) and pneumococcal empyema (PE), in terms of clinical, radiological, and laboratory findings, in under-fives. A cross-sectional nested cohort study, involving under-fives (102 with PE and 128 with BPP), was conducted at 12 centers in Argentina, Brazil, and the Dominican Republic. Among those with PE, mean age was higher; disease duration was longer; and tachypnea, dyspnea, and high leukocyte counts were more common. Among those with BPP, fever and lethargy were more common. It seems that children with PE can be distinguished from those with BPP on the basis of clinical and laboratory findings. Because both conditions are associated with high rates of morbidity and mortality, prompt diagnosis is crucial.