[Urinary Tract Infections Caused by Community-Acquired Extended-Spectrum ß-Lactamase-Producing Enterobacteriaceae in a Level III Hospital - A Retrospective Study]. / Infeções Urinárias Causadas por Enterobacteriaceae Produtoras de ß-Lactamases de Espetro Expandido Adquiridas na Comunidade num Hospital de Nível III - Um Estudo Retrospetivo.

INTRODUCTION: The emergence of ß-lactamases producing bacteria is a problem worldwide, with increasing importance in communityacquired infections, especially in urinary tract infections. Data regarding the use of non-carbapenem antimicrobials in these infections are scarce. The aim of this study was to analyse the treatment and outcome of urinary tract infections caused by community-acquired ß-lactamase-producing bacteria in children. MATERIAL AND METHODS: Retrospective study performed in a level III paediatric hospital, between June 2007 and December 2017. All children with ß-lactamase-producing Enterobacteriaceae identified in aseptically collected urine culture were included. RESULTS: A total of 175 urinary infections caused by ß-lactamases producing bacteria were diagnosed, 34 (19%) were community-acquired: 25 Escherichia coli (74%), 4 Klebsiella pneumoniae (12%), 4 Proteus mirabilis (12%) and 1 Proteus vulgaris (3%). In 30 (88%) cases, it was the first urinary infection. After identification of the microorganism and antimicrobial susceptibility, 33 (97%) children were re-evaluated and 24 (71%) had a repeat urine culture, which was positive in three (13%). In six (18%) cases, antibiotic treatment was modified. Four (12%) children had another UTI in the following month. In 30 (88%) children, imaging was carried out, with no nephrourological malformations detected. DISCUSSION: In the last decade, about 20% of urinary infections caused by ß-lactamase-producing Enterobacteriaceae were community-acquired with a relatively stable number of cases over the years. No nephro-urological malformations were identified in these children. CONCLUSION: Although the number of cases is small, the clinical and microbiological outcomes showed that most were successfully treated with non-carbapenem antibiotics, with low recurrence of new episodes of urinary tract infections.

Introdução: A emergência de bactérias produtoras de ß-lactamases de espetro expandido é um problema mundial, com importância crescente nas infeções adquiridas na comunidade, nomeadamente nas infeções urinárias. Os dados pediátricos de utilização de antimicrobianos não carbapenemos nestas infeções são escassos. O objetivo do estudo foi analisar a terapêutica antibiótica instituída nas infeções urinárias causadas por estes agentes, assim como a evolução clínica e laboratorial.Material e Métodos: Estudo retrospetivo efetuado num hospital pediátrico entre junho de 2007 e dezembro de 2017. Foram incluídas todas as crianças com urocultura positiva para Enterobacteriaceae produtoras de ß-lactamases.Resultados: Foram diagnosticadas 175 infeções urinárias causadas por Enterobacteriaceae produtoras de ß-lactamases, das quais 34 (19%) foram adquiridas na comunidade: 25 Escherichia coli (74%), 4 Klebsiella pneumoniae (12%), 4 Proteus mirabilis (12%) e 1 Proteus vulgaris (3%). Em 30 (88%) episódios tratou-se da primeira infeção urinária. Após conhecimento do microrganismo e suas suscetibilidades, 33 (97%) crianças foram reavaliadas e 24 (71%) repetiram urocultura, que foi positiva em três (13%). Em seis (18%) casos foi alterado o antimicrobiano. No mês subsequente, quatro (12%) crianças tiveram nova infeção urinária e 30 (88%) crianças realizaram investigação imagiológica, sem deteção de malformações nefro-urológicas.Discussão: Na última década, cerca de 20% das infeções urinárias causadas por Enterobacteriaceae produtoras de ß-lactamases foram adquiridas na comunidade, com um número relativamente estável ao longo dos anos. Estas crianças não apresentavam malformações nefro-urológicas.Conclusão: Embora o número de casos seja pequeno, a evolução clínica e microbiológica mostrou que a maioria foi tratada com sucesso com antimicrobianos não carbapenemos, com baixa ocorrência de novos episódios.

Viable Neisseria meningitidis is commonly present in saliva in healthy young adults: Non-invasive sampling and enhanced sensitivity of detection in a follow-up carriage study in Portuguese students.

INTRODUCTION AND AIMS: Improved sensitivity and efficiency of detection and quantification of carriage of Neisseria meningitidis (Nm) in young people is important for evaluation of the impact of vaccines upon transmission and associated population-wide effects. Saliva collection is quick, non-invasive and facilitates frequent sampling, but has been reported to yield low sensitivity by culture. We re-evaluated this approach in a follow-up cross sectional study using direct and culture-amplified PCR. MATERIAL/METHODS: In April 2016 we collected paired oropharyngeal swabs (OPS) and saliva samples from 1005 healthy students in Portugal into STGG broth and stored them at -80°C until DNA extraction and batched qPCR analysis. Samples were also cultured on GC agar plates for 72h and PCR done on DNA extracts from overall growth. Nm isolates were also sought from a selection of 50 samples. qPCR amplification targets were superoxide dismutase sodC and capsular locus/genogroup-specific genes (B, C, W, X and Y) and, for cultured isolates only, porA. Cycle threshold values of ≤36 were considered positive. RESULTS: 556 tests (460 samples, 363 subjects, 36.1%) were positive for Nm (sodC) and 65 (45, 36, 3.6%) for MenB. More salivas were positive by direct sodC qPCR (211, 21.0%) than OPS (126, 12.5%) but fewer were positive by culture-amplified qPCR (94 vs. 125). For both sample types, many that were negative on direct qPCR came positive on culture-amplification and Nm was consistently isolated from salivas in which culture amplified the PCR signal. Using both methods on both samples yielded 36.1% Nm and 5.5% encapsulated Nm carriage rates while direct qPCR on OPS alone detected 12.5% and 2.2%. CONCLUSIONS: Detectable MenB carriage rates (2.9%) were lower than 4 years earlier (6.8%) in this population (p = 0.0003). Viable meningococci were often present in saliva. Although evidence of encapsulated Nm was less frequent in saliva than OPS, collection is more acceptable to subjects allowing more frequent sampling. Use of culture-amplification increases detection sensitivity in both sample types, especially when combined with direct PCR. Combining these samples and/or methodologies could greatly enhance the power of carriage studies to detect the impact of vaccines upon carriage and transmission.

[Diagnosis and treatment of acute pharyngitis -Is there any benefit on ten-day course of antibiotics?] / Diagnóstico y tratamiento de la faringitis aguda. ¿Hay alguna ventaja en la pauta de antibióticos de 10 días?

INTRODUCTION: In group A streptococcal (GAS) pharyngitis a ten-day course of amoxicillin is recommended. However, short-course treatments seem to be equally effective. The aim of this study was to retrospectively evaluate and compare the outcome of patients treated with 7-day course and 10-day course of amoxicillin. MATERIALS AND METHODS: Retrospective analysis of all GAS pharyngitis admitted to a paediatric emergency department in 2014. Demographic variables, the application and results of the rapid antigenic diagnostic test (RADT), treatment, complications and return in the next 30 days were analysed. Two groups were defined for comparative analysis according to the duration of treatment with amoxicillin: A) short-course (up to 7 days) and B) long-course (10 days). RESULTS: Were included 989 GAS pharyngitis. The median age was 5.2 years, 50.1% male. Amoxicillin was the most prescribed antibiotic (94.9%) with a median duration of 7 days. 10-day course therapy was prescribed in 31.9% of the cases. There were no differences between short and long-course treatment groups regarding age (P=.600), gender (P=.429) and complications (P=.436). Considering the endpoint "return to the emergency department", we concluded that up to 7 days of treatment was non-inferior to 10 days of treatment. CONCLUSION: The most commonly prescribed antibiotic was amoxicillin, but a 10-day course was prescribed in few cases. In our analysis there seems to be no benefit with long-course treatments with amoxicillin in GAS pharyngitis.

[Paediatric Invasive Pneumococcal Disease Before Universal Vaccination: 1995 - 2015]. / Doença Invasiva Pneumocócica Pediátrica Antes da Vacinação Universal: 1995 - 2015.

INTRODUCTION: Pneumococcal conjugate vaccine was introduced in the private market in Portugal in 2001, reaching over the years a moderately high coverage. In July 2015, it was included in the National Immunisation Program. The aim of this study was to characterize invasive pneumococcal disease in a pediatric hospital before universal use of the vaccine. MATERIAL AND METHODS: Retrospective analysis of medical records of all children with Streptococcus pneumoniae identified by culture and/or molecular biology (available since 2008), in products obtained from sterile sites, from January 1995 to June 2015. We evaluated demographic, clinical and microbiological data. Serotype results are available since 2004. RESULTS: Over those 20 years, 112 invasive pneumococcal disease cases were identified, with a median age of 15 months (1 month - 15 years). The median number of cases /year was 4, the highest between 2001 - 2002 (8/year) and 2007 - 2012 (7 - 11/year). The identification occurred mostly in blood culture (72), cerebrospinal fluid (24), pleural fluid (11) an others (5). The most frequent diagnoses were pneumonia (38%), occult bacteraemia (34%) and meningitis (21%). Over the period under review, there was an increase of pneumonia and slight increase of OB, with meningitis cases remaining relatively unchanged. DISCUSSION: In the last two decades, there was no reduction in the number of cases of invasive pneumococcal disease. There was an increase in isolates from pneumonia and occult bacteraemia that might be due to the introduction of molecular biological methods for Streptococcus pneumoniae detection. Vaccine serotypes were predominant. CONCLUSION: This retrospective analysis before universal vaccination will contribute to evaluate the impact of vaccination in the Portuguese pediatric population.

Introdução: A vacina conjugada pneumocócica foi introduzida no mercado privado português em 2001, atingindo ao longo dos anos coberturas moderadamente elevadas. Em julho de 2015 foi integrada no Programa Nacional de Vacinação. O objetivo deste estudo foi caracterizar a doença invasiva pneumocócica num hospital pediátrico antes da vacinação universal. Material e Métodos: Análise retrospetiva dos processos clínicos de todas as crianças com identificação de Streptococcus pneumoniae por cultura e/ou por biologia molecular (disponível desde 2008), em produtos obtidos de locais estéreis, de janeiro 1995 a junho 2015, avaliando dados demográficos, clínicos e microbiológicos. Os serotipos estão disponíveis desde 2004. Resultados: Ao longo destes 20 anos identificámos 112 casos de doença invasiva pneumocócica, com idade mediana de 15 meses (1 mês - 15 anos). A mediana de casos/ano foi 4, com valores máximos entre 2001 - 2002 (8/ano) e 2007 - 2012 (7 - 11/ano). A identificação ocorreu maioritariamente em hemocultura (72), líquido cefalorraquidiano (24), líquido pleural (11) e outros (5). Os diagnósticos mais frequentes foram pneumonia (38%), bacteriemia oculta (34%) e meningite (21%). Ao longo do período em análise, observou-se um aumento do diagnóstico de pneumonia e aumento ligeiro de bacteriemia oculta, tendo-se mantido relativamente constante o de meningite. Discussão: Nas últimas duas décadas não se observou redução do número de casos de doença invasiva pneumocócica, tendo ocorrido um aumento da identificação de pneumococo em pneumonia e bacteriemia oculta, para o qual poderão ter contribuído a introdução dos métodos de biologia molecular e a realização de mais hemoculturas. Os serotipos vacinais foram predominantes. Conclusão: Esta analise retrospetiva pré vacinação universal, contribuirá para avaliar o impacto da vacinação na população pediátrica portuguesa.

Density Distribution of Pharyngeal Carriage of Meningococcus in Healthy Young Adults: New Approaches to Studying the Epidemiology of Colonization and Vaccine Indirect Effects.

BACKGROUND: Improved understanding of Neisseria meningitidis (Nm) carriage biology and better methods for detection and quantification would facilitate studies of potential impact of new vaccines on colonization and transmission in adolescents. METHODS: We performed plate cultures on 107 oropharyngeal swabs stored frozen in skim milk tryptone glucose glycerol (STGG) broth and previously positive for Nm. We compared quantitative polymerase chain reaction (qPCR) detection of Nm in 601 STGG-swabs with culture. Using qPCR (n = 87), a log-phase broth culture standard curve and semiquantitative plate cultures (n = 68), we measured density of carriage. We compared qPCR genogrouping of DNA extracts from STGG-swabs and from plate culture lawns (n = 110) with purified isolates (n = 80). RESULTS: Swab storage resulted in only 10% loss of culture sensitivity. Direct sodC qPCR Nm detection yielded more positives (87/601, 14.5%) than culture (80/601, 13.3%). Most samples (57/110) positive by culture were also positive by qPCR and vice versa, but discrepancies (single positives) were frequent among low-density samples. sodC qPCR was positive in 79/80 isolates but in only 65 by ctrA qPCR. Density both by culture and qPCR varied across 4 orders of magnitude with the majority being low (<50 bacteria-gene copies/mL) and a minority being high (>1000). Genogrouping qPCRs yielded more positive results when performed on DNA extracts from lawn cultures. CONCLUSIONS: We provide the first description of the distribution of Nm carriage density. This could be important for understanding transmission dynamics and population-level effectiveness of adolescent vaccine programs. Storage of swabs frozen in STGG for batched laboratory analysis facilitates carriage studies and direct sodC qPCR for Nm combined with qPCR genogrouping of lawn culture extracts provides accurate, detailed description of colonization.

Oropharyngeal Carriage of Meningococcus in Portugal by Group and Clonal Complex 6 Years After Adolescent Vaccine Campaign.

Portugal introduced (2+1) conjugate Meningococcal group C vaccine in 2006 with high coverage catch up to 18 years and has given only 1 dose at 1 year since 2012. Among 601 student oropharyngeal swabs, meningococcal carriage rate was 13.3% (A-0%, B-5.3%, C-0.3%, W-0.2%, X-0.2% and Y-1.7%). C and W strains were of potentially disease-causing clonal complexes (cc) but not the hyperinvasive cc11.

Case control study of rotavirus vaccine effectiveness in Portugal during 6 years of private market use.

BACKGROUND: Although recommended by the vaccine committee of the Portuguese Paediatric Society, rotavirus vaccines have not been included in the routine immunization schedule. They have been available privately since 2006 with estimated coverage reaching approximately 30%. However, unlike other European countries using the vaccine, sentinel surveillance has detected fluctuations but no clear trends in the rate of gastrointestinal disease presentations. In this study, we set out to establish the real world effectiveness of rotavirus immunization in this low vaccine coverage setting. METHODS: We carried out a test-negative case control study on a population of children attending a regional pediatric hospital, between 2006 and 2012, with symptoms of acute gastroenteritis and producing a stool sample for routine rotavirus testing. We calculated exposure odds ratio (ratio of odds of antecedent vaccination among cases compared with controls) to derive vaccine effectiveness ([1 - adjusted odds ratio]/100) against both hospital attendance and admission. RESULTS: Vaccine effectiveness against attendance with rotavirus acute gastroenteritis was 83.7% (95% confidence interval: 73.9-89.8) and against hospital admission was 96.1% (95% confidence interval: 83.8-99.1). No significant difference between the 2 available vaccines was detected. CONCLUSION: Both rotavirus vaccines offer a high degree of individual protection in this population.

Multiple Streptococcus pneumoniae serotypes in aural discharge samples from children with acute otitis media with spontaneous otorrhea.

Among 55 children with cultures positive for acute otitis media with spontaneous otorrhea, 28 (51%) had cultures positive for aural Streptococcus pneumoniae, and in 10 of these, two distinct strains were detected, in which 5 had pairs of strains that were both capsule-bearing serotypes. Such cases were more likely to have cultures positive for other otopathogens than those with only one pneumococcus present.

Relationships between rhinitis symptoms, respiratory viral infections and nasopharyngeal colonization with Streptococcus pneumoniae, Haemophilus influenzae and Staphylococcus aureus in children attending daycare.

BACKGROUND: Nasal bacterial colonization is often dubbed "asymptomatic." We hypothesized that rhinitis, common in preschool children, is associated with bacterial colonization and that respiratory viruses, which cause rhinitis, interact with bacteria in ways which promote transmission. METHODS: Five hundred eighty-five children (4.2-73.6 months) attending daycare had clinical information, a rhinitis score and nasal swabs collected in February 2009. Swabs in soya tryptone glucose glycerine broth were cultured for Streptococcus pneumoniae (Sp), Haemophilus influenzae (Hi) and Staphylococcus aureus and analyzed by real-time polymerase chain reaction for respiratory viruses, both semiquantitatively. RESULTS: Rhinitis symptoms, carriage of Sp and Hi and viral detection fell, whereas S. aureus carriage rates rose with age. Significant, age-independent associations between rhinitis symptoms and detection of Hi (P < 0.033) and Hi colonization density (P < 0.027) were observed. Of the 42% with detected viruses, most (78%) had picornavirus detection. There was a significant age-independent association between viral detection (and viral load, picornavirus detection and picorn aviral load) and detection of Sp (P = 0.020, 0.035, 0.005, 0.014) and between viral detection and viral load and Sp colonization density (P = 0.024, 0.028) [corrected]. CONCLUSIONS: Hi may promote its own transmission by inducing or ampli¬fying rhinitis in children. There isa close quantitative relationship between respiratory viral detection, including picornavirus detection and Spcoloni¬zation. These findings have implications for understanding disease patho¬genesis and formulating prevention strategies using vaccines [corrected].

The evolving epidemiology of rotavirus gastroenteritis in central Portugal with modest vaccine coverage.

BACKGROUND: Rotavirus (RV) vaccines have been available on the private market in Portugal since 2006, with an estimated coverage rising from 16 to 42% between 2007 and 2010. OBJECTIVES: To assess trends, surveillance of children presenting with acute gastroenteritis (AG) to a large paediatric emergency service (ES) in the central region of Portugal was conducted yearly during the winter-spring seasons. STUDY DESIGN: Stool samples, collected throughout five epidemic seasons (January-June, 2006 to 2010) from children ≤ 36 months of age attending the ES with AG, were tested for RV by immunochromatographic rapid test and positive samples were genotyped. RESULTS: A total of 6145 AG cases were identified: 1956 (32%) provided a stool sample (range: 28% in 2008-37% in 2009). The proportion of AG subjects who tested positive for RV fluctuated over the five surveillance seasons (49%, 39%, 25%, 26% and 39%, respectively) as did the distribution of co-circulating RV genotypes. There were no consistent changes in seasonality or age distribution and the proportion of admitted AG subjects who tested RV-positive did not show progressive trends over time. CONCLUSIONS: Our results demonstrate fluctuations in RVAG incidence with no clear progressive trends or seasonal RV shifts among our surveillance subjects over five years, in the context of limited rotavirus vaccine coverage. Significant annual changes in genotype distributions were detected. Higher vaccine coverage may be necessary than at present for consistent impact on disease.

[Neonatal mastitis: 12 years of experience]. / Mastite neonatal: experiência de 12 anos.

INTRODUCTION AND AIMS: Mastitis is an inflammation of the breast that may be accompanied by an infectious process. The most frequently isolated bacteria is Staphylococcus aureus. The vast majority of cases are unilateral and have good prognosis. The aim of this study was to characterize neonatal infectious mastitis diagnosed and treated in a tertiary hospital. METHODS: Retrospective analysis of all clinical records of infants < 2 months of age diagnosed with neonatal mastitis between January 2000 and June 2011. Clinical, laboratory and microbiological data, as well as treatment and outcome, were analyzed. RESULTS: Twenty-one children met inclusion criteria, fourteen were female. The median age at diagnosis was 21 days. Mastitis was unilateral in 19 cases. The most frequent signs were swelling and erythema. Fever was documented in three children. The bacteria identified in the breast exudate was methicillin susceptible Staphylococcus aureus in six cases and methicillin-resistant Staphylococcus aureus in three cases. The most frequently used antibiotic was flucloxacillin, with a median duration of ten days. There were 11 cases of breast abscess, ten drained surgically and one with spontaneous drainage. In two cases with isolation of methicillin-resistant Staphylococcus aureus there was a good outcome with surgical drainage, despite treatment with a ß-lactam. There were no other complications. CONCLUSIONS: As described in literature, in this series neonatal mastitis was more frequent in girls and unilateral. The development of breast abscess occurred in half of the cases. The only bacteria isolated was Staphylococcus aureus (9 cases), methicillin resistant in three cases, two of which with good outcome with surgical drainage, despite treatment with a ß-lactam.

Progressive changes in pneumococcal carriage in children attending daycare in Portugal after 6 years of gradual conjugate vaccine introduction show falls in most residual vaccine serotypes but no net replacement or trends in diversity.

OBJECTIVES: To track ongoing trends in pneumococcal (Sp) serotype carriage under the selection pressure of moderate pneumococcal conjugate vaccine (PCV) use, children in a community in Portugal were studied in the same months in 3 consecutive years. METHODS: Nasopharyngeal specimens were collected (children aged 3 months to <7 years) in 8 urban daycare centers in February 2008 (n=561) and 2009 (n=585). Sp isolates were serotyped. RESULTS: While demographics were similar in 2008-2009 and a previously reported sample in 2007, PCV coverage (at least one dose) in the children studied rose from 76.5% to 84% although national coverage was lower than this. Sp carriage fell from 61% to 51% with a concomitant fall in PCV7 serotype carriage from 12.1% to 4.3%. Remaining PCV7 serotypes declined to near (23F) or totally (6B, 14) undetectable levels except 19F which persisted unchanged in around 4% of children. Although carriage of 3 and 6C rose, there was no net increase in non-PCV7 serotypes and no progressive trend in serotype diversity. CONCLUSIONS: Ecological changes induced by PCVs where uptake is moderate appear to be different from high usage settings. We report falling Sp carriage due to PCV7 serotype disappearance with persistence of 19F and no ongoing net replacement after several years of PCV7 use and slowly rising uptake.

Epidemiology of rotavirus in Portugal: G9 as a major cause of diarrhoea in non-hospitalised children.

BACKGROUND: Rotavirus is a major cause of gastroenteritis in children worldwide, but there is no data available on the incidence of rotavirus gastroenteritis or on the strains circulating in Portugal. METHODS: We determined prospectively the incidence of rotavirus infection in non-hospitalised children and the genotypes circulating during one winter season in the central region of Portugal. RESULTS: Rotavirus was found in 45% of the samples tested. The peak incidence was in February (54% positive) and March (60% positive). Genotyping was performed in 195 samples; unexpectedly, G9P[8] was present in 90% of the cases, a much higher percentage than previously reported in other countries. CONCLUSIONS: These results contribute to the assessment of the burden of disease attributable to rotavirus in Portugal and facilitate preparation for intervention by vaccination. The predominance of G9 in Portugal is unlikely to be a local phenomenon, and may be observed elsewhere in Portugal and Europe. The epidemiology of rotaviruses in Portugal should be monitored in subsequent years.