Predictors of mortality and clinical characteristics among carbapenem-resistant or carbapenemase-producing Enterobacteriaceae bloodstream infections in Spanish children.

BACKGROUND: Carbapenem-resistant Enterobacteriaceae (CRE) are an emerging problem in the paediatric population worldwide with high mortality rates in bloodstream infection (BSI). OBJECTIVES: To evaluate predictors of 30 day mortality in CRE BSI in a paediatric cohort. METHODS: A retrospective observational single-centre study (December 2005-August 2018) was conducted. Cases of CRE BSI in children 0 to 16 years were included. Microbiological identification (MALDI Biotyper) and antimicrobial susceptibility testing (Vitek2® and MicroScan panel NBC44) according to EUCAST breakpoints were performed. PCR OXVIKP® was used to confirm carbapenemase genes (OXA-48, VIM, KPC, NDM). Demographic characteristics, underlying diseases, source of bacteraemia, antimicrobial therapy and outcomes were collected from medical records. Survival analysis to establish predictors of 30 day mortality was performed. RESULTS: Thirty-eight cases were included; 76.3% were hospital-acquired infections and 23.7% related to healthcare. All patients had at least one underlying comorbidity and 52.6% were recipients of an organ transplant. VIM carbapenemase was the predominant mechanism (92.1%). Previous CRE colonization or infection rate was 52.6%. Intestinal tract (26.3%) and vascular catheter (21.1%) were the most common sources of infection. Crude mortality within 30 days was 18.4% (7/38); directly related 30 day mortality was 10.5%. Conditions associated with an increment in 30 day mortality were intensive care admission and inadequate empirical therapy (P < 0.05). Combination-antibiotic targeted treatment and a low meropenem MIC were not related to improved survival. CONCLUSIONS: CRE BSI mortality rate is high. The most important factor related to 30 day survival in our CRE BSI cohort in children was empirical treatment that included at least one active antibiotic.

[Cytomegalovirus infection causing protracted diarrhea in an immunocompetent child]. / Infección por citomegalovirus como causa de diarrea grave rebelde en un lactante inmunocompetente.

Cytomegalovirus infection is a frequent cause of complications in immunodeficient patients. In healthy hosts, cytomegalovirus infection is usually asymptomatic. We describe a case of a 3 month old immunocompetent boy who suffered from protracted diarrhoea that required parenteral nutrition. After treatment with ganciclovir he recovered without any after effects.

[Ménétriers disease associated with cytomegalovirus infection]. / Enfermedad de Ménétrier asociada a infección por citomegalovirus.

Menetrier's disease is a rare entity in children, characterized by a protein-losing gastroenteropathy with thickening of the gastric mucosa and generalized edema. The most common etiology is viral, and cytomegalovirus is the agent most frequently implicated. Unlike in the adult, it is a self-limited disorder with a good prognosis in children. Four patients (three boys and one girl) diagnosed with Ménétrier disease in the past five years were reviewed. The mean age at presentation was 28.7 months (range: 10-48 months). The most common clinical symptoms were fever, vomiting, and edema. Endoscopy showed thickened gastric folds and erosions in several stages. All patients had an associated gastric cytomegalovirus infection, and a favorable outcome, with resolution of the disorder,was observed within a few weeks.

[Plasma citrulline concentration as a biomarker of intestinal function in short bowel syndrome and in intestinal transplant]. / Valor de la citrulina plasmática como biomarcador de función intestinal en el síndrome de intestino corto y en el trasplante intestinal.

INTRODUCTION: Citrulline is a non-essential amino acid produced solely in the enterocyte. The aim of this study was to analyse the role of serum citrulline as a biomarker of enterocyte load in children with intestinal failure due to short bowel syndrome (SBS) and its relationship to enteral adaptation. MATERIAL AND METHODS: Plasma citrulline concentration was determined by chromatography (normal value>15 µmol/L) in 57 patients (age 0.5-18 years) admitted to our Intestinal Rehabilitation Unit with intestinal failure. Those who were dehydrated, with renal insufficiency, or other conditions able to modify the results were excluded. Patients were divided into 4 groups: group i: SBS totally dependent on parenteral nutrition (PN); group ii: SBS under mixed enteral-parenteral nutrition; group iii: IF weaned from PN after a rehabilitation period; group iv: small bowel transplanted patients weaned from PN and taking a normal diet. RESULTS: The mean ± SD plasma citrulline values were: group i (n=15): 7.1 ± 4.1; group ii (n=11): 15.8 ± 8.9; group iii (n=13): 20.6 ± 7.5; group iv (n=25): 28.8 ± 10.1. Values were significantly lower in group i in comparison with groups ii-iii-iv (P<.001), and in group ii in comparison with groups iii-iv (P<.001). A low citrulline was associated with remnant small bowel length (P<.001, r=0.85). In group iv citrulline levels decreased >50% in 3 patients who developed moderate-severe rejection, and in one patient who developed viral enteritis. CONCLUSIONS: 1. Plasma citrulline could be a sensitive and specific biomarker of the residual functional enterocyte load. 2. It is related to enteral feeding tolerance. 3. Its prognostic value in the process of intestinal adaptation and as a rejection marker in small bowel transplanted patients needs to be confirmed.

Enfermedad de Ménétrier asociada a infección por citomegalovirus / Ménétrier′ s disease associated with cytomegalovirus infection

La enfermedad de Ménétrier es una entidad poco frecuente en el niño, caracterizada por una gastroenteropatía pierde proteínas con engrosamiento de la mucosa gástrica y edemas generalizados. La etiología vírica es la más frecuente, siendo el citomegalovirus el agente infeccioso más habitualmente implicado. A diferencia del adulto, es un trastorno autolimitado y con buen pronóstico en el niño. Se revisa a 4 pacientes (3 varones y una mujer) diagnosticados de enfermedad de Ménétrier en los últimos 5 años. La edad media de presentación fue de 28,7 meses (rango: 10-48 meses). La sintomatología clínica más común fue fiebre, vómitos y edemas. La endoscopia demostró engrosamiento de pliegues gástricos y erosiones en grado variable. Todos los pacientes asociaban infección gástrica por citomegalovirus y presentaron una evolución favorable, con resolución del trastorno en pocas semanas

Menetrier's disease is a rare entity in children, characterized by a protein-losing gastroenteropathy with thickening of the gastric mucosa and generalized edema. The most common etiology is viral, and cytomegalovirus is the agent most frequently implicated. Unlike in the adult, it is a self-limited disorder with a good prognosis in children. Four patients (three boys and one girl) diagnosed with Ménétrier disease in the past five years were reviewed. The mean age at presentation was 28.7 months (range: 10-48 months). The most common clinical symptoms were fever, vomiting, and edema. Endoscopy showed thickened gastric folds and erosions in several stages. All patients had an associated gastric cytomegalovirus infection, and a favorable outcome, with resolution of the disorder,was observed within a few weeks

Valor de la citrulina plasmática como biomarcador de función intestinal en el síndrome de intestino corto y en el trasplante intestinal / Plasma citrulline concentration as a biomarker of intestinal function in short bowel syndrome and in intestinal transplant

Introducción: La citrulina es un aminoácido producido exclusivamente por los enterocitos. Se estudió su valor como biomarcador de masa enterocitaria funcionante en pacientes con fracaso intestinal por síndrome de intestino corto (SIC) y su relación con la tolerancia digestiva. Material y métodos: Se determinó la concentración plasmática de citrulina por cromatografía líquida de alta resolución (normal > 15 μmol/L) en 57 pacientes (edad 0, 5-18 años) con fracaso intestinal en distintas situaciones evolutivas. Fueron excluidos pacientes deshidratados, con insuficiencia renal u otras situaciones que pudieran alterar los resultados. Se clasificaron en grupos: I : SIC extremo dependientes de nutrición parenteral (NP); II : SIC en alimentación mixta enteral-parenteral; III : SIC adaptados y autónomos sin NP; IV : trasplantados y autónomos sin NP. Resultados: Los valores medios ± DE de citrulina plasmática fueron: grupo I (n = 15): 7,1 ± 4,1; grupo II (n = 11): 15,8 ± 8,9; grupo III (n = 13): 20,6 ± 7,5; grupo IV (n = 25): 28,8 ± 10,1. Los valores resultaron inferiores en el grupo I comparados con los grupos II - III - IV (p < 0,001) y en el grupo II comparados con los grupos III - IV (p < 0,001). Se observó una fuerte correlación entre la citrulinemia y la longitud del intestino delgado remanente (r = 0,85; p < 0,001). En el grupo IV la citrulina descendió > 50% coincidiendo con rechazo moderado-severo en 3 pacientes y con enteritis viral en un paciente. Conclusiones: 1. La citrulina plasmática puede ser un biomarcador sensible y específico del intestino funcional residual. 2. Se relaciona con la tolerancia a la alimentación enteral. 3. Debe confirmarse su valor pronóstico en el proceso de adaptación intestinal y como marcador de rechazo en pacientes trasplantados (AU)

Introduction: Citrulline is a non-essential amino acid produced solely in the enterocyte. The aim of this study was to analyse the role of serum citrulline as a biomarker of enterocyte load in children with intestinal failure due to short bowel syndrome (SBS) and its relationship to enteral adaptation. Material and methods: Plasma citrulline concentration was determined by chromatography (normal value > 15 mol/L) in 57 patients (age 0.5-18 years) admitted to our Intestinal Rehabilitation Unit with intestinal failure. Those who were dehydrated, with renal insufficiency, or other conditions able to modify the results were excluded. Patients were divided into 4 groups: group I: SBS totally dependent on parenteral nutrition (PN); group II: SBS under mixed enteral parenteral nutrition; group III: IF weaned from PN after a rehabilitation period; group IV: small bowel transplanted patients weaned from PN and taking a normal diet. Results: The mean ± SD plasma citrulline values were: group I (n = 15): 7.1±4.1; group II (n = 11): 15.8±8.9; group III (n = 13): 20.6±7.5; group IV (n = 25): 28.8±10.1. Values were significantly lower in group I in comparison with groups II-III-IV (P <0 .001), and in group II in comparison with groups III-IV (P < 0.001). A low citrulline was associated with remnant small bowel length (P < 0.001, r = 0.85). In group IV citrulline levels decreased > 50% in 3 patients who developed moderates ever e rejection, and in one patient who developed viral enteritis. Conclusions: 1. Plasma citrulline could be a sensitive and specific biomarker of the residual functional enterocyte load. 2. It is related to enteral feeding tolerance. 3. Its prognostic value in the process of intestinal adaptation and as a rejection marker in small bowel transplanted patients needs to be confirmed (AU)

Infección por citomegalovirus como causa de diarrea grave rebelde en un lactante inmunocompetente / Cytomegalovirus infection causing protracted diarrhea in an immunocompetent child

La infección por citomegalovirus (CMV) es una causa frecuente de complicaciones en pacientes inmunodeprimidos. En huéspedes sanos, la infección por CMV cursa generalmente de forma asintomática. A continuación se presenta el caso de un paciente de 3 meses de edad inmunocompetente, en el que se desarrolló un cuadro de diarrea grave que precisó nutrición parenteral. El cuadro se resolvió sin secuelas tras tratamiento con ganciclovir (AU)

Cytomegalovirus infection is a frequent cause of complications in immunodeficient patients. In healthy hosts, cytomegalovirus infection is usually asymptomatic. We describe a case of a 3 month old immunocompetent boy who suffered from protracted diarrhoea that required parenteral nutrition. After treatment with ganciclovir he recovered without any after effects (AU)