Epidemiology and clinical features of Streptococcus pyogenes bloodstream infections in children in Madrid, Spain.

Studies have shown increased invasive Group A Streptococcus (GAS) disease, including bloodstream infections (GAS-BSI). However, the epidemiological data of GAS-BSI are limited in children. We aimed to describe GAS-BSI in children in Madrid, over 13 years (2005-2017). Multicenter retrospective cohort study from 16 hospitals from Madrid, Spain. Epidemiology, symptomatology, laboratory, treatment, and outcome of GAS-BSI in children ≤ 16 years were analyzed. 109 cases of GAS-BSI were included, with incidence rate of 4.3 episodes/100,000 children attended at the emergency department/year. We compared incidence between two periods (P1: 2005-June 2011 vs P2: July 2011-2017) and observed a non-significant increase along the study period (annual percentage change: + 6.0% [95%CI: -2.7, + 15.4]; p = 0.163). Median age was 24.1 months (IQR: 14.0-53.7), peaking during the first four years of life (89/109 cases; 81.6%). Primary BSI (46.8%), skin and soft tissue (21.1%), and osteoarticular infections (18.3%) were the most common syndromes. We compared children with primary BSI with those with a known source and observed that the former had shorter hospital stay (7 vs. 13 days; p = 0.003) and received intravenous antibiotics less frequently (72.5% vs. 94.8%; p = 0.001) and for shorter duration of total antibiotic therapy (10 vs. 21 days; p = 0.001). 22% of cases required PICU admission. Factors associated with severity were respiratory distress, pneumonia, thrombocytopenia, and surgery, but in multivariate analysis, only respiratory distress remained significant (adjusted OR:9.23 [95%CI: 2.16-29.41]). Two children (1.8%) died.   Conclusion: We observed an increasing, although non-significant, trend of GAS-BSI incidence within the study. Younger children were more frequently involved, and primary BSI was the most common and less severe syndrome. PICU admission was frequent, being respiratory distress the main risk factor. What is known: • In recent decades, several reports have shown a worldwide increase in the incidence of invasive Group A streptococcal disease (GAS), including bloodstream infection (BSI). Recently, there have been a few reports showing an increase in severity as well. • There needs to be more information on the epidemiology in children since most studies predominantly include adults. What is new: • This study, carried out in children with GAS-BSI in Madrid, shows that GAS-BSI affects mostly younger children, with a broad spectrum of manifestations, needing PICU admission frequently. Respiratory distress was the leading risk factor for severity, whereas primary BSI seemed to be less severe. • We observed an increasing, although non-significant, trend of GAS-BSI incidence in recent years (2005-2017).

Tuberculosis screening after detection of a case in a paediatric haemato-oncology unit in a low prevalence country.

BACKGROUND: There are no guidelines to screen haemato-oncologic children when a tuberculosis (TB) outbreak is suspected. METHODS: After exposition to an adult with active TB, children exposed from a haemato-oncology unit were screened according to immunosuppression status and time of exposure. Until an evaluation after 8-12 weeks from last exposure, isoniazid was indicated to those with negative initial work-up. RESULTS: After 210 interventions, we detected a case of pulmonary TB, and another with latent TB infection. Pulmonary findings and treatment approach were challenging in some patients. CONCLUSIONS: The TB screening of oncologic children required a multidisciplinary approach, and clinicians managed challenging situations.

Impact of Coronavirus Pandemic on Tuberculosis and Other Imported Diseases Screening among Migrant Minors in Spain.

BACKGROUND: In recent decades, the increase in population movements has turned the focus to imported diseases. The COVID-19 pandemic has negatively impacted the access to health care systems, especially in highly vulnerable populations. We address the effects of the pandemic on the health screening of migrant unaccompanied minors (UM) in Spain. METHOD: Retrospective cross-sectional study including UM screened for imported diseases with a unified protocol at a pediatric reference unit for tropical and infectious diseases in Madrid, Spain. We compared the pre-pandemic (2018-2019) and post-pandemic periods (2020-2021). RESULTS: A total of 192 minors were screened during the study period, with a drop in UM's referral to our center in the post-pandemic years (140 in 2018-2019 vs. 52 in 2020-2021). Out of 192, 161 (83.9%) were diagnosed with at least one medical condition. The mean age was 16.8 years (SD 0.8) and 96.9% were males. Most cases were referred for a health exam; only 38% of children were symptomatic. Eosinophilia was present in 20.8%. The most common diagnosis were latent tuberculosis infection (LTBI) (72.9%), schistosomiasis (15.1%), toxocariasis (4.9%) and strongyloidiasis (4.9%). The prevalence of LTBI did not vary significantly (69.3% vs. 82.7%, p = 0.087). A total of 38% of the patients diagnosed with LTBI never started treatment or were lost to follow-up, as were two out of three patients with active pulmonary tuberculosis. CONCLUSIONS: In this series, the number of UM referred for health screening has dropped dramatically after the COVID pandemic, and two years after the beginning of the pandemic, access to care is still limited. Lost to follow-up rates are extremely high despite institutionalization. Specific resources, including multidisciplinary teams and accessible units are needed to improve diagnoses and linkage to care in this vulnerable population.

Telemedicine follow-ups for COVID-19: Experience in a tertiary hospital.

INTRODUCTION: Telemedicine is an attractive option for the follow-up of paediatric patients with SARS-CoV-2 infection. The aim of this article is to describe the experience with telephone consultations in a tertiary hospital. PATIENTS AND METHODS: Retrospective descriptive study of children with confirmed or probable diagnosis of COVID-19 attended by telephone consultations in Hospital La Paz (Madrid) between March and June 2020. Patients were referred from the Emergency Department after being discharged from the hospital. Telephone consultations were made every 48 h until symptoms resolved, then weekly until completing 14 days without symptoms. RESULTS: A total of 72 children were included, with median age of 83.5 months [IQR = 16.3-157.5]. Of those 46 (63.9%) were male, and 14 (19.4%) had comorbidities. There were 32 (44.4%) hospital admissions. COVID-19 diagnosis was confirmed in 33 children by RT-PCR, and in 7 by serology tests. The seroconversion rate was 67.7% in those patients with a positive RT-PCR. Other infections were found in 7 patients (5 Mycoplasma pneumoniae, 1 parvovirus, and 1 CMV). Median symptom duration was 25.5 days [IQR = 13.8-37], while median follow-up duration was 28 days [IQR = 21-39]. The median number of telephone consultations per patient was 6 [IQR = 4-8]. Clinical worsening was reported in 19 (26.4%) during follow-up, and 14 (19.4%) were re-evaluated in the Emergency Department. One patient required hospital admission, but he had a favourable outcome. CONCLUSIONS: Children with suspected SARS-CoV-2 infection should be followed-up due to prolonged duration of symptoms, and the risk of clinical deterioration. Telephone consultations are a useful and safe alternative for the follow-up of patients with mild symptoms, and for children discharged from the hospital.

Tuberculosis screening after detection of a case in a paediatric haemato-oncology unit in a low prevalence country.

BACKGROUND: There are no guidelines to screen haemato-oncologic children when a tuberculosis (TB) outbreak is suspected. METHODS: After exposition to an adult with active TB, children exposed from a haemato-oncology unit were screened according to immunosuppression status and time of exposure. Until an evaluation after 8-12 weeks from last exposure, isoniazid was indicated to those with negative initial work-up. RESULTS: After 210 interventions, we detected a case of pulmonary TB, and another with latent TB infection. Pulmonary findings and treatment approach were challenging in some patients. CONCLUSIONS: The TB screening of oncologic children required a multidisciplinary approach, and clinicians managed challenging situations.

[Spanish consensus document on diagnosis, stabilisation and treatment of pediatric multisystem inflammatory syndrome related to SARS-CoV-2 (SIM-PedS)]. / Documento español de consenso sobre diagnóstico, estabilización y tratamiento del síndrome inflamatorio multisistémico pediátrico vinculado a SARS-CoV-2 (SIM-PedS).

A new paediatric multisystem inflammatory syndrome, linked to SARS-CoV-2, has been described. The clinical picture is variable and is associated with an active or recent infection due to SARS-CoV-2. A review of the existing literature by a multidisciplinary group of paediatric specialists is presented in this document. Later, they make recommendations on the stabilisation, diagnosis, and treatment of this syndrome.

[Telemedicine follow-ups for COVID-19: Experience in a tertiary hospital]. / Seguimiento telemático de COVID-19: experiencia de un hospital terciario.

INTRODUCTION: Telemedicine is an attractive option for the follow-up of paediatric patients with SARS-CoV-2 infection. The aim of this article is to describe the experience with telephone consultations in a tertiary hospital. PATIENTS AND METHODS: Retrospective descriptive study of children with confirmed or probable diagnosis of COVID-19 attended by telephone consultations in Hospital La Paz (Madrid) between March and June 2020. Patients were referred from the Emergency Department after being discharged from the hospital. Telephone consultations were made every 48hours until symptoms resolved, then weekly until completing 14 days without symptoms. RESULTS: A total of 72 children were included, with median age of 83.5 months (IQR=16.3-157.5). Of those 46 (63.9%) were male, and 14 (19.4%) had comorbidities. There were 32 (44.4%) hospital admissions. COVID-19 diagnosis was confirmed in 33 children by RT-PCR, and in 7 by serology tests. The seroconversion rate was 67.7% in those patients with a positive RT-PCR. Other infections were found in 7 patients (5 Mycoplasma pneumoniae, 1 parvovirus, and 1 cytomegalovirus). Median symptom duration was 25.5 days (IQR=13.8-37), while median follow-up duration was 28 days (IQR=21-39). The median number of telephone consultations per patient was 6 (IQR=4-8). Clinical worsening was reported in 19 (26.4%) during follow-up, and 14 (19.4%) were re-evaluated in the Emergency Department. One patient required hospital admission, but he had a favourable outcome. CONCLUSIONS: Children with suspected SARS-CoV-2 infection should be followed-up due to prolonged duration of symptoms, and the risk of clinical deterioration. Telephone consultations are a useful and safe alternative for the follow-up of patients with mild symptoms, and for children discharged from the hospital.

Severe Rifampicin-induced Vitamin K Deficiency Coagulopathy in a Child.

An 8-month-old child under tuberculosis treatment presented with multiple ecchymotic lesions. A severe coagulopathy was evidenced compatible with vitamin K deficiency [II (3%), VII (2%), IX (3%) and X (1%)]. It was reversed with vitamin K and plasma administration. Rifampicin-induced vitamin K deficiency is very rare, reported only once before, possibly related to an inhibition of vitamin K cycle.

Previous or coincident infections with suspected Kawasaki disease. Should we change our approach?

INTRODUCTION: Kawasaki disease (KD) is a multisystem vasculitis associated with coronary artery abnormalities. Infections could be a trigger of the inflammation. The main aim of this study was to describe the presence of infections in children with KD, and to analyse the clinical characteristics and the presence of coronary abnormalities in these cases. PATIENTS AND METHODS: A retrospective study was performed within the Kawasaki Disease network (KAWA-RACE (2011-2016). An analysis was performed that included patients with positive microbiological findings (PMF) during the acute phase, as well as those with a previous recent infection (PRI) during the 4 weeks preceding KD diagnosis. RESULTS: The study included a total of 621 children with KD, with PMF being found in 101 (16.3%) patients, and a PRI in 107 (17.2%). Significantly less echocardiographic abnormalities were found in the group with a PRI, when compared to those without a PRI (23 vs. 35%, P = .01) and also a lower proportion of overall coronary artery lesions (16 vs. 25%, P = .054). No significant differences were found in the proportion of aneurysms in either of these groups (PRI or PMF) when compared to those without infection. CONCLUSIONS: In the present study, no differences were found in the incidence of coronary aneurysms in either of the groups, with or without PRI or PMF. Therefore, if KD is suspected, appropriate treatment should be started despite having a confirmed infection.

INTRODUCCIÓN: La enfermedad de Kawasaki (EK) es una vasculitis multisistémica asociada a lesiones en las arterias coronarias. Las infecciones podrían ser un desencadenante de la inflamación. Nuestro objetivo fue describir la presencia de infecciones en los niños con EK y analizar las características clínicas y la presencia de alteraciones coronarias en estos casos. PACIENTES Y MÉTODOS: Análisis retrospectivo de los pacientes incluidos en la red KAWA-RACE entre 2011 y 2016. Se estudió tanto a los pacientes que tuvieron una identificación microbiológica confirmada (IMC) en el periodo agudo como a los que presentaron antecedente de infección previa reciente (IPR) las 4 semanas anteriores. RESULTADOS: Se incluyó a un total de 621 niños, de los cuales 101 (16,3%) tuvieron una IMC y 107 (17,2%) una IPR. Encontramos una significativa menor afectación ecocardiográfica en el grupo de IPR respecto a los niños sin infección previa (23 vs. 35%; p 0,01), con menor proporción no significativa de las alteraciones coronarias globales (16 vs. 25%; p 0,054). Sin embargo, no se detectaron diferencias en la proporción de aneurismas en ninguno de los 2 grupos (IMC o IPR) respecto al resto de los pacientes sin infecciones asociadas. CONCLUSIONES: En nuestro estudio no encontramos diferencias en la incidencia de aneurismas coronarios en niños con y sin IMC o IPR, por lo que ante la sospecha de EK debe iniciarse siempre tratamiento, aunque se tenga infección confirmada microbiológicamente.

[Previous or coincident infections with suspected Kawasaki disease. Should we change our approach?] / Infecciones previas o coincidentes con la sospecha de enfermedad de Kawasaki ¿debemos cambiar nuestra actitud?

INTRODUCTION: Kawasaki disease (KD) is a multisystem vasculitis associated with coronary artery abnormalities. Infections could be a trigger of the inflammation. The main aim of this study was to describe the presence of infections in children with KD, and to analyse the clinical characteristics and the presence of coronary abnormalities in these cases. PATIENTS AND METHODS: A retrospective study was performed within the Kawasaki Diseases Network (KAWA-RACE (2011-2016). An analysis was performed that included patients with positive microbiological findings (PMF) during the acute phase, as well as those with a previous recent infection (PRI) during the 4 weeks preceding KD diagnosis. RESULTS: The study included total of 621 children with KD, with PMF being found in 101 (16.3%) patients, and a PRI in 107 (17.2%). Significantly less echocardiographic abnormalities were found in the in the group with a PRI, when compared to those without a PRI (23 vs. 35%, P=.01) and also a lower proportion of overall coronary artery lesions (16 vs. 25%, P=.054). No significant differences were found in the proportion of aneurysms in either of these groups (PRI or PMF) when compared to those without infection. CONCLUSIONS: In the present study, no differences were found in the incidence of coronary aneurysms in either of the groups, with or without PRI or PMF. Therefore, if KD is suspected, appropriate treatment should be started despite having a confirmed infection.

Epidemiological and clinical features of Kawasaki disease in Spain over 5 years and risk factors for aneurysm development. (2011-2016): KAWA-RACE study group.

BACKGROUND: Kawasaki disease (KD) is an acute self-limited systemic vasculitis of unknown etiology affecting mainly children less than 5 years of age. Risk factors for cardiac involvement and resistance to treatment are insufficiently studied in non-Japanese children. OBJECTIVE: This study aimed to investigate the epidemiology, clinical features and risk factors for resistance to treatment and coronary artery lesions (CAL) in KD in Spain. METHODS: Retrospective study (May 2011-June 2016) of all patients less than 16 years of age diagnosed with KD included in KAWA-RACE network (84 Spanish hospitals). RESULTS: A total of 625 cases were analyzed, 63% were males, 79% under 5 year-olds and 16.8% younger than 12 months. On echocardiographic examination CAL were the most frequent findings (23%) being ectasia the most common (12%). Coronary aneurysms were diagnosed in 9.6%, reaching 20% in infants under 12 months (p<0.001). A total of 97% of the patients received intravenous immunoglobulin (IVIG) with a median number of days from fever onset to IVIG administration of 7.2. A second dose was given to 15.7% and steroids to 14.5% patients. Only 1.4% patients received infliximab. No deaths were reported. A multivariate analysis identified anemia, hypoalbuminemia, hyponatremia, higher creatinine and procalcitonin as independent risk factors for treatment failure and length under 103 cm, hemoglobin < 10.2 mg/dL, platelets > 900,000 cells/mm3, maximum temperature < 39.5°C, total duration of fever > 10 days and fever before treatment ≥ 8 days as independent risk factors for developing coronary aneurysms. CONCLUSIONS: In our population, children under 12 months develop coronary aneurysms more frequently and children with KD with anemia and leukocytosis have high risk of cardiac involvement. Adding steroids early should be considered in those patients, especially if the treatment is not started before 8 days of fever. A score applicable to non-Japanese children able to predict the risk of aneurysm development and IVIG resistance is necessary.

Tuberculosis en pediatría

La tuberculosis (TB) continúa siendo una enfermedad muy presente en nuestros días, incluido entre la población pediátrica, y con una fuerte asociación con el VIH. A pesar de los esfuerzos realizados para el control de la enfermedad, es una importante causa de morbimortalidad en algunos países. La dificultad para confirmar el diagnóstico y la variedad en las formas de presentación, conducen a una baja noti cación. La OMS reportó en 2013, una incidencia mundial de 9 millones de casos, en el 2011 se reportaron 500.000 casos en menores de 15 años, y 64.000 fallecimientos en población pediátrica por tuberculosis (pacientes no infectados por VIH) y para el 2013 se reportaron 80,000 defunciones en niños infectados por VIH y tuberculosis. En 2013 se diagnosticaron 480,000 nuevos casos a nivel mundial de tuberculosis multiresistente (MDR resistentes por lo menos a rifampicina e isoniacida) y tuberculosis extremadamente resistente a drogas (XDR resistentes a rifampicina, isoniacida más una uroquinolona y por lo menos a una de las tres drogas de segunda línea inyectable como amikacina, kanamicina y capreomicina)