Early mortality in children with advanced mature B-cell malignancies in a middle-income country.

Scant information about the early toxicity of high-dose chemotherapy regimens for the treatment of mature B-cell malignancies (B-non-Hodgkin lymphoma) in developing countries is available, so we performed a retrospective evaluation of children with B-non-Hodgkin lymphoma treated with Berlin-Frankfurt-Muenster-based protocols in Argentina (1993 to 2007). In the second protocol, induction chemotherapy was modified introducing high-dose cytarabine and etoposide (block CC) instead of high-dose methotrexate (block AA). Forty-one patients with stage III and elevated lactate dehydrogenase or stage IV or B-acute lymphoblastic leukemia were included. Five patients (12.1%) had an early death at a median of 23 days after treatment initiation, caused by sepsis in 4 and by a Stevens Johnson syndrome in 1. Children that had an early death were significantly more likely to present with renal failure (P=0.04) and have significantly higher levels of phosphate and creatinine on admission (P=0.02 and 0.008). Eighty percent of children dying early had prior extensive abdominal surgery and positive blood cultures after the first cycle. Induction with AA block was associated with a higher frequency of severe orointestinal toxicity (P=0.04). We conclude that renal failure was associated to increased risk of mortality leading to a higher risk of sepsis, especially in patients that underwent abdominal surgery.

Clinical features and outcome of 2009 influenza A (H1N1) virus infections in children with malignant diseases: a case-control study.

BACKGROUND: The impact of the novel 2009 influenza A (H1N1) (2009 H1N1) virus in children with malignant diseases under therapy is not well known. OBJECTIVE: To analyze the clinical features and outcome in children with anticancer therapy infected with the 2009 H1N1 virus. PATIENTS AND METHODS: Descriptive, case-control study. Between May and July 2009, 24 cases of 2009 (H1N1) virus infections in children with malignant diseases were registered and 48 control cases of similar patients infected with common influenza A virus (IA) diagnosed between 2006 and 2008 were selected. RESULTS: Median age for cases was 72 months and for controls was 83 months (P ≥ 0.05). Children with IA showed neutropenia more frequently (52% vs. 17%), longer period of time with illness before diagnosis (3 d vs. 1.7 d), higher rate of earlier medical consultation (69% vs. 25%), and more antibiotic therapy courses (54% vs. 4%; P ≤ 0.05) than patients with 2009 H1N1 virus. Children infected with this virus presented hypoxemia more frequently (42% vs. 8%) and higher rates of intensive care unit hospitalizations (29% vs. 2%; P ≤ 0.05). Three children with 2009 H1N1 virus and 1 in the control group died. CONCLUSIONS: Children infected with 2009 H1N1 virus presented more morbidity and mortality than patients infected with seasonal IA virus.

[Community onset of methicillin resistant Staphylococcus aureus infections in previously healthy or health care-associated children in Argentina]. / Infecciones por Staphylococcus aureus resistente a meticilina adquiridas en la comunidad en niños antes sanos y en niños relacionados al hospital en la Argentina.

INTRODUCTION: Community-acquired methicillin-resistant Staphylococcus aureus infections (CA-MRSA) are prevalent in several countries of the world. These infections seem to differ clinically from those occurring within the health care system (HCS-MRSA). OBJECTIVE: To compare clinical characteristics of infections by CA-MRSA and HCA-MRSA in the same community. MATERIAL AND METHODS: Prospective, multicentric and comparative study. Children with clinically and microbiologically documented CA-MRSA were included. RESULTS: Between 11/2006 and 11/2007, 840 infections caused by S. aureus were diagnosed. Of them 582 (68%) were community-acquired. Among these 356 (61%) were CA-MRSA. In this group, 75 (21%) were HCA-MRSA and 281 (79%) CA-MRSA. The median age was 36 months (range: 1-201). Chronic skin disease (13) and chronic disease of CNS (9) were the underlying disease predominant. Children with CA-MRSA had more frequency of previous antibiotic treatment (63 vs 34%) and previous medical consult (76 vs 52%), invasive procedures (31 vs 8%), surgery (15 vs 0.3%) and fever (94 vs 74%) (p = < 05). Children with CA-MRSA had subcutaneous abscesses (34 vs 15%) (p = < .05) more frequently. Bacteremia and sepsis rate was similar in both groups (21 vs 18%) and 17 vs 11%) respectively) (p = NS). Antibiotic resistance was more frequent in children with HCA-MRSA: Rifampin (7 vs 1%), trimethoprim-sulphametoxazole (7 vs 1%) and clindamycin (25 vs 9%) (p = < .05). Four children (5%) with HCA-MRSA infections died and 3 (1%) mCA-MRSA group (p = .05). CONCLUSION: Children with HCA-MRSA infections more frequent antibiotic resistance than CA-MRSA should be reconsider the empiric antibiotic treatment of community-acquired infections in children in our area.

Risk factors for mortality caused by nontyphoidal Salmonella sp. in children.

OBJECTIVE: To identify the risk factors for mortality in extraintestinal nontyphoidal Salmonella (NTS) infections in infants and children. METHODS: We performed a retrospective analysis of 107 patients with at least one nonfecal culture for NTS seen from January 1988 to December 1995. RESULTS: The median age was 12 (range 1-216) months. Malnutrition was found in 55 patients (51%), and 22 (20%) displayed severe features (weight loss >40%). Seventy-two patients (67%) had previously been hospitalized, and 59 (55%) had received antibiotics during the month before admission. Fever (85%) and diarrhea (56%) were the most frequent clinical manifestations. Nineteen children (18%) had leukopenia. Forty-nine patients (46%) had only bacteremia, 33 (31%) bacteremia with focal infections, and 25 (23%) focal infections with negative blood cultures. Forty-seven strains (44%) were multiresistant, and 40 of them were nosocomially acquired. Eight patients (7%) had received inappropriate antibiotic treatment, and two of them died. Thirteen (12%) children died. Age, underlying disease, previous admission, previous antibiotic therapy, type of infection, susceptibility of the strains and inappropriate antibiotic treatment were not statistically significant risk factors for mortality. A logistic regression analysis selected the following variables as independently influencing outcome: malnutrition (P<0.01), leukopenia (P<0.002) and presence of diarrhea (P<0.02). CONCLUSIONS: Children with extraintestinal infections by NTS with leukopenia, malnutrition and presence of diarrhea have a higher risk of death.

[Pharmacokinetic characteristics and antimicrobial spectrum of teicoplanin]. / Caracteristicas farmacocinéticas y espectro antimicrobiano de la teicoplanina.

Teicoplanin is a glycopeptide antibiotic with similar spectrum to vancomycin. Its long half-life permits administration in a single daily dose. The adverse effects of teicoplanin are less frequent than those of vancomycin. Rash and local intolerance are the most frequent. Staphylococcus aureus, coagulase-negative staphylococci and Enterococcus sp. are susceptible to teicoplanin. Clinical data have shown teicoplanin to be less nephrotoxic than vancomycin when combined with amino glycosides. Teicoplanin, alone or in combination with additional antibacterial drugs, has proven to be effective in the treatment of several Gram-positive infections, such as sepsis, bone and joint infections, endocarditis and skin and soft tissue infections. Clinical efficacy was obtained in more than 90% of the patients treated. Similar data have been reported in adults, children and elderly patients. Due to its easy administration and dosage, teicoplanin is a treatment of choice for outpatient parenteral therapies.

[Role of teicoplanin in the ambulatory treatment of infections in children due to gram-positive microorganisms]. / Rol de la teicoplanina en el tratamiento ambulatorio de infecciones causadas por microorganisamos grampositivos en niños.

Infections caused by Gram-positive bacteria remain a major cause of morbidity and mortality. Teicoplanin is a glycopeptide antibiotic with similar spectrum to vancomycin. Easy administration and dosage encourage its use in children, particularly due to its long half-life which allows single daily dose regimens. We evaluated the efficacy of teicoplanin in severe infections in children due to Gram-positive organisms. We retrospectively analyzed 171 children with proven or suspected Gram-positive infection treated with teicoplanin between January 1996 and December 2000. Of them, 166 cases were valuable for clinical assessment. Staphylococcus aureus (72) and coagulase-negative staphylococci (38) were the most frequent pathogens isolated. Osteoarthritis (35) and catheter-related infections (31) were the predominant clinical foci. The cure and improvement rates were 88% (150 patients) and 5% (9 patients) respectively. There were 7 (4%) cases of therapeutic failure. Mean treatment duration was 10 +/- 34.3 days (range: 1-205). Adverse events were registered in 11 patients (6%, 15 adverse events). In this study population, teicoplanin was safe and effective in the ambulatory treatment of severe Gram-positive infections in children.

Spread of epidemic MRSA-ST5-IV clone encoding PVL as a major cause of community onset staphylococcal infections in Argentinean children.

BACKGROUND: Community-associated methicillin-resistant Staphylococcus aureus-(CA-MRSA) strains have emerged in Argentina. We investigated the clinical and molecular evolution of community-onset MRSA infections (CO-MRSA) in children of Córdoba, Argentina, 2005-2008. Additionally, data from 2007 were compared with the epidemiology of these infections in other regions of the country. METHODOLOGY/PRINCIPAL FINDINGS: Two datasets were used: i) lab-based prospective surveillance of CA-MRSA isolates from 3 Córdoba pediatric hospitals-(CBAH1-H3) in 2007-2008 (compared to previously published data of 2005) and ii) a sampling of CO-MRSA from a study involving both, healthcare-associated community-onset-(HACO) infections in children with risk-factors for healthcare-associated infections-(HRFs), and CA-MRSA infections in patients without HRFs detected in multiple centers of Argentina in 2007. Molecular typing was performed on the CA-MRSA-(n: 99) isolates from the CBAH1-H3-dataset and on the HACO-MRSA-(n: 51) and CA-MRSA-(n: 213) isolates from other regions. Between 2005-2008, the annual proportion of CA-MRSA/CA-S. aureus in Córdoba hospitals increased from 25% to 49%, P<0.01. Total CA-MRSA infections increased 3.6 fold-(5.1 to 18.6 cases/100,000 annual-visits, P<0.0001), associated with an important increase of invasive CA-MRSA infections-(8.5 fold). In all regions analyzed, a single genotype prevailed in both CA-MRSA (82%) and HACO-MRSA(57%), which showed pulsed-field-gel electrophoresis-(PFGE)-type-"I", sequence-type-5-(ST5), SCCmec-type-IVa, spa-t311, and was positive for PVL. The second clone, pulsotype-N/ST30/CC30/SCCmecIVc/t019/PVL(+), accounted for 11.5% of total CA-MRSA infections. Importantly, the first 4 isolates of Argentina belonging to South American-USA300 clone-(USA300/ST8/CC8/SCCmecIVc/t008/PVL(+)/ACME(-)) were detected. We also demonstrated that a HA-MRSA clone-(pulsotype-C/ST100/CC5) caused 2% and 10% of CA-MRSA and HACO-MRSA infections respectively and was associated with a SCCmec type closely related to SCCmecIV(2B&5). CONCLUSIONS/SIGNIFICANCE: The dissemination of epidemic MRSA clone, ST5-IV-PVL(+) was the main cause of increasing staphylococcal community-onset infections in Argentinean children (2003-2008), conversely to other countries. The predominance of this clone, which has capacity to express the h-VISA phenotype, in healthcare-associated community-onset cases suggests that it has infiltrated into hospital-settings.

[Community-acquired Staphylococcus aureus bacteremia: 17 years of experience in Argentine children]. / Bacteriemias por Staphylococcus aureus adquiridas en la comunidad: 17 años de experiencia en niños de la Argentina.

BACKGROUND: Community-acquired methicillin-resistant Staphylococcus aureus (CAMRSa) emerged in recent years. Few studies analyzed the impact of these infections in bacteremias (B). OBJECTIVES: To analyze clinical, epidemiological, microbiological and outcome of CASa B between two periods (Period I: 1993-2004, and Period II: 2004-2007). MATERIAL AND METHODS: Retrospective, observational and comparative study. All children older than 1 month of age and CASaB were included. RESULTS: During the study period 647 SaB were diagnosed (Period I: 499 and Period II: 148). Of them, 140 (28%) and 49 (33%) were CSaB, respectively. The median age of patients was 5.9 and 4.8 years, respectively (p= NS). Clinical foci of infection and septic shock were more frequent in the period I (78% vs. 47%) and (5% vs. 16%) (p <0.05), respectively. Skin infection and septic shock were similar in both periods (78% vs. 67% and 5% vs. 8%; p= NS). Four CAMRSa B (3%) were diagnosed during the first period. One predisposing factor was identified in all cases. Inversely, 23 cases (47%) were diagnosed during the Period II (p <0.05). Resistance rates to clindamycin and gentamicin were more high during the second period (10% vs. 2% and 20% vs. 3%, respectively) (p <0.05). Patients in the second period had longer antibiotic treatment (X 16.6 vs. 10.1 days) and more frequent inappropriate treatment at admission (53% vs. 5%) (p <0.05). Hospital stay time was longer during de first period (19.2 vs. 12.2 days) (p <0.05). The mortality rate was higher in the first period (13% vs. 4%) (p= NS). CONCLUSION: A significant increase of CAMRSa B were detected in recent years. It is necessary to evaluate the empirical treatment of severe community infections in children in our country.

[Community-acquired methicillin-resistant Staphylococcus aureus infections in children: multicenter trial]. / Estudio multicéntrico sobre las infecciones pediátricas por Staphylococcus aureus meticilino-resistente provenientes de la comunidad en la Argentina.

INTRODUCTION: Methicillin-resistant Staphylococcus aureus (MRSA) isolates are increasingly frequent causes of skin and soft-tissue infections or invasive infections in many communities. Local data are scarce. OBJECTIVE: To determine the frequency, clinical features and outcome of infections caused by MRSA. MATERIAL AND METHODS: Prospective and multicentric study of surveillance for community-acquired S. aureus infections in children from Argentina. Infections meeting the definition of community-acquired were identified. Demographic and clinical data were collected. Antibiotic susceptibilities were determined in the clinical microbiology laboratory with the methodology of the NCCLS. RESULTS: From November 2006 to November 2007, 840 S. aureus infections were diagnosed, 447 of them were community-acquired. One hundred and thirty-five children with underlying disease or previous hospital admission were excluded. Two hundred and eighty one (62%) infections were community-acquired MRSA (CA-MRSA). The median age of children was 36 months (r:1-201), 60% were male. Among the CA-MRSA isolates, 62% were obtained from children with skin and soft-tissue infections, and 38% from children with invasive infections. Of them, osteomyelitis, arthritis, empyema and pneumonia were prevalent. Eigthteen percent of children had bacteremia and 11% sepsis. The rate of clindamycin resistance of CA-MRSA isolates was 10% and 1% for trimethoprim-sulfamethoxazole. Only 31% of children had appropriate treatment at admission. The median time of treatment delayed was 72 h. The median time of parenteral treatment was 6 days (r:1-70). In 72% of patients surgical treatment was required. Three children died (1%). CONCLUSIONS: CA-MRSA isolates account for a high percentage and number of infections in children of Argentina. Community surveillance of CA-MRSA infections is critical to determine the appropriate empiric antibiotic treatment for either local or invasive infections. Clindamycin resistance was under 15% in the strains tested. Clindamycin should be use when CA-MRSA infection is suspected in children.

A prospective, multicentric scoring system to predict mortality in febrile neutropenic children with cancer.

BACKGROUND: Many studies have succeeded in identifying a subset of children with febrile neutropenia (FN) who are at lower risk of infectious complications and eventual death. Conversely, to the authors' knowledge, no scoring system has been published to date with which to assess the risk of mortality for the whole group of children with neutropenia and fever. METHODS: Between March 2000 and July 2004, 1520 episodes of FN in 981 children were included in a multicentric prospective study to evaluate a scoring system that was designed to identify high mortality risk at the onset of an FN episode in children with cancer. RESULTS: In the derivation set (714 episodes), 18 patients died (2.5%). A multivariate analysis yielded the following significant mortality-related risk factors: advanced stage of underlying malignant disease (odds ratio [OR], 3122.1; 95% confidence interval [95% CI], 0.0001-5.2), associated comorbidity (OR, 25.3; 95% CI, 7.7-83.2), and bacteremia (OR, 7.2; 95% CI, 2.4-22.0). A mortality score could be built with 3 points scored for the presence of advanced-stage underlying malignant disease, 2 points scored for the presence of associated comorbidity, and 1 point scored for bacteremia. If patients collected 4 points of the risk score at onset, then their risk of mortality was 5.8%; if patients had a score of 5 points, then their risk of mortality was 15.4%; and, if they reached the maximum score of 6 points, then their risk of mortality was raised to 40%. The sensitivity of the scoring system was 100%, and it had a specificity of 84.2%. In the validation set (806 episodes), 19 children died (2.3%). For children with scores >3, the scoring system had a sensitivity of 84.2%, a specificity of 83.2%, and a negative predictive value of 99.54% for predicting mortality. CONCLUSIONS: The use of a mortality score for high-risk patients was validated statistically by the current results. This is a major prognostic approach to categorize patients with high-risk FN at onset. A better initial predictive approach may allow better therapeutic decisions for these children, with an eventual impact on reducing mortality.

[Cytomegalovirus detection in blood and bronchoalveolar lavage, and prophylaxis or preemptive treatment with ganciclovir in children with allogeneic stem cell transplantation]. / Detección de citomegalovirus en sangre y lavado broncoalveolar y tratamiento profiláctico o preventivo con ganciclovir en niños receptores de trasplante alogénico de células progenitoras hematopoyéticas.

INTRODUCTION: Cytomegalovirus disease is one of the complications of allogeneic stem cell transplantation (SCT). The objective of this study was to determine the frequency of CMV infection and CMV disease in children undergoing allogeneic SCT, and in whom antigenemia and bronchoalveolar lavage (BAL) were performed for early detection of CMV infection. METHODS: A total of 59 consecutive children who underwent allogeneic-identical, related SCT were prospectively evaluated. The patients were classified into: group 1 (low risk), donor and recipient CMV-seronegative; group 2 (intermediate risk), donor and/or recipient CMV-seropositive; and group 3 (high risk), recipient with acute graft-versus-host disease (GVHD) resistant to steroid therapy. Weekly antigenemia was carried out in all the patients until day 1100. In antigenemia-negative patients in group 2, BAL was performed on day 145. Patients in groups 1 and 2 with positive antigenemia or BAL received ganciclovir until day 1100. In group-3 children, ganciclovir was given until GVHD was controlled. RESULTS: The frequency of CMV infection and CMV disease was 45% and 1.5%, respectively. Testing for CMV in BAL in group-2 patients increased the frequency of early diagnosis by 10%. Ganciclovir was administered to 57% of the patients in this study. CONCLUSION: As compared to other series, a lower frequency of CMV disease and a reduction in ganciclovir use were observed with this strategy.

A scoring system to predict superinfections in high-risk febrile neutropenic children with cancer

Background. No scoring system has been published to date to assess the risk of superinfections (SI) for high-risk children with febrile neutropenia (HRFN). Methods. SI diagnoses during or 1 week after initiating antibiotic therapy in HRFN children were evaluated. Eight hundred and forty-nine episodes of febrile neutropenia (FN) were included in a prospective study to evaluate a scoring system designed to identify SI. Results. In the derivation set (566 episodes), 17% had SI. A multivariate analysis identified the following significant SI-related risk factors: acute lymphoblastic leukemia-acute myeloid leukemia (ALL-AML, OR, 1.87; 95% CI, 1.13-3.10), central venous catheter (OR, 2.11; 95% CI, 1.23-3.62), and febrile episode occurring within 10 days after chemotherapy (OR, 1.86; 95% CI, 1.09-3.15). A SI scoring system could be built: 1 point for ALL-AML, 1 point for the presence of a central venous catheter, and 1 point for the febrile episode occurring within 10 days after chemotherapy. If patients collected 3 points, then their risk of SI was 25.8%. With 2 points the risk was 16.7%, and with one minimum score of 1 point, their risk was 10.9%. The sensitivity to predict SS was 100% and its negative predictive value (NPV) was 100%. In the validation set (283 episodes), 49 (17%) children had SI. For children with scores > 0, the scoring system yielded a sensitivity of 100%, and a NPV of 100% for predicting SI. Conclusions. The use of a SI score for HRFN patients was statistically validated by these results. A better initial predictive approach may allow improved therapeutic decisions for these children.

Diagnóstico y tratamiento de la neutropenia febril en niños con cáncer: Consenso de la Sociedad Latinoamericana de Infectología Pediátrica / Diagnosis and treatment of febrile neutropenia in pediatric cancer patients: Consensus of the Sociedad Latinoamericana de Infectología Pediátrica

La Sociedad Latinoamericana de Infectología Pediátrica, a través de su Comité de Infecciones en Niños Inmunocomprometidos, propone un documento de consenso sobre "Diagnóstico y tratamiento de la neutropenia febril en niños con cáncer". Este documento-guía aborda el manejo de la neutrope-nia febril orientado a la atención de niños con cáncer en América Latina. Se realizó una búsqueda exhaustiva de la literatura, y se consideró particularmente la experiencia publicada proveniente de centros de nuestro continente, que aporta una mirada regional y adecuada a la realidad de nuestros países. El manuscrito contiene un panorama epidemiológico de la Región y recomendaciones para la evaluación clínica y de laboratorio necesarios para el manejo de estos pacientes, establece criterios de categorización de riesgo de infecciones bacterianas invasoras, analiza las medidas de cuidado general de los pacientes en el ambiente hospitalario y extra-hospitalario, propone diferentes enfoques terapéuticos de acuerdo a las realidades epidemiológicas institucionales, parámetros clínicos y de categorización de riesgo, establece diferentes algoritmos de seguimiento según la evolución de cada paciente, especifica las situaciones en que está indicada algún tipo de profilaxis y da los lineamientos generales sobre el tipo y oportunidad de terapia antifúngica a utilizar en ellos. Se ha puesto especial énfasis en entregar, de forma práctica, y con la mayor evidencia posible, las recomendaciones para el mejor manejo de los niños con cáncer, fiebre y neutropenia, buscando la equidad y la excelencia en todos los centros oncológicos latinoamericanos.

This document is a consensus guideline on the "Diagnosis and treatment of febrile neutropenia in children with cancer" developed by the Committee for Infectious Diseases in Immunocompromised Children of the Sociedad Latinoamericana de Infectología Pediátrica. This guideline discusses the management of febrile neutropenia focused on Latin American children with cancer. It is based on a thorough review of the literature, with particular attention to experiences reported by centers within the continent in order to provide recommendations applicable to the region. The manuscript includes a description of the regional epidemiology of cancer and infections in children, recommendations for clinical and laboratory studies required for patient management, description of a classification method to identify patients at different risk for invasive bacterial infections, outpatient and inpatient general care strategies and differential treatment strategies adjusted to local epidemiological realities, different algorithms for patient follow-up according to clinical course, a discussion of the rationale for prophylaxis strategies in specific situations including general guidelines for antifungal treatment. The Guidelines intend to provide practical, evidence-based recommendations in order to promote the best possible management for children with cancer, fever and neutropenia, throughout oncology centers of Latin America.

Six-month multicenter study on invasive infections due to Streptococcus pyogenes and Streptococcus dysgalactiae subsp. equisimilis in Argentina.

During a 6-month period, 95 invasive infections due to Streptococcus pyogenes and group C or group G Streptococcus dysgalactiae subsp. equisimilis were recorded from 40 centers of 16 cities in Argentina. We describe here epidemiologic data available for 55 and 19 patients, respectively, associated with invasive infections due to S. pyogenes and S. dysgalactiae subsp. equisimilis. The associated isolates and 58 additional pharyngeal isolates were genotyped and subjected to serologic and/or antibiotic susceptibility testing. Group A streptococcal emm type distribution and strain association with toxic shock appeared to differ somewhat from results found within the United States; however, serologic characterization and sof sequence typing suggested that emm types found in both countries are reflective of shared clonal types.

Bacteriemias por Staphylococcus aureus adquiridas en la comunidad: 17 años de experiencia en niños de la Argentina / Community-acquired Staphylococcus aureus bacteremia: 17 years of experience in Argentine children

Introducción. Escasos estudios han evaluado el impacto de S. aureus meticilino-resistente proveniente de la comunidad en bacteriemias. Objetivos. Analizar las características epidemiológicas, microbiológicas, clínicas y de evolución de los niños con bacteriemias por S. aureus (SA) provenientes de la comunidad. Material y métodos. Estudio retrospectivo, observacional y comparativo (Período I: 1993-2004 y Período II: 2004-2007). Se incluyeron niños mayores de 1 mes con bacteriemias por S. aureus provenientes de la comunidad. Resultados. Se registraron 647 bacteriemias por SA (Período I: 499 y Período II: 148), 140 (28%) y 49 (33%) fueron de la comunidad en cada período. La edad (media) fue 5,9 y 4,8 años, respectivamente (p= NS). La presencia de foco clínico de infección y shock séptico fue semejante en ambos períodos (78 contra 67%; p= NS). La celulitis prevaleció durante el segundo período (56 contra 40%) (p= NS). En el primer período se detectaron 4 niños con bacteriemias por SA de la comunidad resistentes a meticilina (3%) mientras que en el segundo período ocurrieron 23 casos (47%) (p <0,05). La resistencia a clindamicina y gentamicina fue mayor en el segundo período (10% contra 2% y 20% contra 3%, respectivamente) (p <0,05). En el período II hubo mayor duración del tratamiento antibiótico (media: 16,6 contra 10,1; p < 0,05) y mayor porcentual de tratamiento discordante (53 por ciento contra por ciento)(p <0,05). Durante el primer período fue mayor el tiempo de internación (19,2 contra 12,2 días) (p <0,05). La mortalidad fue más alta durante el primer período (14% contra 5%) (p= NS). Conclusión. Se registró un aumento significativo de niños con bacteriemias por SA de la comunidad resistentes a meticilina a partir de 2004. Estomotivó la revaloración del tratamiento empírico de estos niños con infección grave.

Background. Community-acquired methicillinresistant Staphylococcus aureus (CAMRSa) emerged in recent years. Few studies analyzed the impact of these infections in bacteremias (B). Objectives. To analyze clinical, epidemiological, microbiological and outcome of CASa B between two periods (Period I: 1993-2004, and Period II: 2004-2007).Material and methods. Retrospective, observational and comparative study. All children older than 1 month of age and CASa B were included. Results. During the study period 647 SaB werediagnosed (Period I: 499 and Period II: 148). Of them, 140 (28%) and 49 (33%) were CSa B, respectively. The median age of patients was 5.9 and4.8 years, respectively (p= NS). Clinical foci of infection and septic shock were more frequent in the period I (78% vs. 47%) and (5% vs. 16%) (p <0.05), respectively. Skin infection and septicshock were similar in both periods (78% vs. 67% and 5% vs. 8%; p=NS). Four CAMRSa B (3%) were diagnosed during the first period. One predisposing factor was identified in all cases. Inversely, 23 cases (47%) were diagnosed during the Period II (p<0.05). Resistance rates to clindamycin and gentamicin were more highduring the second period (10% vs. 2% and 20% vs. 3%, respectively) (p <0.05). Patients in the second period had longer antibiotic treatment (X16.6 vs. 10.1 days) and more frequent inappropriate treatment at admission (53% vs. 5%) (p <0.05). Hospital stay time was longer during de first period (19.2 vs. 12.2 days) (p <0.05). Themortality rate was higher in the first period (13% vs. 4%) (p=NS). Conclusion. A significant increase of CAMRSa B were detected in recent years. It is necessary to evaluate the empirical treatment of severe community infections in children in our country.

[Clinical study and analysis of risk factors for mortality in 86 cases of infectious endocarditis in children and adolescents in Argentina: 1988-2000]. / Análisis clínico y de los factores de riesgo de mortalidad de 86 casos de endocarditis infecciosa en niños y adolescentes en Argentina (1988-2000).

INTRODUCTION: IE is a rare infection in children. Scarce reports with large number of patients are published. METHODS: Between January 1988 to December 2000 we analyzed all cases of IE cases admitted to our hospital. RESULTS: 86 cases of IE (4.9/10,000 admissions) in 86 children were diagnosed. The median age was 7.6 years. In 77% of patient previous cardiac disease was detected, interventricular defects and Tetralogy of Fallot were the more frequent. Three percent of children had rheumatic heart disease. Thirty-six percent of children had previous heart surgery. Fifty-seven percent have been received previous antibiotics. Eighty-seven percent had positive blood cultures, being the S. aureus and S. viridans the predominantly. Forty-eight percent of children had complications. The metabolic disorders and the nosocomial infections were the most frequent. Twenty-four percent required surgery, 24% of them in the first week of the diagnosis. The mortality in operated children was 19%. In the multivariate analysis we could observe that children with more than 7 years and S. aureus isolation in blood cultures had more incidence of complications and posterior surgery (p < 0.05). Children with S. aureus IE had longer duration of fever, more incidence of complications than patients with S. viridans IE (p < 0.05). Ten percent of children were treated as outpatients. The global mortality was 12,8%. Previous surgery (OR = 6.89; IC 95% 1.54-30.7) and previous antibiotic treatment (OR = 9.98; IC 95% 1.12-88.8) were the factors related with higher mortality in the multivariate analysis. S. aureus was the predominat pathogen and caused more morbidity and mortality than S. viridans IE. CONCLUSION: Children with IE with previous surgery and previous antibiotic treatment died with more frequency.

Six-month multicenter study on invasive infections due to group B streptococci in Argentina.

There is little information about invasive infections by group B streptococci (GBS) and their antimicrobial susceptibilities in Latin America. We performed a prospective multicenter study to determine the serotype distribution and the antimicrobial susceptibility of GBS in Argentina. We identified 58 cases, but only 44 had sufficient data to be evaluated. Eight early-, four late-, and one fatal late, late-onset neonatal infections due to GBS were found. A total of 31 patients were adults with bacteremia, skin and soft tissue infections, osteomyelitis, arthritis, meningitis, abdominal infections, and renal abscess. Serotype III was prevalent in late-onset neonatal disease, and several serotypes (Ia/c, III, Ia, and II) were involved in early-onset neonatal infections. Serotypes II, Ia/c, III, and IV were commonly found in adults, with serotype II prevalent in younger adults (18 to 69 years old) and serotype Ia/c prevalent in elderly adults (>70 years old). The mortality rate attributable to GBS infections was 10.8%. All GBS were susceptible to penicillin and ceftriaxone. Resistance to clindamycin (1.7%), erythromycin (5.2%), azithromycin (5.2%), minocycline (69%), and tetracycline (72.4%), to high levels of kanamycin and amikacin (1.7%), and to intermediately high levels of gentamicin (1.7%) was observed. The bifunctional enzyme AAC6'-APH2" was detected in the isolate resistant to aminoglycosides, and other genetic determinants were identified in other resistant isolates: tetM and tetO in tetracycline-resistant streptococci and mefA and ermTR for efflux-mediated and inducible macrolide-lincosamide-streptogramin B-resistant streptococci, respectively. For clinical purposes and rapid and easy detection of high-level aminoglycoside-resistant GBS, a screening method that used 1,000- micro g kanamycin disks is proposed.

Outpatient, sequential, parenteral-oral antibiotic therapy for lower risk febrile neutropenia in children with malignant disease: a single-center, randomized, controlled trial in Argentina.

BACKGROUND: Recent reports and previous randomized trials conducted at the authors' institution suggested that children with lower risk febrile neutropenic (LRFN) may benefit from substitution of oral antibiotic therapy for parenteral therapy. The objective of this study was to determine the efficacy of parenteral-oral outpatient therapy in the management of children with LRFN who were receiving treatment for malignant disease. METHODS: From August 2000 to April 2002, 135 children with a median age of 7.5 years (range, 1.6-15.8 years) who had a total of 177 episodes of LRFN were included in a prospective, randomized, single-institution trial. Children with LRFN received a single dose of ceftriaxone and amikacin and completed a risk-assessment work-up. All patients were discharged immediately and, at 24 hours, were allocated randomly to two groups: Group A (89 episodes) received oral ciprofloxacin, and Group B (88 episodes) received intravenous ceftriaxone. RESULTS: Most patients (61% in Group A and 51% in Group B) were receiving treatment for leukemia (P value not significant [NS]). Twenty-eight children (31%) in Group A and 22 children (25%) in Group B displayed unexplained fever (P value NS). No significant differences in sites of initial infection were found between the two groups. The median duration of neutropenia was 4.2 days and 4.7 days for Group A and Group B, respectively (P value NS); the median duration of fever was 2.3 days and 2.6 days, respectively (P value NS); and the median duration of antibiotic treatment was 4.5 days and 4.8 days, respectively (P value NS). The overall results of the study were excellent. Only four treatment failures in Group A (5%) and 6 treatment failures in Group B (7%) were observed. These patients were readmitted to the hospital and did well with appropriate treatment. CONCLUSIONS: In children with LRFN who are receiving treatment for malignant disease, outpatient oral ciprofloxacin after 24 hours of a single dose of intravenous ceftriaxone and amikacin was as safe and efficacious as parenteral ceftriaxone. Outpatient management and early antibiotic withdrawal were safe for both groups.

Infecciones por Staphylococcus aureus resistente a meticilina adquiridas en la comunidad en niños antes sanos y en niños relacionados al hospital en la Argentina / Community onset of methicillin resistant Staphylococcus aureus infections in previously healthy or health care-associated children en Argentina

Introduction: Community-acquired methicillin-resistant Staphylococcus aureus infections (CA-MRSA) are prevalent in several countries of the world. These infections seem to differ clinically from those occurring within the health care system (HCS-MRSA). Objective: To compare clinical characteristics of infections by CA-MRSA and HCA-MRSA in the same communitty. Material and Methods: Prospective, multicentric and comparative study. Children with clinically and microbiologicaly documented CA-MRSA were included. Results: Between 11/2006 and 11/2007, 840 infections caused by S. aureus were diagnosed. Of them 582 (68 percent) were community-acquired. Among these 356 (61 percent) were CA-MRSA. In this group, 75 (21 percent) were HCA-MRSA and 281 (79 percent) CA-MRSA. The median age was 36months (range: 1-201). Chronic skindisease (13) and chronic disease of CNS (9) were the underlying disease predominant. Children with CA-MRSAhad more frequency of previous antibiotic treatment (63 vs 34 percent) and previous medical consult (76 vs 52 percent), invasive procedures (31 vs 8 percent), surgery (15 vs 0,3 percent) and fever (94 vs 74 percent) (p = <05). Children with CA-MRSAhad subcutaneous abscesses (34 vs 15 percent) (p = <.05) more frequently. Bacteremia and sepsis rate was similar in both groups (21 vs 18 percent) and 17 vs 11 percent) respectively) (p = NS). Antibiotic resistance was more frequent in children with HCA-MRSA: Rifampin (7 vs 1 percent), trimethoprim-sulphametoxazole (7 vs 1 percent) and clindamycin (25 vs 9 percent) (p = <.05). Four children (5 percent) with HCA-MRSA infections died and 3 (1 percent) mCA-MRSAgroup (p = .05). Conclusión: Children with HCA-MRSA infections more frequent antibiotic resistance than CA-MRSA should be reconsider the empiric antibiotic treatment of community-acquired infections in children in our área.

Introducción: Staphylococcus aureus meticilina-resistente proveniente de la comunidad (SAMRC) es altamente prevalente en diversos países del planeta. Objetivos: Realizar un análisis clínico comparativo entre las infecciones por SAMRC en niños antes sanos (SAMR-CO) y aquellos con S. aureus MR en pacientes con patologías previas (SAMR-RH). Material y Métodos: Estudio multicéntrico, prospectivo y comparativo. Fueron incluidos los niños que tenían infección clínica y microbiológicamente documentada por SAMRC. Resultados: Entre 11/2006 y 11/2007 fueron diagnosticadas 840 infecciones porS. aureus. De ellas 582 (69 por ciento) fueron detectadas en la comunidad. Entre estas 356 (61 por ciento) fueron SAMRC. Entre estas últimas 75 (21 por ciento) fueron SAMR-RH y 281 (79 por ciento) SAMR-CO. La mediana de edad fue de 36 meses (rango: 1-201). Las enfermedades de base más frecuentes fueron: dermatopatías crónicas (13) y enfermedad crónica del SNC (9). Los niños con infección por SAMR-RH presentaron con mayor frecuencia tratamiento antimicrobiano previo (63 vs 34 por ciento), consultas médicas previas (76 vs 52 por ciento), procedimiento invasor previo (31 vs 8 por cientoo), cirugía (15 vs 0,3 por ciento) y fiebre al momento de la consulta (94 vs 74 por ciento) (p < 0,05). Los niños con infección por SAMR-CO tuvieron con mayor frecuencia abscesos subcutáneos (34 vs 15 por ciento) (p < 0,05). La tasa de bacteriemia y se sepsis fue semejante en ambos grupos (21 vs 18 por ciento y 17 vs 11 por ciento)) (p =NS). La resistencia a antimicrobianos fue mayor en niños con SAMR-RH: rifampicina (7 vs l por cientoo), cotrimoxazol (7 vs 1 por ciento) y clindamicina (25 vs 9 por ciento) (p < 0,05). Fallecieron 4 niños con SAMR-RH (5 por ciento) y 3 niños con SAMR-CO (1 por ciento) (p = 0,05). Conclusión: Los niños con SAMR-RH presentan mayor tasa de resistencia a antimicrobianos que SAMR-CO. Debe replantearse el tratamiento antimicrobiano empírico en niños con ...

Estudio multicéntrico sobre las infecciones pediátricas por Staphylococcus aureus meticilino resistente provenientes de la comunidad en la Argentina / Community acquired methicillin resistant Staphylococcus aureus infections in children: multicenter trial

En los últimos años se ha informacion diversas partes del mundo la aparición deinfecciones extrahospitalarias causadas por S.aureus resistentes a la meticilina (SAMRC). Losdatos de nuestro país son muy escasos y de informesindividuales.Objetivo. Determinar la frecuencia, las característicasclínicas y la evolución final de las infeccionescausadas por SAMRC.Material y métodos. Estudio prospectivo y multicéntricode vigilancia de las infecciones extrahospitalariaspor S. aureus en niños de la Argentina. Seincluyeron niños con alguna infección clínica y microbiológicamentedocumentada por S. aureus. Lasensibilidad a los antibióticos de las cepas aisladasse investigó según normas NCCLS.Resultados. Entre 11/2006 y 11/2007 se diagnosticaron840 infecciones por S. aureus. De ellas, 582(69 por ciento) fueron comunitarias. Se excluyeron 135 niñoscon enfermedad de base o internación previa enhospitales. Para el análisis se incluyeron 447 infecciones,de las cuales 281 (62 por ciento) fueron causadas porSAMRC. La mediana de edad fue de 36 meses (r: 1-201). Un 60 por ciento fueron varones. Prevalecieron lasinfecciones de piel y partes blandas (62 por ciento). Las infeccionesosteoarticulares, el empiema pleural y laneumonía fueron las formas invasivas más frecuentes.El 18 por ciento presentó bacteriemia y el 11 por ciento sepsis. El10 por ciento de las cepas fue resistente a clindamicina y el1 por ciento a trimetoprima-sulfametoxazol. Sólo el 31 por ciento tuvoun tratamiento concordante al ingreso. La medianade retraso en el tratamiento adecuado fue de 72 h. Lamediana del tratamiento parenteral fue de 6 días (r:1-70). El 72 por ciento requirió tratamiento quirúrgico, principalmentedrenaje de colecciones purulentas (87 por ciento).Fallecieron 3 niños (1 por ciento).Conclusiones. La tasa de infecciones causadas porSAMRC es alta en niños de nuestro país. Esto constituyeun alerta epidemiológico, particularmentepara los pediatras.