Maternal Immunization with Pneumococcal Polysaccharide Vaccine: Persistence of Maternal Antibodies in Infants.

OBJECTIVE: To evaluate the level and the persistence of maternal antibodies in infants after maternal immunization with pneumococcal polysaccharide vaccine (Pn23V). METHODS: Pregnant women were assigned to two groups, during routine low-risk pre-natal visits. The first Group (VAC) received the Pn23V vaccine shortly after enrolment at 28 weeks or later, and the second Group (NO_VAC) received no vaccine. To investigate the antibody persistence, we collected blood samples from the mothers after 1 month of delivery and from the infants at 1 and 6 months of age. RESULTS: Antibody titers were measured for serotypes 1, 6B and 14. Geometric mean antibody concentrations of specific immunoglobulin G were significantly higher in the vaccinated group compared with unvaccinated controls for all three serotypes tested. CONCLUSION: Despite the antibody level's decline, at 6 months of age, proportions >0.35 µg/ml remained higher in the infants of vaccinated mothers than controls for all three serotypes.

Pneumococcal nasopharyngeal carriage in infants of mothers immunized with 23V non-conjugate pneumococcal polysaccharide vaccine.

To assess the effects of maternal immunization on pneumococcal colonization in infants, pregnant women were assigned into three groups. The group Pregn Vac received the Pn23V during pregnancy, the group Puerp Vac received vaccine during immediate puerperium and the group No Vac received no vaccine. Nasopharyngeal samples were collected at 3 and 6 months. A total of 150 pregnant women were selected during the prenatal period. The proportion of pneumococcal carriage in at least one evaluation was in group Pregn Vac 22.2% (10/45), group Puerp Vac 23.4% (11/47) and group No Vac 21.2% (10/47), respectively. The most frequently isolated serotype in group Puerp Va and group No Vac was 6B and 6A. In the Pregn Vac, the most important serotype was 19F. Although this study was unable to demonstrate any effect of maternal vaccination in reducing pneumococcal colonization, reduction of colonization for serotype 6B in infants may be an important effect.

Factors Associated With Hospitalization or Intensive Care Admission in Children With COVID-19 in Latin America.

Background: Limited data is available from low-middle and upper-middle income countries of the factors associated with hospitalization or admission to pediatric intensive care unit (PICU) for children with COVID-19. Objective: To describe the factors associated with hospitalization or PICU admission of children with COVID-19 in Latin America. Method: Multicenter, analytical, retrospective study of children reported from 10 different Latin American countries to the Latin-American Society of Pediatric Infectious Diseases (SLIPE-COVID) research network from June 1, 2020, and February 28, 2021. Outpatient or hospitalized children <18 years of age with COVID-19 confirmed by polymerase chain reaction or antigen detection from the nasopharynx were included. Children with multisystem inflammatory syndrome in children (MIS-C) were excluded. Associations were assessed using univariate and multivariable logistic regression models. Results: A total of 1063 children with COVID-19 were included; 500 (47%) hospitalized, with 419 (84%) to the pediatric wards and 81 (16%) to the ICU. In multivariable analyses, age <1 year (Odds Ratio [OR] 1.78; 95% CI 1.08-2.94), native race (OR 5.40; 95% CI 2.13-13.69) and having a co-morbid condition (OR 5.3; 95% CI 3.10-9.15), were associated with hospitalization. Children with metabolic or endocrine disorders (OR 4.22; 95% CI 1.76-10.11), immune deficiency (1.91; 95% CI 1.05-3.49), preterm birth (OR 2.52; 95% CI 1.41-4.49), anemia at presentation (OR 2.34; 95% CI 1.28-4.27), radiological peribronchial wall thickening (OR 2.59; 95% CI 1.15-5.84) and hypoxia, altered mental status, seizures, or shock were more likely to require PICU admission. The presence of pharyngitis (OR 0.34; 95% CI 0.25-0.48); myalgia (OR 0.47; 95% CI 0.28-0.79) or diarrhea (OR 0.38; 95% CI 0.21-0.67) were inversely associated with hospital admission. Conclusions: In this data analysis reported to the SLIPE research network in Latin America, infants, social inequalities, comorbidities, anemia, bronchial wall thickening and specific clinical findings on presentation were associated with higher rates of hospitalization or PICU admission. This evidence provides data for prioritization prevention and treatment strategies for children suffering from COVID-19.

SCCmec Type IV, PVL-Negative, Methicillin-Resistant Staphylococcus aureus in Cystic Fibrosis Patients from Brazil.

Twenty seven S. aureus isolates were obtained from cystic fibrosis (CF) patients at a tertiary care hospital in Brazil. Nineteen (70.4%) were methicillin-susceptible S. aureus (MSSA) and eight (29.6%) methicillin-resistant S. aureus (MRSA). Of the MRSA isolates, four had SCCmec type III and four had SCCmec type IV. PVL genes were not detected in any of the MSSA or MRSA isolates. New studies are necessary to evaluate the exact impact of these different MRSA clones in CF patients.

Dynamics of antimicrobial resistance of Streptococcus pneumoniae following PCV10 introduction in Brazil: Nationwide surveillance from 2007 to 2019.

BACKGROUND: Brazil introduced 10-valent pneumococcal conjugate vaccine (PCV10) into its immunization program in 2010. We assessed antimicrobial susceptibility of Streptococcus pneumoniae (Spn) obtained from a national surveillance system for invasive pneumococcal diseases (IPD) before/after PCV10 introduction. METHODS: Antimicrobial non-susceptible isolates were defined as intermediate or resistant. Minimum inhibitory concentrations (MICs) to penicillin and ceftriaxone were analyzed by year. Antimicrobial susceptibility rates were assessed for each three-year-period using the pre-PCV10-period as reference. Susceptibility of vaccine-types was evaluated for 2017-2019. RESULTS: 11,380 isolates were studied. Spn with penicillin ≥ 0.125 mg/L and ceftriaxone ≥ 1.0 mg/L decreased in the three-years after PCV10 introduction (2011-2013: penicillin, 28.1-22.5%; ceftriaxone, 11.3%-7.6%) versus pre-PCV10-years (2007-2009: penicillin, 33.8-38.1%; ceftriaxone, 17.2%-15.6%). After 2013, the proportion of Spn with those MICs to penicillin and ceftriaxone increased to 39.4% and 19.7% in 2019, respectively. Non-susceptibility to penicillin and ceftriaxone increased in 2014-2016, and again in 2017-2019 especially among children < 5 years with meningitis (penicillin, 53.9%; ceftriaxone, 28.0%); multidrug-resistance reached 25% in 2017-2019. Serotypes 19A, 6C and 23A were most associated with antimicrobial non-susceptibility. CONCLUSIONS: Antimicrobial non-susceptible Spn decreased in the three-years after vaccination but subsequently increased and was associated with non-PCV10-types. Antimicrobial susceptibility surveillance is fundamental for guiding antibiotic therapy policies.

Impact of a twelve-year rotavirus vaccine program on acute diarrhea mortality and hospitalization in Brazil: 2006-2018.

BACKGROUND: Monitoring the impact of vaccine programs is necessary to identify changes in vaccine efficacy. We report the impact of the 12-year rotavirus vaccine program on diarrhea mortality and hospitalizations and their correlation to socioeconomic indicators. METHODS: this ecological study describes diarrhea hospitalizations and deaths from 2006 to 2018 in Brazil and correlates rotavirus vaccine coverage, hospitalizations and deaths to socioeconomic indicators and social vulnerability index (SVI) by state and region. Hospitalizations, deaths, and vaccine coverage trends were analyzed using Joinpoint regression models. Associations between hospitalizations, mortality and rotavirus vaccination coverage and socioeconomic and SVI indicators were established using Ordinary Least Square regressions. RESULTS: Rotavirus vaccine coverage remained stable between 2006 and 2018 (annual percentage changes (APC) [95%CI]: 4.4% [-0.3%, 9.2%]). Diarrhea hospitalization rates decreased 52.5% (-5.7% [-7.5%, -3.8%]), from 68.4 to 32.5 hospitalizations per 10,000 children <5 years-old between 2006 and 2018, with significant decreases in diarrhea mortality (-9.8% [-11.2%, -8.5%]). The Northeast region experienced the largest reductions (-13.9% [-15.7%, -12.2%]). Vaccination coverage and diarrhea-mortality were inversely correlated with the SVI. CONCLUSION: The burden of childhood diarrhea has decreased over an extended period. States with high SVI, but high vaccination coverage had the largest reductions in hospitalizations and deaths.

Brazilian adolescents infected by HIV: epidemiologic characteristics and adherence to treatment.

Over the last 3 decades since the first AIDS cases appeared, we have witnessed great progress in therapeutic methodologies that have transformed the evolution of the disease from debilitating and fatal, into chronic and controllable. HIV-infected children are arriving at adolescence and bringing specific challenges, not only to themselves, but also to their families and caregivers. This retrospective study sets forth epidemiological and treatment characteristics of 46 HIV-infected adolescents followed in a specialized university service relating said characteristics to therapy adherence assessed through a combination of three indirect methods. Therapy adherence did not reveal any association with either epidemiologic characteristics regarding age, sex, school level, household composition, age at diagnosis, mode of infection, knowledge of diagnosis, treatment time, or initial antiretroviral scheme. Patients with good therapy adherence presented lower viral load and used a smaller number of antiretroviral schemes.

Human parainfluenza virus surveillance in pediatric patients with lower respiratory tract infections: a special view of parainfluenza type 4.

OBJECTIVE: Characterize the role of human parainfluenza virus and its clinical features in Brazilian children under 2 years of age presenting with acute lower respiratory tract infections. METHODS: Real-time assays were used to identify strains of human parainfluenza virus and other common respiratory viruses in nasopharyngeal aspirates. One thousand and two children presenting with acute lower respiratory tract illnesses were enrolled from February 2008 to August 2010. RESULTS: One hundred and four (10.4%) patients were human parainfluenza virus positive, of whom 60 (57.7%) were positive for human parainfluenza virus-3, 30 (28.8%) for human parainfluenza virus-4, 12 (11.5%) for human parainfluenza virus-1, and two (1.9%) for human parainfluenza virus-2. Seven (6.7%) patients had more than one strain of human parainfluenza virus detected. The most frequent symptoms were tachypnea and cough, similar to other viral respiratory infections. Clinical manifestations did not differ significantly between human parainfluenza virus-1, -2, -3, and -4 infections. Human parainfluenza virus-1, -3, and -4 were present in the population studied throughout the three years of surveillance, with human parainfluenza virus-3 being the predominant type identified in the first two years. CONCLUSION: Human parainfluenza viruses contribute substantially to pediatric acute respiratory illness (ARI) in Brazil, with nearly 30% of this contribution attributable to human parainfluenza virus-4.

Distribution of Streptococcus pneumoniae serotypes in nasopharyngeal carriage and in invasive pneumococcal disease in Sao Paulo, Brazil.

To determine whether serotypes of S. pneumoniae isolated from the nasopharynx (NP) are representative of data from patients with invasive disease, we collected NP swab specimens from children, between 3 months and 5 years and obtained data from 105 children hospitalized with invasive disease. The prevalence of penicillin nonsusceptible strains in the NP carriage and invasive disease group was 16.4% and 17%, respectively, in the first period and 42% and 45% in the second period. The serotypes 23F, 6A, 14 and 19F were the most common in the NP study and 14, 1, 5 and 6B were the most common in invasive infections.

Risk factors for nosocomial bloodstream infection caused by multidrug resistant gram-negative bacilli in pediatrics.

The aim of this study was to identify the risk factors for nosocomial bloodstream infections by multidrug resistant Gram-negative bacilli. From November 2001 to December 2003, in the Pediatric Department of the Santa Casa de São Paulo, a retrospective case-control study was developed concerning patients who had nosocomial bloodstream infection caused by Gram-negative bacilli. Patients with multidrug resistant infections were designated as case patients, and control patients were those with an infection that did not meet the criteria for multidrug resistance. Previous use of central venous catheter and previous use of vancomycin plus third generation cephalosporins were associated to a higher chance of infections by multidrug resistant Gram-negative bacilli (Odds ratio--5.8 and 5.2, respectively). Regarding sensitivity of the isolated agents, 47.8% were multidrug resistant, 54.2% were Klebsiella spp. ESBL producers and 36.4% were imipenem resistant Pseudomonas aeruginosa. The lethality rate was 36.9% in the studied cases and this rate was significantly higher in the group of patients with multidrug resistant infections (p=0.013). Risk factor identification as well as the knowledge of the susceptibility of the nosocomial infectious agents gave us the possibility to perform preventive and control strategies to reduce the costs and mortality related to these infections.

Streptococcus pyogenes meningitis in children: report of two cases and literature review.

Streptococcus pyogenes meningitis (SPM) occurs sporadically, even with the increase of invasive streptococcal disease observed in the past years. We reported two cases of SPM in infants to alert pediatricians for the possibility of this agent as a cause of meningitis in previously healthy children.

[Comparative analysis of clinical and laboratory methods for diagnosing streptococcal sore throat]. / Comparação entre métodos clínicos e laboratoriais no diagnóstico das faringotonsilites estreptocócicas.

OBJECTIVES: Diagnosis and correct treatment of group A streptococcal sore throat is important particularly to prevent non-suppurative sequelae. Clinical findings continue to be used to differentiate streptococcal infection from viral sore throat. The American Academy of Pediatrics recommends that streptococcal sore throat diagnosis should always be performed by microbiological identification methods. The aim of this study is to evaluate the accuracy of clinical diagnosis in comparison with culture and rapid test. METHODS: Children aged 2 to 13 years who had received a clinical diagnosis of sore throat and sought treatment at the pediatric emergency unit of São Paulo Santa Casa were evaluated and those with clinical signs or viral infection were excluded. Clinical findings were recorded and swabs were taken for group A Streptococcus cultures and a Streptococcus rapid test. RESULTS: The culture was positive in 96 (24.4%) of the 376 children evaluated. The presence of petechiae, purulent exudate and painful tonsils were more likely to occur in children with positive streptococcus cultures, however they exhibited low diagnostic accuracy. The doctors' subjective evaluation failed to identify 21% of positive cases and antibiotics were prescribed in 47% of negative cases, compared with 3 and 6%, respectively, for the rapid test. CONCLUSIONS: A microbiologic method is necessary for the correct prescription of antibiotics in children with streptococcal sore throat.

[Sequential microbiological monitoring of tracheal aspirates in intubated patients admitted to a pediatric intensive care unit]. / Monitoramento microbiológico seqüencial da secreção traqueal em pacientes intubados internados em unidade de terapia intensiva pediátrica.

OBJECTIVE: To evaluate, sequentially, tracheal aspirates from patients admitted to a pediatric intensive care unit and to associate these pathogens with length of hospital stay, previous use of antimicrobial therapy and diagnoses of ventilator-associated pneumonia. METHODS: The study population consisted of patients admitted to a pediatric intensive care unit, between November 2002 and December 2003, on ventilator support. Three tracheal aspirates were collected serially from each patient. The first tracheal aspirate sample was obtained 6 hours after admission to the intensive care unit and the remaining samples were collected after 48 and 96 hours. RESULTS: One hundred patients aged from one day to 14 years were assessed. Positive tracheal cultures were observed to have increased in the three tracheal aspirate samples collected from each patient for Pseudomonas aeruginosa, from 6 to 22% (p = 0.002), and to have decreased for Staphylococcus aureus, from 23 to 8% (p = 0.009). Isolation of Candida spp increased for the subset that had received previous antimicrobial therapy (p < 0.05). Sixteen (23.5%) out of 68 patients admitted without pneumonia developed ventilator-associated pneumonia. Positive tracheal aspirate cultures were obtained in 10 out of 16 of these patients: six were positive for Staphylococcus aureus (three associated with Acinetobacter baumanii), two for Klebsiella spp (one associated with Enterobacter spp), one for Pseudomonas aeruginosa and one for Candida spp. CONCLUSION: Sequential evaluation of tracheal aspirates may be useful to track changes in bacterial flora at pediatric intensive care units.

Clinical presentation and follow up of children with congenital toxoplasmosis in Brazil.

We evaluated the clinical presentation and determined the ocular and neurologic sequelae in children with congenital toxoplasmosis in Brazil, taking into consideration the shortage of national publications on this disease. Follow-up evaluations were made of 43 children with congenital toxoplasmosis referred to Santa Casa de São Paulo, during a period of at least five years. Selection of the cases was based in clinical and laboratory criteria. A clear predominance of children with subclinical presentation of the disease at birth (88%) was found. Of the 43 children, 22 (51%) developed neurological manifestations. Using skull radiography, we detected neuroradiologic alterations in seven children (16%) and with tomography in 33 children (77%). Neurological sequelae were identified in 15 children (54%) in the group with cerebral calcifications and in 7 (47%) in the group without cerebral calcifications. We observed chorioretinitis in 95% of the cases. Reactivation of cicatricial lesions and the emergence of new ocular lesions were observed in five cases. The most frequent neurological manifestation was a delay in neuropsychomotor development. Most remarkable was the finding that cerebral calcifications were not associated with a higher incidence of neurological sequelae among the children. Chorioretinitis was the main ocular sequel of the infection, found in nearly all children; it can manifest years from birth, even in children submitted to specific therapy druing the first year of life, highlighting the importance of a follow-up of these children.

[Pneumococcal meningitis in children: clinical findings, most frequent serotypes and outcome]. / Meningite pneumocócica na infância: características clínicas, sorotipos mais prevalentes e prognóstico.

OBJECTIVE: To determine mortality, morbidity, antimicrobial susceptibility and the most frequent serotypes in children admitted to hospital due to pneumococcal meningitis METHODS: Patients with meningitis caused by Streptococcus pneumoniae detected by culture in cerebrospinal fluid or blood, aged between 1 month and 15 years old, admitted to two hospitals in the city of São Paulo, were included in the study. Susceptibility to penicillin was determined by the disk diffusion test using oxacillin 1 microg disk. If the inhibition area with oxacillin disk was less than 20mm, the strains were tested for penicillin, chloramphenicol, ceftriaxone, vancomycin and sulfamethoxazole /trimethoprim using the E test. RESULTS: We identified 55 patients, 52.5% of which were younger than 6 months. The prevalence of penicillin-nonsusceptible strains was 36%. All the strains were intermediately resistant (0.1 microg/ml < or =; MIC < or = 1.0 microg/ml) and 35% of the penicillin intermediate resistant strains were resistant to sulfamethoxazole/trimethoprim. The mortality rate was 20% and impaired neurological outcome was present in 40% of the children. The audiometric test revealed alteration in 60% of the children tested. Age less than 6 months was associated with poor outcome. The most frequent serotypes were 1, 5, 6B, 14, 19A and 23F, and 70% of the serotypes were included in the new 7-valent vaccine. CONCLUSIONS: These findings suggest that pneumococcal meningitis presents high mortality and morbidity and that the 7-valent conjugate vaccine would be potentially useful in preventing serious pneumococcal infections.

Gram-negative infections in pediatric and neonatal intensive care units of Latin America.

In order to review the epidemiology of Gram-negative infections in the pediatric and neonatal intensive care units (PICUs and NICUs) of Latin America a systematic search of PubMed and targeted search of SciELO was performed to identify relevant articles published since 2005. Independent cohort data indicated that overall infection rates were higher in Latin American PICUs and NICUs versus developed countries (range, 5%-37% vs 6%-15%, respectively). Approximately one third of Latin American patients with an acquired PICU or NICU infection died, and crude mortality was higher among extremely low-birth-weight infants and those with an infection caused by Gram-negative bacteria. In studies reporting > 100 isolates, the frequency of Gram-negative pathogens varied from 31% (Colombia) to 63% (Mexico), with Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli the predominant pathogens in almost all countries, and Acinetobacter spp. and Serratia spp. isolated sporadically. The activity of quinolones and third-generation cephalosporins against P. aeruginosa, Acinetobacter spp., and Enterobacteria was seriously compromised, coincident with a high prevalence of circulating extended-spectrum ß-lactamases. Furthermore, we identified two observational studies conducted in Chile and Brazil reporting infections by P. aeruginosa and Acinetobacter baumannii in PICUs, demonstrating resistance to carbapenems, and two outbreaks of carbapenem-resistant K. pneumoniae in Colombia and Brazil. The endemicity of multidrug-resistant Gram-negative infections in Latin American PICUs and NICUs is punctuated by intermittent clonal outbreaks. The problem may be alleviated by ensuring ICUs are less crowded, increasing staffing levels of better-trained health care personnel, and implementing antimicrobial stewardship and surveillance programs.

Mupirocin susceptibility in Staphylococcus aureus nasal and oropharyngeal isolates from Brazilian children.

Mupirocin is a topical antimicrobial agent and part of most Staphylococcus aureus decolonization regimens. Thus, knowing the mupirocin susceptibility profile of colonizing S. aureus is paramount for the proper use of this agent. We evaluated S. aureus isolates from 128 colonized children, using disc diffusion (with 5 mcg and 200 mcg discs) and Etest. None were low-level or high-level mupirocin-resistant. Since mupirocin will be increasingly needed for the control of S. aureus infection, continuous monitoring of its susceptibility status is necessary.

Acute respiratory viral infections in pediatric cancer patients undergoing chemotherapy.

OBJECTIVE: to estimate the prevalence of infection by respiratory viruses in pediatric patients with cancer and acute respiratory infection (ARI) and/or fever. METHODS: cross-sectional study, from January 2011 to December 2012. The secretions of nasopharyngeal aspirates were analyzed in children younger than 21 years with acute respiratory infections. Patients were treated at the Grupo em Defesa da Criança Com Câncer (Grendacc) and University Hospital (HU), Jundiaí, SP. The rapid test was used for detection of influenza virus (Kit Biotrin, Inc. Ireland), and real-time multiplex polymerase chain reaction (FTD, Respiratory pathogens, multiplex Fast Trade Kit, Malta) for detection of influenza virus (H1N1, B), rhinovirus, parainfluenza virus, adenovirus, respiratory syncytial virus, human parechovirus, bocavirus, metapneumovirus, and human coronavirus. The prevalence of viral infection was estimated and association tests were used (χ(2) or Fisher's exact test). RESULTS: 104 samples of nasopharyngeal aspirate and blood were analyzed. The median age was 12 ± 5.2 years, 51% males, 68% whites, 32% had repeated ARIs, 32% prior antibiotic use, 19.8% cough, and 8% contact with ARIs. A total of 94.3% were in good general status. Acute lymphocytic leukemia (42.3%) was the most prevalent neoplasia. Respiratory viruses were detected in 50 samples: rhinoviruses (23.1%), respiratory syncytial virus AB (8.7%), and coronavirus (6.8%). Co-detection occurred in 19% of cases with 2 viruses and in 3% of those with 3 viruses, and was more frequent between rhinovirus and coronavirus 43. Fever in neutropenic patients was observed in 13%, of which four (30.7) were positive for viruses. There were no deaths. CONCLUSIONS: the prevalence of respiratory viruses was relevant in the infectious episode, with no increase in morbidity and mortality. Viral co-detection was frequent in patients with cancer and ARIs.

Clinical and epidemiological aspects related to the detection of adenovirus or respiratory syncytial virus in infants hospitalized for acute lower respiratory tract infection.

OBJECTIVE: To characterize and compare clinical, epidemiological, and laboratory aspects of infants with acute lower respiratory infection (ALRI) associated with the detection of adenovirus (ADV) or respiratory syncytial virus (RSV). METHODS: A preliminary respiratory infection surveillance study collected samples of nasopharyngeal aspirate (NPA) for viral research, linked to the completion of a standard protocol, from children younger than two years admitted to a university hospital with ALRI, between March of 2008 and August of 2011. Polymerase chain reaction (PCR) was used for eight viruses: ADV, RSV, metapneumovirus, Parainfluenza 1, 2, and 3, and Influenza A and B. Cases with NPA collected during the first 24 hours of admission, negative results of blood culture, and exclusive detection of ADV (Gadv group) or RSV (Grsv group) were selected for comparisons. RESULTS: The preliminary study included collection of 1,121 samples of NPA, 813 collected in the first 24 hours of admission, of which 50.3% were positive for at least one virus; RSV was identified in 27.3% of cases surveyed, and ADV was identified in 15.8%. Among the aspects analyzed in the Gadv (n = 58) and Grsv (n = 134) groups, the following are noteworthy: the higher mean age, more frequent prescription of antibiotics, and the highest median of total white blood cell count and C-reactive protein values in Gadv. CONCLUSIONS: PCR can detect persistent/latent forms of ADV, an aspect to be considered when interpreting results. Additional studies with quantitative diagnostic techniques could elucidate the importance of the high frequency observed.