Variability in firearm injury among major pediatric trauma centers across the USA.

Objectives: In 2020, firearm injuries surpassed automobile collisions as the leading cause of death in US children. Annual automobile fatalities have decreased during 40 years through a multipronged approach. To develop similarly targeted public health interventions to reduce firearm fatalities, there is a critical need to first characterize firearm injuries and their outcomes at a granular level. We sought to compare firearm injuries, outcomes, and types of shooters at trauma centers in four pediatric health systems across the USA. Methods: We retrospectively extracted data from each institution's trauma registry, paper and electronic health records. Study included all patients less than 19 years of age with a firearm injury between 2003 and 2018. Variables collected included demographics, intent, resources used, and emergency department and hospital disposition. Descriptive statistics were reported using medians and IQRs for continuous data and counts with percentages for categorical data. χ2 test or Fisher's exact test was conducted for categorical comparisons. Results: Our cohort (n=1008, median age 14 years) was predominantly black and male. During the study period, there was an overall increase in firearm injuries, driven primarily by increases in the South (S) site (ß=0.11 (SE 0.02), p=<0.001) in the setting of stable rates in the West and decreasing rates in the Northeast and Mid-Atlantic sites (ß=-0.15 (SE 0.04), p=0.002; ß=-0.19 (SE0.04), p=0.001). Child age, race, insurance type, resource use, injury type, and shooter type all varied by regional site. Conclusion: The incidence of firearm-related injuries seen at four sites during 15 years varied by site and region. The overall increase in firearm injuries was predominantly driven by the S site, where injuries were more often unintentional. This highlights the need for region-specific data to allow for the development of targeted interventions to impact the burden of injury.Level of Evidence: II, retrospective study.

Social-environmental factors as mediators of IQ and achievement differences across race groups in adolescents with high risk congenital heart disease.

An increasing number of neuropsychologists are evaluating children with congenital heart disease (CHD). When conceptualizing results, the provider must consider medical risks such as abnormal neuroimaging and comorbidities, along with social risks such as socioeconomic status. The aim of the current study was to examine the influence of parent income and education on IQ and achievement across race groups in adolescents with CHD, while also accounting for medical risk (e.g., gestational age, number of ventricles, neuroimaging). This is a single-center cross-sectional study, including 92 children ages 12-19 years (median 14.9 years; 59% male; 71% White; 29% Black) with high risk CHD (i.e., cardiac surgery <12 months) who were referred for a neuropsychological evaluation. Retrospective data were retrieved from a larger clinical registry. Patients completed an intellectual assessment (WISC-V; WAIS-IV; WASI-II), Word Reading and Math Calculation tests. Parents completed questionnaires assessing the family environment [income, parent education]. Results revealed significant differences in IQ when comparing children who were Black versus White (11.4 point IQ difference); however, around 70% of this variance was explained by parent income and education. Medical variables accounted for 12% of the variance in IQ. For academics, parent income and education accounted for 91.5% and 78.8% of the variance in race group differences for reading and math, respectively. Medical risk and sex explained 11.7% and 14.7% of the variance in reading and math, respectively. Findings suggest that sociodemographic factors should be weighed heavily during the neuropsychological evaluation, including prioritizing risk, making recommendations, and facilitating referrals.

Brief Report: Performance of Tuberculosis Symptom Screening Among Hospitalized ART-Naive Children With HIV in Kenya.

BACKGROUND: The World Health Organization (WHO) recommends tuberculosis (TB) diagnostic evaluation for children with HIV (CHIV) who have history of TB contact, poor weight gain, cough, or fever. These screening criteria were developed based on studies of symptomatic CHIV with incomplete microbiologic confirmation. We performed routine TB microbiologic evaluation of hospitalized CHIV with and without symptoms to develop a data-driven TB symptom screen. METHODS: Among hospitalized antiretroviral therapy-naive Kenyan CHIV enrolled in the Pediatric Urgent Start of Highly Active Antiretroviral Therapy (PUSH) trial, we performed Xpert MTB/RIF and mycobacterial culture of respiratory and stool specimens independent of TB symptoms. We evaluated performance of WHO and other published pediatric TB screening criteria and derived optimized criteria using a combination of symptoms. RESULTS: Of 168 CHIV who underwent TB microbiologic evaluation, 13 (8%) had confirmed TB. WHO TB symptom screening had 100% sensitivity and 4% specificity to detect confirmed TB. Published TB screening criteria that relied on prolonged symptoms missed cases of confirmed TB (sensitivity 85%-92%). An optimized symptom screen including weight loss, cough, anorexia, or TB contact had 100% sensitivity and improved specificity (31%) compared with the WHO pediatric TB symptom screen. CONCLUSIONS: The WHO TB symptom screen was highly sensitive but resulted in a high proportion of hospitalized CHIV who would require TB diagnostic evaluation. Other published TB screening criteria missed CHIV with confirmed TB. Our optimized screening tool increased specificity while preserving sensitivity. Future multicenter studies are needed to improve TB screening tools for CHIV in both inpatient and outpatient settings.

Comparison of Targeted and Routine Adolescent HIV Screening in a Pediatric Emergency Department.

OBJECTIVES: The aims of the study were (1) to compare targeted and routine HIV screening in a pediatric emergency department (PED) and (2) to compare provider documented HIV risk assessment with adolescent perception of HIV risk assessment conducted during the PED visit. METHODS: This prospective study ran concurrent to a PED routine HIV screening pilot. Adolescents could be tested for HIV by the PED provider per usual care (targeted testing); if not tested, they were approached for the routine screening pilot. A subset of adolescents completed a questionnaire on HIV risk. χ 2 analysis compared adolescents with targeted testing and routine screening. HIV-tested patients were asked if HIV risk was assessed; κ analysis compared this with documentation in the provider note. RESULTS: Over 4 months, 107 adolescents received targeted testing and 344 received routine screening. One 14-year-old patient tested positive by routine screening; this adolescent had 2 PED visits without targeted testing within 60 days. Compared with routine screening, adolescents with targeted testing were more likely female (82% vs 57%, P < 0.001), 16 years or older (71% vs 44%, P < 0.001), or had genitourinary/gynecologic concerns (48% vs 6%, P < 0.001). Adolescents with HIV risk factors were missed by targeted testing but received routine screening. Adolescents with documented HIV risk assessment were more likely to receive targeted testing. There was moderate agreement (κ = 0.61) between provider documentation and adolescent perception of HIV risk assessment. CONCLUSIONS: There are gaps in PED HIV risk assessment and testing, which may miss opportunities to diagnose adolescent HIV. Routine HIV screening addresses these gaps and expands adolescent HIV testing in the PED.

Management of esophageal button battery ingestions: resource utilization and outcomes.

PURPOSE: Institutions are adopting the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition (NASPGHAN) guidelines for pediatric esophageal button battery ingestion (EBBI). Our objective was to evaluate the guidelines' impact on in-hospital resource utilization and short-term clinical outcomes in hemodynamically stable patients after endoscopic battery removal. METHODS: A single-center retrospective review of all EBBI admissions from 2010 to 2020. Patients were divided into two groups based on adoption of national guidelines: pre-guideline (2010-2015) and post-guideline (2016-2020). RESULTS: Sixty-five patients were studied (pre-guideline n = 23; post-guideline n = 42). Compared with pre-guideline, post-guideline use of magnetic resonance imaging (MRI) increased (2/23 [8.7%]; 30/42 [71.4%]; p < 0.001). Post-guideline increases resulted for median days (IQR) receiving antibiotics (0 [0, 4]; 6 [3, 8]; p = 0.01), total pediatric intensive care unit admission (0 [0, 1]; 3 [0, 6]; p < 0.001), and total hospital length of stay (5 [2, 11]; 11.5 [4, 17]; p = 0.02). Two patients in the post-guideline group had delayed presentations despite normal imaging: one with TEF and one with aorto-esophageal fistula. All survived to discharge. CONCLUSION: In EBBI cases managed using the consensus based NASPHAGN guidelines, we report increased resource utilization without improved patient outcomes. Further research should evaluate post-guideline costs and resource utilization.

Osteopontin as a biomarker for COVID-19 severity and multisystem inflammatory syndrome in children: A pilot study.

This study sought to evaluate the candidacy of plasma osteopontin (OPN) as a biomarker of COVID-19 severity and multisystem inflammatory condition in children (MIS-C) in children. A retrospective analysis of 26 children (0-21 years of age) admitted to Children's Healthcare of Atlanta with a diagnosis of COVID-19 between March 17 and May 26, 2020 was undertaken. The patients were classified into three categories based on COVID-19 severity levels: asymptomatic or minimally symptomatic (control population, admitted for other non-COVID-19 conditions), mild/moderate, and severe COVID-19. A fourth category of children met the Centers for Disease Control and Prevention's case definition for MIS-C. Residual blood samples were analyzed for OPN, a marker of inflammation using commercial ELISA kits (R&D), and results were correlated with clinical data. This study demonstrates that OPN levels are significantly elevated in children hospitalized with moderate and severe COVID-19 and MIS-C compared to OPN levels in mild/asymptomatic children. Further, OPN differentiated among clinical levels of severity in COVID-19, while other inflammatory markers including maximum erythrocyte sedimentation rate, C-reactive protein and ferritin, minimum lymphocyte and platelet counts, soluble interleukin-2R, and interleukin-6 did not. We conclude OPN is a potential biomarker of COVID-19 severity and MIS-C in children that may have future clinical utility. The specificity and positive predictive value of this marker for COVID-19 and MIS-C are areas for future larger prospective research studies.

Comparison of Invasive and Oscillometric Blood Pressure Measurement in Obese and Nonobese Children.

BACKGROUND: Obesity and hypertension are public health priorities, with obesity considered to be a potential cause of hypertension. Accurate blood pressure (BP) determination is required and often obtained by automated oscillometric cuff devices. We sought to determine the correlation of oscillometric measurement in children, and if obesity was associated with worse correlation between methods than nonobese children. METHODS: Retrospective matched case-controlled study of 100 obese (97-99th percentile) and 100 nonobese (25-70th percentile) children after cardiac surgery with simultaneous systolic, diastolic, and mean invasive and oscillometric measurements. Matching was 1:1 for age, sex, race, and Risk Adjustment for Congenital Heart Surgery-1 score. Intraclass correlation coefficients and Bland-Altman plots were used to determine agreement with 0.75 as threshold. RESULTS: Median age was 13 years (10-15). Agreement was low for systolic (0.65 and 0.61), diastolic (0.68 and 0.61), and mean measurements (0.73 and 0.69) (obese/nonobese). Bland-Altman plots demonstrated oscillometric BP measurements underestimated systolic hypertension (oscillometric readings lower than intra-arterial). Oscillometric measurements underestimated hypotension (systolic oscillometric measurements were higher than intra-arterial). This occurred in obese and nonobese patients. Correlation of oscillometric measurements was similar for nonobese and obese patients. CONCLUSIONS: In this first ever study of simultaneous BP measurement by oscillometric vs. intra-arterial in obese and nonobese children, correlation is below accepted norms. The correlation of oscillometric cuff measurements is not affected by habitus in children. There is less correlation between oscillometric measurements and intra-arterial measurements during hypertension or hypotension. Healthcare providers should be aware of the limitations of oscillometric measurements.

Validation of a new instrument to measure disease-related distress among patients with haemophilia.

INTRODUCTION: In patients with haemophilia, general psychological distress as measured by the National Comprehensive Cancer Network (NCCN) distress thermometer has been associated with pain, disability and increased healthcare utilization. AIMS: To develop and validate a measure of haemophilia-related distress. METHODS: After qualitative interviews, the Hemophilia-Related Distress Questionnaire (HRDq) was developed. To validate the HRDq, adults (≥18 years) with haemophilia were enrolled, reported demographic and clinical information, and completed the HRDq and other questionnaires that measured similar constructs. Analysis included factor analysis and assessment of internal consistency using Cronbach's α, convergent validity using Pearson's correlation coefficient, and discriminant validity by comparing subgroups of patients. Test-retest reliability was assessed using an intraclass correlation coefficient (ICC). RESULTS: Among 130 enrolled participants, 126 (median age=32.7 years) completed the 24 item HRDq in a median time of 5.4 minutes with overall HRDq scores ranging from 2 to 83 (median score=31.5; higher scores indicating higher distress). Assessment of convergent validity demonstrated a strong correlation (ρ>.60) of the HRDq total score with the NCCN Distress Thermometer, Haem-A-QoL total Score, and PROMIS-29 Profile social role domain and a mild to moderate correlation with all other questionnaire domains (.3-.59, p < .05). Distress was higher among those who had less education, were not employed, and were disabled and was not significantly different among those with severe compared with non-severe disease. Assessment of test-retest reliability demonstrated an ICC value of .84 (95% CI .71-.91) for the total score. CONCLUSIONS: The HRDq demonstrates good internal consistency, construct and discriminant validity, and retest reliability with a low responder burden.

Does ERAS impact outcomes of laparoscopic sleeve gastrectomy in adolescents?

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols have been successfully implemented in several surgical fields; however, the application of ERAS in the pediatric population is still limited. OBJECTIVES: The aim was to determine if implementation of an ERAS protocol can improve outcomes of laparoscopic sleeve gastrectomy (LSG) in adolescents. SETTING: University Hospital, United States. METHODS: A retrospective analysis of 112 adolescent patients who underwent LSG from February 2011 to July 2019 was conducted. An ERAS protocol was instituted in June 2016. Conventional care patients (n = 51) were compared with ERAS patients (n = 61). Comparisons were made using Χ2 tests or Fisher's exact for categoric data and Wilcoxon-rank sum tests for continuous data. Multiple linear regression was used to adjust length of stay for patient characteristics. RESULTS: The 2 cohorts were similar in age, sex, race, number of co-morbidities, and preoperative body mass index. The volume of intraoperative fluid, intraoperative and postoperative opioids were significantly reduced in the ERAS group (P < .0001). The number of ERAS elements received per patient increased from a median of 9 to 15 (P < .0001). ERAS group had more discharges on postoperative day 1 (48% versus 6 %, respectively). Length of stay was significantly lower in the ERAS group (2.34 versus 2.04 median d, respectively). Difference was still significant after adjusting for age, sex, race/ethnicity, payor status, American Society of Anesthesiologists score, preoperative body mass index, and the duration of surgery (P < .0001). There were no differences in postoperative complications and 30-day readmissions. CONCLUSIONS: An LSG ERAS protocol is associated with significant reduction in perioperative opioid use and length of stay with no increase in complications or readmission rates.

Use of Factor VIIa and Anti-inhibitor Coagulant Complex in Pediatric Cardiac Surgery Patients.

OBJECTIVES: Postoperative bleeding is a common cause of morbidity and mortality in cardiac patients who undergo cardiopulmonary bypass (CPB). Pediatric patients are especially at risk for adverse effects of surgery and CPB on the coagulation system. This can result in bleeding, transfusions, and poor outcomes. Excessive bleeding unresponsive to blood products can warrant the off-label use of recombinant activated clotting factor VIIa (rFVIIa) and/or anti-inhibitor coagulant complex (FEIBA). Several studies have shown the utility in these agents off-label in patients who have undergone cardiac bypass surgery with acute bleeding episodes that are refractory to blood products. However, data regarding use of these agents in pediatrics are sparse. The purpose of this study is to report the use of rFVIIa and FEIBA in pediatric cardiac surgery patients in our institution. METHODS: This was a retrospective chart review of pediatric cardiothoracic surgery patients who received rFVIIa or FEIBA at Children's Healthcare of Atlanta during the study period. RESULTS: Thirty-three patients received rFVIIa and 9 patients received FEIBA either intraoperatively or postoperatively for bleeding related to the cardiac procedure. Approximately 13% of rFVIIa patients and 55% of FEIBA patients required repeat doses. There were decreases for all blood products administered after rFVIIa and FEIBA were given. However, the doses used did not correlate with either positive or negative outcomes. Seventeen percent (n = 7) of rFVIIa patients experienced a thrombus and 22% (n = 2) of FEIBA patients experienced a thrombus. CONCLUSIONS: Both rFVIIa and FEIBA reduced blood product usage in pediatric patients following cardiac procedures.

Unique Needs for the Implementation of Emergency Department Human Immunodeficiency Virus Screening in Adolescents.

BACKGROUND: The Centers for Disease Control and Prevention (CDC) recommend universal human immunodeficiency virus (HIV) screening starting at 13 years, which has been implemented in many general U.S. emergency departments (EDs) but infrequently in pediatric EDs. We aimed to 1) implement a pilot of routine adolescent HIV screening in a pediatric ED and 2) determine the unique barriers to CDC-recommended screening in this region of high HIV prevalence. METHODS: This was a prospective 4-month implementation of a routine HIV screening pilot in a convenience sample of adolescents 13 to 18 years at a single pediatric ED, based on study personnel availability. Serum-based fourth-generation HIV testing was run through a central laboratory. Parents were allowed to remain in the room for HIV counseling and testing. Data were collected regarding patient characteristics and HIV testing quality metrics. Comparisons were made using chi-square and Fisher's exact tests. Regression analysis was performed to assess for an association between parent presence at the time of enrollment and adolescent decision to participate in HIV screening. RESULTS: Over 4 months, 344 of 806 adolescents approached consented to HIV screening (57% female, mean ± SD = 15.1 ± 1.6 years). Adolescents with HIV screening were more likely to be older than those who declined (p = 0.025). Other blood tests were collected with the HIV sample for 21% of adolescents; mean time to result was 105 minutes (interquartile range = 69 to 123) and 79% were discharged before the result was available. Having a parent present for enrollment was not associated with adolescent participation (adjusted odds ratio = 1.07, 95% CI = 0.67 to 1.70). Barriers to testing included: fear of needlestick, time to results, cost, and staff availability. One of 344 tests was positive in a young adolescent with Stage 1 HIV. CONCLUSIONS: Routine HIV screening in adolescents was able to be implemented in this pediatric ED and led to the identification of early infection in a young adolescent who would have otherwise been undetected at this stage of disease. Addressing the unique barriers to adolescent HIV screening is critical in high-prevalence regions and may lead to earlier diagnosis and treatment in this vulnerable population.

Diagnostic Yield Variation with Colonoscopy among Pediatric Endoscopists.

BACKGROUND: The primary aim of our study was to determine provider variation in diagnostic yield in a pediatric endoscopy center. Secondary aims were to examine ileal intubation rates as well as procedural complications at the provider level. METHODS: A retrospective review of sequential pediatric patients who underwent a colonoscopy, completed by June 2018, determined the rates of endoscopically abnormal (EA) and isolated histologically abnormal (IHA) colonoscopies; the overall diagnostic yield was the combination of EA and IHA. RESULTS: In total, 374 charts were reviewed. This study found high variability in diagnostic yield among the 16 clinicians ranging from as low as 22% to as high as 86% (p = 0.11) with an overall diagnostic yield of 48% for colonoscopy; excluding follow-up colonoscopies, the diagnostic yield was 42%. Abnormal calprotectin and abnormal blood tests were associated with higher diagnostic yields of 83 and 65%, respectively, compared with symptoms such as abdominal pain, diarrhea, and rectal bleeding which had yields of 39, 43, and 61%. Ileal intubation rates averaged 90% (range -63-100%, p = 0.06). In patients with a normal colon, there were 21 (6%) patients with an EA ileum and an additional 16 (4%) with an IHA ileum. Prep quality was rated excellent, good, or average in 97%. In addition, there was a low rate of serious complications (1 of 374). CONCLUSIONS: This study highlights the individual variability in diagnostic yield and ileal intubation rates in a pediatric gastroenterology practice. Goals for pediatric endoscopy could include ileal intubation rates of >90% and provider diagnostic yields of >40%.

Production-related contaminants (pesticides, antibiotics and hormones) in organic and conventionally produced milk samples sold in the USA.

OBJECTIVE: Consumption of cow's milk, which is associated with diet and health benefits, has decreased in the USA. The simultaneous increase in demand for more costly organic milk suggests consumer concern about exposure to production-related contaminants may be contributing to this decline. We sought to determine if contaminant levels differ by the production method used. DESIGN: Half-gallon containers of organic and conventional milk (four each) were collected by volunteers in each of nine US regions and shipped on ice for analysis. Pesticide, antibiotic and hormone (bovine growth hormone (bGH), bGH-associated insulin-like growth factor 1 (IGF-1)) residues were measured using liquid or gas chromatography coupled to mass or tandem mass spectrometry. Levels were compared against established federal limits and by production method. SETTING: Laboratory analysis of retail milk samples. RESULTS: Current-use pesticides (5/15 tested) and antibiotics (5/13 tested) were detected in several conventional (26-60 %; n 35) but not in organic (n 34) samples. Among the conventional samples, residue levels exceeded federal limits for amoxicillin in one sample (3 %) and in multiple samples for sulfamethazine (37 %) and sulfathiazole (26 %). Median bGH and IGF-1 concentrations in conventional milk were 9·8 and 3·5 ng/ml, respectively, twenty and three times that in organic samples (P < 0·0001). CONCLUSIONS: Current-use antibiotics and pesticides were undetectable in organic but prevalent in conventionally produced milk samples, with multiple samples exceeding federal limits. Higher bGH and IGF-1 levels in conventional milk suggest the presence of synthetic growth hormone. Further research is needed to understand the impact of these differences, if any, on consumers.

Outcomes and risk factors associated with tricuspid valve repair in children with hypoplastic left heart syndrome.

OBJECTIVES: Tricuspid valve (TV) competence is important for successful palliation of hypoplastic left heart syndrome (HLHS). We report our experience with TV repair in HLHS patients with a focus on TV and right ventricular (RV) function and associated clinical outcomes. METHODS: From 2002 to 2012, 219 neonates with HLHS underwent the Norwood operation. Thirty patients who underwent TV repair at various stages comprised our current series cohort. Echocardiographic and clinical data were reviewed to determine the effectiveness of TV repair and outcomes of the patients. RESULTS: Thirty patients received TV repair during Norwood (n = 4), Glenn (n = 17) and Fontan (n = 9) operations. Median age at TV repair was 188 days (range 3-1498). Preoperatively, all patients had ≥moderate TV regurgitation and 4 (13%) patients had ≥moderate RV dysfunction. After repair, TV regurgitation was none or trivial (n = 12, 40%), mild (n = 8, 27%), ≥moderate (n = 10, 33%), whereas 10 (33%) had ≥moderate regurgitation at last follow-up; ≥moderate RV dysfunction was present in 5 (17%) patients following TV repair and 10 (33%) patients at last follow-up. Competing risk analysis showed that 10 years following TV repair, 21% of patients had TV reoperation, 18% died or underwent transplantation and 61% were alive without subsequent reoperation. Overall, 10-year survival, transplant-free survival and freedom from second TV reoperation were 89%, 71% and 78%, respectively; ≥moderate RV dysfunction following TV repair was associated with diminished transplant-free survival (P = 0.0277). CONCLUSIONS: Although TV repair is successful in reducing regurgitation in the majority of HLHS patients, outcomes are restricted by limited repair durability with recurrent significant regurgitation in one-third of the patients. RV dysfunction in these patients is progressive and a major determinant of transplant-free survival.

Identificación fenotípica y molecular de beta-lactamasas de espectro extendido TEM y SHV producidas por Escherichia coli y Klebsiella spp. aislados clínicos de hospitales / Phenotypic and molecular identification of extended-spectrum beta-lactamase (ESBL) TEM and SHV produced by clinical isolates Escherichia coli and Klebsiella spp. in hospitals

Se evaluó la prevalencia de beta-lactamasas de espectro extendido (BLEE) tipo TEM y SHV producidas por Escherichia coli y Klebsiella spp. y se determinó la susceptibilidad a otras familias de antimicrobianos. Un total de 326 cepas fueron colectadas entre 2002-2004, procedentes de hospitales en Ciudad de La Habana; los ensayos de susceptibilidad se realizaron de acuerdo con las guías NCCLS y fueron confirmados como productores de BLEE, por el método de doble difusión con discos. La caracterización molecular se realizó mediante la reacción en cadena de la polimerasa, utilizando oligonucleótidos específicos para detectar los genes blaTEM y blaSHV. El fenotipo BLEE fue detectado en 31 de los aislados de Escherichia coli (10 por ciento); de estos 19 (61 por ciento) fueron portadores del gen blaTEM, 5 (16 por ciento) del gen blaSHV; 4 (12 por ciento) portaban ambos genes y 11 (35 por ciento) no portaban ninguno de los genes evaluados. En las cepas de Klebsiella spp. el fenotipo BLEE fue detectado en 10 aislados (36 por ciento) y solo una cepa presentó genotipo blaTEM 1 (10 por ciento). Los antimicrobianos más activos frente Escherichia coli fueron ciprofloxacina (64,5 por ciento) y gentamicina (58,07 por ciento). Los mismos antimicrobianos fueron los más activos para Klebsiella spp., con igual sensibilidad (70 por ciento). Los carbapenémicos aún permanecen activos en las cepas productoras de BLEE, no obstante su uso debe vigilarse cuidadosamente.

Nosocomial infections caused by gram-negative bacilli which produce extended spectrum beta-lactamase (ESBL) are associated with the increase of morbidity and mortality in hospitals. The objective of this study was to evaluate the frequency of ESBL, specifically the TEM and SHV type, produced by Escherichia coli and Klebsiella spp. strains, and also to determine the antimicrobial susceptibility of these isolates in comparison with other antibiotic families. A total of 326 strains were collected between 2002-2004 from hospitals in Havana City. The susceptibility tests were carried out according to the NCCLS guides and they were confirmed as . ESBL producers by the double disk diffusion method. The molecular characterization of these enzymes was determined by polymerase chain reaction (PCR), using two sets of oligonucleotides to amplify genes encoding TEM and SHV type b-lactamase. The ESBL phenotype was detected in 31 (10 percent) Escherichia coli isolates, 19 of these strains (61 percent) carried the blaTEM genes, 5 (16 percent) blaSHV genes, 4 (12 percent) strains carried both genes and 11 strains (35 percent) carried the non-ESBL blaTEM and blaSHV genes. In Klebsiella spp the ESBL phenotype was detected in 10 (36 percent) isolates, only one strain carried the blaTEM gene. The most active antimicrobials against Escherichia coli were ciprofloxacin (64.5 percent) and gentamicin (58.07 percent); in the case of Klebsiella spp. the same antimicrobials were the most active with similar susceptibility (70 percent) for both. The carbapenems still remain the most active antibiotics against Escherichia coli and Klebsiella spp. strains, which are ESBL producers. However, their use should be closely controlled.

Frecuencia de aislamiento de Staphylococcus spp meticilina resistentes y Enterococcus spp vancomicina resistentes en hospitales de Cuba / Frequency of methicilline-resistant Staphylococcus spp and vancomycin-resistant Enterococcus isolates in Cuban hospitals

La resistencia a meticilina en el género Staphylococcus spp es un problema creciente en el ámbito mundial. La producción de una PBP alterada (PBP2a) con baja afinidad a betalactámicos, mediada por el gen mec A, es la responsable de esta resistencia. Mientras que los Staphylococcus spp todavía permanecen sensibles a vancomicina, algunos Enterococcus spp han adquirido la capacidad de neutralizar esta droga. En nuestro país no se conocen datos actualizados sobre la tasa de infección por S aureus meticilina resistente (SAMR), ni sobre la circulación de este germen en la comunidad, tampoco existen reportes de Enterococcus spp vancomicina resistente (EVR). En este estudio fueron analizadas 774 cepas, colectadas en hospitales del país. Se determinó el mecanismo de resistencia utilizando métodos sugeridos por las guías NCCLS. El 9,3 por ciento (23) de los S aureus aislados en los hospitales y 4,0 por ciento (7) S aureus aislados en la comunidad, fueron SAMR, portadores del gen mec A, el 69,9 por ciento (72) de Staphylococcus coagulasa negativo, fueron resistentes a oxacilina. En la detección del Enterococcus spp vancomicina resistente (EVR), se encontró una cepa portadora de este fenotipo. Nuestros resultados revelan que en nuestro país los SAMR no son un problema en los hospitales, ni en el ambiente comunitario, a pesar de que se reporta por primera vez la circulación de estos en la comunidad y la circulación de EVR en el ambiente hospitalario, su frecuencia es muy baja lo que refleja los avances obtenidos en la aplicación de políticas encaminadas a racionalizar el uso y consumo de antibióticos