Macrophage profile and homing into breast milk in response to ongoing respiratory infections in the nursing infant.

Studies have shown that immune components of human milk can be changed during an infection in the nursing infant. Macrophages are abundant in human milk and they are classified into inflammatory (CD16-) and noninflammatory (CD16+) subsets. This study investigated CD16+ and CD16- macrophage homing into breast milk in response to ongoing infections in nursing infants. Peripheral blood and mature milk were collected from 33 healthy mothers of nursing infants with respiratory infections (Group I) and from 26 healthy mothers of healthy nursing infants (Group H). Blood and milk total, CD16- and CD16+ monocyte (Mo)/macrophage (Mφ) subsets, respectively, and CCR2 and CX3CR1 expression and cytokine levels were analyzed by flow cytometry. CCL2 and CX3CL1 were quantified by ELISA and cytokines by flow cytometry in serum and milk. There was an increase of total and CD16+ Mφ, and, also a decrease of CD16- Mφ frequencies in maternal milk from Group I compared to Group H, but absolute numbers analyses showed higher numbers of all subpopulations of milk Mφ in Group I compared to Group H. Higher numbers of CX3CR1+CD16+ and double-staining of CCR2 and CX3CR1 in both CD16+ and CD16- cells were observed in milk during infant infection, which weren't observed in the blood. CCR2 expression was hardly found in milk CD16- Mφ in both groups. CCL2 and CX3CL1 were both higher in milk than in blood from both groups, but Group I showed higher levels of these chemokines in milk than Group H. Breast milk showed higher IL-6 and IL-8 concentrations than serum, and infant infection caused an increase in these cytokines only in milk. Our findings suggest that milk Mφ profiles are different from blood Mo, and the ongoing infection in the nursing infant could change milk Mφ to a more anti-inflammatory profile compared to that in the healthy group, possibly as an additional strategy of infant protection.

Update on the diagnosis and management of COVID-19 in pediatric patients

Coronavirus disease (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), became a pandemic in March 2020, affecting millions of people worldwide. However, COVID-19 in pediatric patients represents 1-5% of all cases, and the risk for developing severe disease and critical illness is much lower in children with COVID-19 than in adults. Multisystem inflammatory syndrome in children (MIS-C), a possible complication of COVID-19, has been described as a hyperinflammatory condition with multiorgan involvement similar to that in Kawasaki disease or toxic shock syndrome in children with evidence of SARS-CoV-2 infection. This review presents an update on the diagnostic methods for COVID-19, including reverse-transcriptase polymerase chain reaction (RT-PCR) tests, serology tests, and imaging, and summarizes the current recommendations for the management of the disease. Particular emphasis is placed on respiratory support, which includes noninvasive ventilation and invasive mechanical ventilation strategies according to lung compliance and pattern of lung injury. Pharmacological treatment, including pathogen-targeted drugs and host-directed therapies, has been addressed. The diagnostic criteria and management of MIS-C are also summarized.

Clinical and laboratory features of urinary tract infections in young infants / Aspectos clínicos e laboratoriais da infecção do trato urinário em lactentes jovens

ABSTRACT Introduction: Urinary tract infection (UTI) is the most common serious bacterial infection in young infants. Signs and symptoms are often nonspecific. Objectives: To describe clinical, demographic and laboratory features of UTI in infants ≤ 3 months old. Methods: Cross-sectional study of infants ≤ 3 months old with UTI diagnosed in a pediatric emergency department, for the period 2010-2012. UTI was defined as ≥ 50,000 colony-forming units per milliliter of a single uropathogen isolated from bladder catheterization. Paired urinalysis and urine culture from group culture-positive and group culture-negative were used to determine the sensitivity and specificity of pyuria and nitrite tests in detecting UTI. Results: Of 519 urine cultures collected, UTI was diagnosed in 65 cases (prevalence: 12.5%); with male predominance (77%). The most common etiologies were Escherichia coli (56.9%), Klebsiella pneumoniae (18.5%) and Enterococcus faecalis (7.7%). Frequent clinical manifestations were fever (77.8%), irritability (41.4%) and vomiting (25.4%). The median temperature was 38.7°C. The sensitivity of the nitrite test was 30.8% (95%CI:19.9-43.4%), specificity of 100% (95%CI:99.2-100%). Pyuria ≥ 10,000/mL had a sensitivity of 87.7% (95%CI:77.2-94.5%), specificity of 74.9% (95%CI:70.6 -78.8%). The median peripheral white blood cell count was 13,150/mm3; C-reactive protein levels were normal in 30.5% of cases. Conclusions: The male: female ratio for urinary tract infection was 3.3:1. Non-Escherichia coli etiologies should be considered in empirical treatment. Fever was the main symptom. Positive nitrite is highly suggestive of UTI but has low sensitivity; whereas pyuria ≥ 10,000/mL revealed good sensitivity, but low specificity. Peripheral white blood cell count and C-reactive protein concentration have limited usefulness to suggest UTI.

RESUMO Introdução: A infecção do trato urinário (ITU) é um quadro infeccioso grave mais frequente em lactentes jovens, cujos sinais e sintomas são frequentemente inespecíficos. Objetivos: Descrever aspectos clínicos, demográficos e laboratoriais de ITU em lactentes ≤ 3 meses. Métodos: Estudo transversal de ITU diagnosticada em lactentes ≤ 3 meses, em pronto-socorro geral de pediatria, entre 01/01/2010 a 31/12/2012. Diagnóstico de ITU definida como crescimento ≥ 50.000 unidades formadoras de colônia por mililitro de uropatógeno único, colhido por cateterismo vesical. Urina tipo I e urocultura foram pareadas dos grupos cultura-positiva e cultura-negativa para determinar a sensibilidade e especificidade de piúria e teste do nitrito para o diagnóstico de ITU. Resultados: Das 519 uroculturas colhidas, confirmou-se 65 casos de ITU (prevalência: 12,5%), com predomínio em meninos (77%). As etiologias mais frequentes foram Escherichia coli (56,9%), Klebsiella pneumoniae (18,5%) e Enterococcus faecalis (7,7%). Os sintomas mais frequentes foram febre (77,8%), irritabilidade (41,4%) e vômitos (25,4%). A temperatura mediana foi de 38,7°C. A sensibilidade do nitrito positivo foi de 30,8% (IC95%:19,9-43,4%), especificidade de 100% (IC95%:99,2-100%). Piúria ≥ 10.000/mL apresentou sensibilidade de 87,7% (IC95%:77,2-94,5%), especificidade de 74,9% (IC95%:70,6-78,8%). A contagem mediana de leucócitos foi 13.150/mm3. A proteína C reativa foi normal em 30,5% dos casos. Conclusões: A proporção entre meninos e meninas para ITU foi de 3,3:1. Outros agentes além de Escherichia coli devem ser considerados no tratamento empírico. A febre foi a principal queixa. O nitrito positivo é altamente sugestivo de ITU mas tem baixa sensibilidade; enquanto que a piúria ≥ 10.000/mL revelou boa sensibilidade, porém baixa especificidade. Leucograma e proteína C reativa demonstraram pouca utilidade clínica para sugerir ITU.

Utilização de escore e dosagem de lactato no líquor para diagnóstico diferencial entre meningite bacteriana e meningite asséptica / Use of score and cerebrospinal fluid lactate dosage in differential diagnosis of bacterial and aseptic meningitis

RESUMO Objetivo: Avaliar o Escore para Meningite Bacteriana (EMB) isolado e associado ao valor do lactato no líquor para diferenciar meningite bacteriana (MB) e meningite asséptica (MA). Métodos: Foram selecionadas crianças com meningite atendidas em hospital terciário privado entre janeiro de 2011 e dezembro de 2014. Os dados foram obtidos na admissão. Utilizou-se o EMB com: coloração de Gram no líquor (2 pontos); neutrófilos no líquor ≥1.000 células/mm3 (1 ponto); proteína no líquor ≥80 mg/dL (1 ponto); neutrófilos no sangue periférico ≥10.000 células/mm3 (1 ponto); e convulsão durante/antes da chegada (1 ponto). Analisou-se também o lactato no líquor (elevado: ≥30 mg/dL). Avaliaram-se sensibilidade, especificidade e valor preditivo negativo de diversos valores de corte do EMB e do EMB associado ao lactato elevado para prever MB. Resultados: Dos 439 pacientes elegíveis, 94 não tinham todos os dados necessários para o escore, sendo 345 pacientes selecionados: 7 no grupo de MB e 338 no de MA. Como preditivos de MB, o EMB ≥1 mostrou sensibilidade de 100% (intervalo de confiança de 95% - IC95% 47,3-100), especificidade de 64,2% (58,8-100) e valor preditivo negativo de 100% (97,5-100), enquanto o EMB ≥2 ou EMB ≥1 associado a lactato liquórico ≥30 mg/dL mostrou sensibilidade de 100% (47,3-100), especificidade de 98,5% (96,6-99,5) e valor preditivo negativo de 100% (98,3-100). Conclusões: O EMB com 2 pontos associado à dosagem de lactato no líquor manteve a sensibilidade e o valor preditivo negativo, ao passo que aumentou a especificidade para identificar meningites bacterianas em relação à utilização do EMB com 1 ponto.

ABSTRACT Objective: To evaluate Bacterial Meningitis Score (BMS) on its own and in association with Cerebrospinal Fluid (CSF) lactate dosage in order to distinguish bacterial from aseptic meningitis. Methods: Children diagnosed with meningitis at a tertiary hospital between January/2011 and December/2014 were selected. All data were obtained upon admission. BMS was applied and included: CSF Gram staining (2 points); CSF neutrophil count ≥1,000 cells/mm3 (1 point); CSF protein ≥80 mg/dL (1 point); peripheral blood neutrophil count ≥10,000 cells/mm3 (1 point) and seizures upon/before arrival (1 point). Cutoff value for CSF lactate was ≥30 mg/dL. Sensitivity, specificity and negative predictive value of several BMS cutoffs and BMS associated with high CSF lactate were evaluated for prediction of bacterial meningitis. Results: Among 439 eligible patients, 94 did not have all data available to complete the score, and 345 patients were included: 7 in bacterial meningitis group and 338 in aseptic meningitis group. As predictive factors of bacterial meningitis, BMS ≥1 had 100% sensitivity (95%CI 47.3-100), 64.2% specificity (58.8-100) and 100% negative predictive value (97.5-100); BMS ≥2 or BMS ≥1 associated with high CSF lactate also showed 100% sensitivity (47.3-100); but 98.5% specificity (96.6-99.5) and 100% negative predictive value (98.3-100). Conclusions: 2 point BMS in association with CSF lactate dosage had the same sensitivity and negative predictive value, with increased specificity for diagnosis of bacterial meningitis when compared with 1-point BMS.

Comparison of enterovirus detection in cerebrospinal fluid with Bacterial Meningitis Score in children / Comparação da pesquisa de enterovírus no liquor com Escore de Meningite Bacteriana em crianças

ABSTRACT Objective To measure the role of enterovirus detection in cerebrospinal fluid compared with the Bacterial Meningitis Score in children with meningitis. Methods A retrospective cohort based on analysis of medical records of pediatric patients diagnosed as meningitis, seen at a private and tertiary hospital in São Paulo, Brazil, between 2011 and 2014. Excluded were patients with critical illness, purpura, ventricular shunt or recent neurosurgery, immunosuppression, concomitant bacterial infection requiring parenteral antibiotic therapy, and those who received antibiotics 72 hours before lumbar puncture. Results The study included 503 patients. Sixty-four patients were excluded and 94 were not submitted to all tests for analysis. Of the remaining 345 patients, 7 were in the Bacterial Meningitis Group and 338 in the Aseptic Meningitis Group. There was no statistical difference between the groups. In the Bacterial Meningitis Score analysis, of the 338 patients with possible aseptic meningitis (negative cultures), 121 of them had one or more points in the Bacterial Meningitis Score, with sensitivity of 100%, specificity of 64.2%, and negative predictive value of 100%. Of the 121 patients with positive Bacterial Meningitis Score, 71% (86 patients) had a positive enterovirus detection in cerebrospinal fluid. Conclusion Enterovirus detection in cerebrospinal fluid was effective to differentiate bacterial from viral meningitis. When the test was analyzed together with the Bacterial Meningitis Score, specificity was higher when compared to Bacterial Meningitis Score alone.

RESUMO Objetivo Avaliar o papel da pesquisa de enterovírus no líquido cefalorraquidiano em comparação com o Escore de Meningite Bacteriana em crianças com meningite. Métodos Coorte retrospectiva, realizada pela análise de prontuários, incluindo pacientes pediátricos, com diagnóstico de meningite e atendidos em um hospital privado e terciário, localizado em São Paulo, entre 2011 e 2014. Foram excluídos os pacientes com doença crítica, púrpura, derivação ventricular ou neurocirurgia recente, imunossupressão, outra infecção bacteriana concomitante que necessitasse de antibioticoterapia parenteral e aqueles que receberam antibiótico 72 horas antes da punção lombar. Resultados Foram incluídos no estudo 503 pacientes. Destes, 64 foram excluídos e 94 não realizaram todos os exames para análise. Dos 345 pacientes restantes, 7 ficaram no Grupo de Meningite Bacteriana e 338 no Grupo de Meningite Asséptica. Não houve diferença estatística entre os grupos. Na análise do Escore de Meningite Bacteriana, dos 338 pacientes com possível meningite asséptica (culturas negativas), 121 deles tiveram um ou mais pontos para o Escore de Meningite Bacteriana, com valor de sensibilidade de 100%, especificidade de 64,2% e valor preditivo negativo de 100%. Dos 121 pacientes com Escore de Meningite Bacteriana positivo, 71% (86 pacientes) tiveram a pesquisa de enterovírus positiva no líquido cefalorraquidiano. Conclusão A pesquisa de enterovírus no líquido cefalorraquidiano mostrou-se eficaz em diferenciar a meningite bacteriana da viral. Analisada junto com o Escore de Meningite Bacteriana, a especificidade foi maior em comparação ao Escore de Meningite Bacteriana isolado.

Rapid antigen detection test for respiratory syncytial virus diagnosis as a diagnostic tool / Teste rápido de detecção de antígenos para o diagnóstico do Vírus Sincicial Respiratório como ferramenta de diagnóstico

Abstract Objective: The aim of this study was to evaluate the QuickVue® RSV Test Kit (QUIDEL Corp, CA, USA) as a screening tool for respiratory syncytial virus in children with acute respiratory disease in comparison with the indirect immunofluorescence assay as gold standard. In Brazil, rapid antigen detection tests for respiratory syncytial virus are not routinely utilized as a diagnostic tool, except for the diagnosis of dengue and influenza. Methods: The authors retrospectively analyzed 486 nasopharyngeal aspirate samples from children under age 5 with acute respiratory infection, between December 2013 and August 2014, the samples were analyzed by indirect immunofluorescence assay and QuickVue® RSV Test kit. Samples with discordant results were analyzed by real time PCR and nucleotide sequencing. Results: From 313 positive samples by immunofluorescence assays, 282 (90%) were also positive by the rapid antigen detection test, two were positive only by rapid antigen detection test, 33 were positive only by immunofluorescence assays, and 171 were positive by both methods. The 35 samples with discordant results were analyzed by real time PCR; the two samples positive only by rapid antigen detection test and the five positive only by immunofluorescence assays were also positive by real time PCR. There was no relation between the negativity by QuickVue® RSV Test and viral load or specific strain. The QuickVue® RSV Test showed sensitivity of 90%, specificity of 98.8%, predictive positive value of 99.3%, and negative predictive value of 94.6%, with accuracy of 93.2% and agreement κ index of 0.85 in comparison to immunofluorescence assay. Conclusions: This study demonstrated that the QuickVue® RSV Test Kit can be effective in early detection of Respiratory syncytial virus in nasopharyngeal aspirate and is reliable for use as a diagnostic tool in pediatrics.

Resumo Objetivo: Avaliar o teste QuickVue® RSV Test Kit (QUIDEL Corp, CA, EUA) para o diagnóstico rápido do vírus sincicial respiratório em crianças com doença respiratória aguda, comparandoo com a imunofluorescência indireta como padrão ouro. Visto que, no Brasil, testes rápidos para detecção de antígenos para vírus sincicial respiratório não são rotineiramente utilizados como ferramenta de diagnóstico, exceto para Dengue e Influenza. Métodos: Um total de 486 amostras de aspirado de nasofaringe de crianças menores de 5 anos com doença respiratória aguda, coletadas entre dezembro de 2013 e agosto de 2014, foram analisadas por imunofluorescência e pelo teste QuickVue®. Amostras com resultados discordantes entre os métodos foram submetidas a PCR em tempo real e sequenciamento. Resultados: Das 313 amostras positivas por IFI, 282 foram positivas no teste rápido (90%), 2 amostras foram positivas apenas no teste rápido (0.6%), 33 apenas na imunofluorescência (10.5%) e 171 foram negativas em ambos os métodos. As 35 amostras com resultados discordantes foram testadas por PCR em tempo real, sendo que duas que foram positivas apenas no teste rápido e 5 apenas na imunofluorescência confirmaram-se positivas. Não houve relação entre a ausência de positividade no teste QuickVue® com a carga ou com a cepa viral. O teste QuickVue® mostrou sensibilidade de 90.1%, especificidade 98.9%, valor preditivo positivo 99.3%, valor preditivo negativo de 94.6%, acurácia de 93.2% e índice de concordância de 0.85 em comparação à imunofluorescência. Conclusões: Nosso estudo demonstrou que o teste QuickVue® RSV pode ser efetivo na detecção precoce do vírus sincicial respiratório em amostras de aspirado de nasofaringe e é confiável como uma ferramenta de diagnósticos em pediatria.

The impact of rotavirus vaccination on emergency department visits and hospital admissions for acute diarrhea in children under 5 years / Impacto da vacinação contra rotavírus nas consultas de pronto-socorro e internações por doença diarreica aguda em crianças menores de 5 anos de idade

Summary Introduction: Acute diarrheal disease is the second cause of death in children under 5 years. In Brazil, from 2003 to 2009, acute diarrhea was responsible for nearly 100,000 hospital admissions per year and 4% of the deaths in children under 5 years. Rotavirus is the leading cause of severe acute diarrhea worldwide. In 2006, the rotavirus monovalent vaccine (RV1) was added to the Brazilian National Immunization Program. Objectives: To analyze the impact of the RV1 on emergency department (ED) visits and hospital admissions for acute diarrhea. Method: A retrospective ecologic study at the University Hospital, University of São Paulo. The study analyzed the pre-vaccine (2003–2005) and the post-vaccine (2007–2009) periods. We screened the main diagnosis of all ED attendances and hospital admissions of children under 5 years in an electronic registry system database and calculated the rates of ED visits and hospital admissions. The reduction rate was analyzed according to the following formula: reduction (%) = (1 - odds ratio) x 100. Results: The rates of ED visits for acute diarrhea was 85.8 and 80.9 per 1,000 total ED visits in the pre and post vaccination periods, respectively, resulting in 6% reduction (95CI 4 to 9%, p<0.001). The rates of hospital admissions for acute diarrhea was 40.8 per 1,000 in the pre-vaccine period and dropped to 24.9 per 1,000 hospitalizations, resulting in 40% reduction (95CI 22 to 54%, p<0.001). Conclusion: The introduction of the RV1 vaccine resulted in 6% reduction in the ED visits and 40% reduction in hospital admissions for acute diarrhea.

Resumo Introdução: a doença diarreica aguda é a segunda causa de morte em crianças abaixo de 5 anos de idade. No Brasil, entre 2003 e 2009, a diarreia aguda foi responsável por cerca de 100 mil internações por ano e por 4% das mortes em crianças abaixo de 5 anos de idade. O rotavírus é a principal etiologia de diarreia aguda grave. A vacina monovalente (RV1) contra o rotavírus foi introduzida em 2006. Objetivos: verificar o impacto da vacina monovalente contra rotavírus nas consultas de pronto-socorro e internações por doença diarreica aguda em crianças menores de 5 anos de idade. Método: foi realizado um estudo ecológico retrospectivo no Hospital Universitário da Universidade de São Paulo. O período foi dividido em pré-vacina (2003 a 2005) e pós-vacina (2007 a 2009). Foram incluídas todas as crianças abaixo de 5 anos que passaram em consulta no pronto-socorro. Foram obtidas as taxas de consultas no pronto-socorro e internações por doença diarreica aguda. A redução nas taxas foi obtida através da fórmula: redução (%) = (1 - odds ratio) x 100. Resultados: no período pré-vacina, a taxa de consultas por diarreia aguda foi de 85,8 consultas por 1.000 consultas gerais, enquanto no período pós-vacina a taxa de consultas por diarreia aguda foi 80,9 por 1.000, uma redução de 6% (IC95% 4-9, p<0,001). A taxa de internação por diarreia aguda era 40,8 internações por 1.000 e caiu para 24,9 por 1.000, redução de 40% (IC95% 22-54, p<0,001). Conclusão: após a introdução da vacina contra rotavírus houve uma redução de 6% nas consultas por diarreia aguda no pronto-socorro e de 40% nas internações por diarreia aguda.

The impact of varicella vaccination on varicella-related hospitalization rates: global data review / Impacto da vacina varicela nas taxas de internações relacionadas à varicela: revisão de dados mundiais

Abstract Objective: To describe the impact of varicella vaccination on varicella-related hospitalization rates in countries that implemented universal vaccination against the disease. Data source: We identified countries that implemented universal vaccination against varicella at the http://apps.who.int/immunization_monitoring/globalsummary/schedules site of the World Health Organization and selected articles in Pubmed describing the changes (pre/post-vaccination) in the varicella-related hospitalization rates in these countries, using the Keywords "varicella", "vaccination/vaccine" and "children" (or) "hospitalization". Publications in English published between January 1995 and May 2015 were included. Data synthesis: 24 countries with universal vaccination against varicella and 28 articles describing the impact of the vaccine on varicella-associated hospitalizations rates in seven countries were identified. The US had 81.4%–99.2% reduction in hospitalization rates in children younger than four years, 6–14 years after the onset of universal vaccination (1995), with vaccination coverage of 90%; Uruguay: 94% decrease (children aged 1–4 years) in six years, vaccination coverage of 90%; Canada: 93% decrease (age 1–4 years) in 10 years, coverage of 93%; Germany: 62.4% decrease (age 1–4 years) in 8 years, coverage of 78.2%; Australia: 76.8% decrease (age 1–4 years) in 5 years, coverage of 90%; Spain: 83.5% decrease (age <5 years) in four years, coverage of 77.2% and Italy 69.7%–73.8% decrease (general population), coverage of 60%–95%. Conclusions: The publications showed variations in the percentage of decrease in varicella-related hospitalization rates after universal vaccination in the assessed countries; the results probably depend on the time since the implementation of universal vaccination, differences in the studied age group, hospital admission criteria, vaccination coverage and strategy, which does not allow direct comparison between data.

Resumo Objetivo: Descrever o impacto da vacina varicela nas taxas de internações hospitalares associadas à varicela nos países que adotaram a vacinação universal contra a doença. Fontes de dados: Identificaram-se países que adotaram a vacinação universal contra varicela pelo site http://apps.who.int/immunization_monitoring/globalsummary/schedules da Organização Mundial de Saúde e selecionaram-se os artigos no Pubmed que descrevem a variação (pré/pós-vacinal) nas taxas de internações relacionadas à varicela desses países, com auxílio das palavras chaves: "varicella", "vaccination/vaccine" e "children" (ou) "hospitalization". Incluíram-se publicações em inglês entre janeiro de 1995 e maio de 2015. Síntese dos dados: Foram identificados 24 países com vacinação universal contra a varicela e 28 artigos que descrevem o impacto da vacina nas internações associadas à varicela em sete países. Os EUA tiveram 81,4%-99,2% de redução na taxa de internação em crianças menores de quatro anos, após 6-14 anos do início da vacinação universal (1995), com cobertura vacinal de 90%; Uruguai: 94% de queda (crianças de 1-4 anos) em 6 anos, cobertura vacinal de 90%; Canadá: 93% de redução (1-4 anos) em 10 anos, cobertura de 93%; Alemanha: 62,4% de redução (1-4 anos) em 8 anos, cobertura de 78,2%; Austrália: queda de 76,8% (1-4 anos) em 5 anos, cobertura de 90%; Espanha: 83,5% de queda (<5 anos) em 4 anos, cobertura de 77,2%; e Itália: queda entre 69,7%-73,8% (população geral), cobertura de 60%-95%. Conclusões: As publicações revelaram variação no percentual de queda na hospitalização por varicela após a vacinação universal nos países pesquisados; os resultados provavelmente dependem do tempo decorrido após introdução da vacinação universal, diferenças na faixa etária estudada, critérios de internação, cobertura vacinal e estratégia de vacina, não permitindo comparação direta entre os dados.

Dengue fever as a cause of hemophagocytic lymphohistiocytosis.

Dengue is endemic in more than 100 countries in Southeast Asia, the Americas, the western Pacific, Africa and the eastern Mediterranean regions. The virus is transmitted by Aedes mosquitoes. Dengue disease is the most prevalent arthropod-borne viral disease in humans and is a global and national public health concern in several countries. A seasonal pattern of dengue disease is consistently observed. The highest incidences usually correspond to the period of highest rainfall and humidity, providing suitable conditions for Aedes aegypti breeding and survival. In Brazil for instance it is from January to June. Dengue may cause marked changes in bone marrow that result in hypocellularity and, consequently, thrombocytopenia and leucopenia, along with an increase in hematocrit, which is secondary to capillary leakage. However, those abnormalities are usually self-limited, and do not warrant further investigations, such as a marrow biopsy or a myelogram. The occurrence of persistent reactive hemophagocytosis is uncommon and usually leads to serious adverse outcomes. The authors report the case of an 8-year old girl complaining of high-grade fever, malaise, headache, abdominal pain and a cutaneous rash. Laboratory examination revealed atypical lymphocytosis on peripheral blood count, hyperbilirrunemia, abnormal liver enzymes and clotting tests. Serology was positive for dengue. Because of the persistence of fever and laboratory examinations were consistent with hemophagocytic lymphohistiocytosis (HLH) a bone marrow aspiration was performed, which confirmed the presence of hemophagocytosis. Hence we report a rare presentation of dengue accompanied by self-limited HLH that hopefully evolve to favorable outcome.

Estado nutricional, autopercepção do estado nutricional e experimentação de drogas lícitas em adolescentes / Nutritional status, nutritional self-perception, and use of licit drugs in adolescents

Objetivo:Associar o estado nutricional e a autopercepção do estado nutricional com a experimentação de drogas lícitas em adolescentes.Métodos:Estudo transversal no qual 210 adolescentes responderam a um questionário sobre experimentação de álcool e tabaco e sobre suas autopercepções nutricionais. Foi analisada a concordância entre autopercepção nutricional do adolescente e seu estado nutricional, bem como associações entre o estado nutricional, a autopercepção nutricional, sexo, idade e presença de tabagistas em casa com a experimentação de álcool e tabaco. As variáveis foram analisadas separadamente em análise bivariada e, a seguir, análise múltipla determinou fatores associados à experimentação.Resultados:Participaram do estudo 210 adolescentes com mediana de idade de 148 meses, 56,6% do sexo feminino. Do total da amostra, 6,6% já experimentaram cigarro e 20% já experimentaram álcool; 32,3% tinham Z-escore IMC≥1 e 12,85% tinham Z-escore IMC≥2 e 50,7% acertaram suas classificações nutricionais. Após análise multivariada, apenas a autoimagem sobre o peso influenciou estatisticamente na experimentação de fumo. Pacientes que se identificavam com peso muito alto apresentaram maior chance de experimentação de fumo (odds ratio (OR) 13,57; intervalo de confiança (95% IC) 2,05-89,8; p=0,007); em relação ao uso de álcool, adolescentes que se identificavam com peso alto apresentaram chance de uso de álcool 2,40 vezes maior do que crianças que se viam com peso normal (IC 95% 1,08-5,32; p=0,031).Conclusões:Adolescentes com autopercepção de excesso de peso podem constituir um grupo de risco para a experimentação de álcool e tabaco.

Objective:To associate the nutritional status and the self-perception of nutritional status with the use of licit drugs among adolescents.Methods:A cross-sectional study was conducted in which 210 adolescents answered a questionnaire on alcohol and tobacco experimentation and self-perceptions about their nutritional status. The correspondence between the adolescents' perception of their own nutritional status and actual nutritional status was analyzed, as well as associations between nutritional status, self-perception of nutritional status, gender, age, and presence of smokers at home with alcohol and tobacco use. The variables were analyzed separately in a bivariate analysis and, subsequently, a multivariate analysis determined the factors associated with drug use.Results:The study included 210 adolescents with a median age of 148 months; 56.6% were females. Of the total sample, 6.6% have tried cigarettes, and 20% have tried alcohol; 32.3% had BMI Z-Score ≥1, 12.85% had BMI Z-Score ≥2, and 50.7% had a correct perception of his/her weight. After a multivariate analysis, only the self-perception about weight statistically influenced experimentation of tobacco, and patients who identified themselves as having very high weight were more likely to experiment tobacco (odds ratio (OR) 13.57; confidence interval (95% CI) 2.05-89.8; p=0.007); regarding alcohol use, adolescents who identified themselves as having high weight were 2.4 times more likely to experiment with alcohol than adolescents that identified themselves as having normal weight (95% CI 1.08-5.32, p=0.031).Conclusions:Adolescents with self-perception of excess weight may constitute a risk group for alcohol and tobacco use.

[Nutritional status, nutritional self-perception, and use of licit drugs in adolescents]. / Estado nutricional, autopercepção do estado nutricional e experimentação de drogas lícitas em adolescentes.

OBJECTIVE: To associate the nutritional status and the self-perception of nutritional status with the use of licit drugs among adolescents. METHODS: Cross-sectional study in which 210 adolescents answered a questionnaire on alcohol and tobacco experimentation and self-perceptions about their nutritional status. The correspondence between the adolescents' perception of their own nutritional status and actual nutritional status was analyzed, as well as associations between nutritional status, self-perception of nutritional status, gender, age, and presence of smokers at home with alcohol and tobacco use. The variables were analyzed separately in a bivariate analysis and, subsequently, a multivariate analysis determined the factors associated with drug use. RESULTS: The study included 210 adolescents with a median age of 148 months; 56.6% were females. Of the total sample, 6.6% have tried cigarettes, and 20% have tried alcohol; 32.3% had BMI Z-Score≥1, 12.85% had BMI Z-Score≥2, and 50.7% had a correct perception of his/her weight. After a multivariate analysis, only the self-perception about weight statistically influenced experimentation of tobacco, and patients who identified themselves as having very high weight were more likely to experiment tobacco (odds ratio (OR) 13.57; confidence interval (95% CI) 2.05-89.8; p=0.007); regarding alcohol use, adolescents who identified themselves as having high weight were 2.4 times more likely to experiment with alcohol than adolescents that identified themselves as having normal weight (95% CI 1.08-5.32, p=0.031). CONCLUSIONS: Adolescents with self-perception of excess weight may constitute a risk group for alcohol and tobacco use.

Genetic variability in G2 and F2 region between biological clones of human respiratory syncytial virus with or without host immune selection pressure

Human respiratory syncytial virus (HRSV) is an important respiratory pathogens among children between zero-five years old. Host immunity and viral genetic variability are important factors that can make vaccine production difficult. In this work, differences between biological clones of HRSV were detected in clinical samples in the absence and presence of serum collected from children in the convalescent phase of the illness and from their biological mothers. Viral clones were selected by plaque assay in the absence and presence of serum and nucleotide sequences of the G2 and F2 genes of HRSV biological clones were compared. One non-synonymous mutation was found in the F gene (Ile5Asn) in one clone of an HRSV-B sample and one non-synonymous mutation was found in the G gene (Ser291Pro) in four clones of the same HRSV-B sample. Only one of these clones was obtained after treatment with the child's serum. In addition, some synonymous mutations were determined in two clones of the HRSV-A samples. In conclusion, it is possible that minor sequences could be selected by host antibodies contributing to the HRSV evolutionary process, hampering the development of an effective vaccine, since we verify the same codon alteration in absence and presence of human sera in individual clones of BR-85 sample.

Infecção urinária comunitária: etiologia segundo idade e sexo / Community-acquired urinary tract infection: age and gender-dependent etiology

INTRODUÇÃO: A escolha do antimicrobiano para tratamento inicial de infecção de trato urinário (ITU) costuma ser empírica e deve considerar a prevalência dos uropatógenos nas diversas faixas etárias e sexo. OBJETIVO: Avaliar a prevalência de uropatógenos em ITU comunitária e sua relação com idade e sexo. MÉTODOS: Estudo transversal conduzido em pronto socorro (PS) de hospital geral, de janeiro a dezembro, 2010, em pacientes menores de 15 anos com suspeita clínica de ITU, que colheram urocultura quantitativa. Definida ITU como urocultura com crescimento de agente único > 100.000 unidades formadoras de colônia (ufc)/mL na coleta por jato médio ou > 50.000 ufc/mL na coleta por sondagem vesical. RESULTADOS: Ocorreram 63.464 atendimentos no PS. Foram obtidas 2.577 uroculturas; destas, 291 foram positivas para ITU (prevalência = 11,3% das suspeitas clínicas e 0,46% dos atendimentos); 212 casos (72,8%) em meninas, mediana de idade = 2,6 anos. O uropatógeno predominante foi E.coli (76,6%), seguido por Proteus mirabilis (10,3%) e Staphylococcus saprophyticus (4,1%). Em lactentes < 3 meses, a prevalência de E.coli foi significativamente menor (50% x 78,4%; OR = 0,276; p = 0,006). Maior prevalência de Staphylococcus saprophyticus ocorreu em pacientes > 10 anos (24,4% x 0,4%; OR = 79,265; p < 0,0001). Proteus mirabilis foi significativamente mais prevalente em meninos (24,0% x 5,2%; OR = 5,786; p < 0,001). CONCLUSÕES: E. coli foi o uropatógeno mais prevalente das ITU comunitárias. Entretanto, na escolha do antimicrobiano empírico inicial, deve-se levar em consideração a prevalência significativa de outros agentes diferentes de E. coli em lactentes < 3 meses, a alta prevalência de Staphylococcus saprophyticus em pacientes > 10 anos e de Proteus mirabilis em meninos.

INTRODUCTION: Choosing the antimicrobial agent for initial therapy of urinary tract infection (UTI) is usually empirical and should consider the prevalence of uropathogens in different age groups and gender. OBJECTIVE: To establish prevalence rates of uropathogens in community-acquired UTI in relation to age and gender. METHODS: Crosssectional study conducted in the emergency department (ED) of a general hospital, from January to December, 2010, in patients younger than 15 years old who had clinical suspicion of UTI and collected quantitative urine culture. UTI was defined as urine culture with growth of a single agent > 100.000 colony forming units (cfu)/mL in a midstream collection or > 50.000 cfu/mL in urethral catheterization. RESULTS: There were 63.464 visits to ED. 2577 urine cultures were obtained, of whom 291 were positive for UTI (prevalence = 11.3% of clinical suspicion and 0.46% of visits), 212 cases (72.8%) in females, median age = 2.6 years. The predominant uropathogen was E. coli (76.6%), followed by Proteus mirabilis (10.3%) and Staphylococcus saprophyticus (4.1%). Among infants < 3 months, prevalence rates of E. coli were significantly lower (50% vs 78.4%; OR = 0.276; p = 0.006). Higher prevalences of Staphylococcus saprophyticus occurred among patients > 10 years (24.4% vs 0.4%; OR = 79.265; p < 0.0001). Proteus mirabilis was significantly more prevalent in boys than girls (24.0% vs 5.2%; OR = 5.786; p < 0.001). CONCLUSIONS: E. coli was the most prevalent community-acquired uropathogen. Nevertheless, initial empiric antimicrobial treatment of UTI should consider the significant prevalence of other agents different from E. coli in infants < 3 months, the high prevalence of Staphylococcus saprophyticus in patients > 10 years and Proteus mirabilis in males.

Impacto do uso da prova rápida para estreptococo beta-hemolítico do grupo A no diagnóstico e tratamento da faringotonsilite aguda em pronto-socorro de Pediatria / Impact of the rapid antigen detection test in diagnosis and treatment of acute pharyngotonsillitis in a Pediatric emergency room / Impacto del uso de la prueba rápida para estreptococos beta-hemolíticos del grupo A en el diagnóstico y tratamiento de la faringotonsilitis en emergencia de Pediatría

OBJETIVO: Avaliar o impacto da realização rotineira da prova rápida para pesquisa de estreptococo do grupo A no diagnóstico e tratamento da faringotonsilite aguda em crianças. MÉTODOS: Estudo prospectivo e observacional que contou com a utilização de protocolo de pesquisa estabelecido na Unidade de Emergência do Hospital Universitário da Universidade de São Paulo para o atendimento de crianças e adolescentes com faringotonsilite aguda. RESULTADOS: Com base na avaliação clínica, dos 650 pacientes estudados, antimicrobianos seriam prescritos para 389 indivíduos (59,8%) e, com o uso da pesquisa de estreptococo do grupo A, foram prescritos em 286 pacientes (44,0%). Das 261 crianças que não receberiam antibiótico pelo quadro clínico, 111 (42,5%) tiveram pesquisa de estreptococo do grupo A positiva. O diagnóstico baseado no quadro clínico apresentou sensibilidade de 61,1%, especificidade de 47,7%, valor preditivo positivo de 44,9% e valor preditivo negativo de 57,5%. CONCLUSÕES: O diagnóstico clínico da faringotonsilite estreptocócica mostrou baixa sensibilidade e especificidade. O uso rotineiro da prova rápida para pesquisa de estreptococo permitiu a redução do uso de antibióticos e a identificação de um grupo de risco para as complicações da infecção estreptocócica, pois 42,5% dos pacientes com prova rápida positiva não receberiam antibióticos, se levado em consideração apenas o diagnóstico clínico.

OBJECTIVE: To evaluate the impact of the routine use of rapid antigen detection test in the diagnosis and treatment of acute pharyngotonsillitis in children. METHODS: This is a prospective and observational study, with a protocol compliance design established at the Emergency Unit of the University Hospital of Universidade de São Paulo for the care of children and adolescents diagnosed with acute pharyngitis. RESULTS: 650 children and adolescents were enrolled. Based on clinical findings, antibiotics would be prescribed for 389 patients (59.8%); using the rapid antigen detection test, they were prescribed for 286 patients (44.0%). Among the 261 children who would not have received antibiotics based on the clinical evaluation, 111 (42.5%) had positive rapid antigen detection test. The diagnosis based only on clinical evaluation showed 61.1% sensitivity, 47.7% specificity, 44.9% positive predictive value, and 57.5% negative predictive value. CONCLUSIONS: The clinical diagnosis of streptococcal pharyngotonsillitis had low sensitivity and specificity. The routine use of rapid antigen detection test led to the reduction of antibiotic use and the identification of a risk group for complications of streptococcal infection, since 42.5% positive rapid antigen detection test patients would not have received antibiotics based only on clinical diagnosis.

OBJETIVO: Evaluar el impacto de la realización de rutina de la prueba rápida para investigación de estreptococos del grupo A en el diagnóstico y tratamiento de la faringotonsilitis aguda en niños. MÉTODOS: Estudio prospectivo y observacional que contó con el uso de protocolo de investigación establecido en la Unidad de Emergencia del Hospital Universitario de la USP para la atención a niños y adolescentes con faringotonsilitis aguda. RESULTADOS: Con base en la evaluación crítica, de los 650 pacientes estudiados, antimicrobianos serían prescritos a 389 individuos (59,8%) y, con el uso de la investigación de estreptococos del grupo A se los prescribieron a 286 pacientes (44,0%). De los 261 niños que no recibirían antibióticos por el cuadro clínico, 111 (42,5%) tuvieron investigación de estreptococos del grupo A positiva. El diagnóstico basado en el cuadro clínico presentó sensibilidad del 61,1%, especificidad del 47,7%, valor predictivo positivo del 44,9% y valor predictivo negativo del 57,5%, CONCLUSIONES: En este estudio, el diagnóstico clínico de la faringotonsilitis estreptocócica mostró baja sensibilidad y especificidad. El uso de rutina de la prueba rápida para investigación de estreptococos permitió la reducción del uso de antibióticos y la identificación de un grupo de riesgo para las complicaciones de la infección estreptocócica, pues el 42,5% de los pacientes con prueba rápida positiva no recibirían antibióticos si se llevara en consideración solamente el diagnóstico clínico.

Etiological diagnosis reduces the use of antibiotics in infants with bronchiolitis

OBJECTIVE: Acute bronchiolitis is a leading cause of infant hospitalization and is most commonly caused by respiratory syncytial virus. Etiological tests are not required for its diagnosis, but the influence of viral screening on the therapeutic approach for acute bronchiolitis remains unclear. METHODS: A historical cohort was performed to assess the impact of viral screening on drug prescriptions. The study included infants up to one year of age who were hospitalized for bronchiolitis. Virus screening was performed using immunofluorescence assays in nasopharyngeal aspirates. The clinical data were obtained from the patients' medical records. Therapeutic changes were considered to be associated with viral screening when made within 24 hours of the release of the results. RESULTS: The frequency of prescriptions for beta agonists, corticosteroids and antibiotics was high at the time of admission and was similar among the 230 patients. The diagnosis of pneumonia and otitis was associated with the introduction of antibiotics but did not influence antibiotics maintenance after the results of the virus screening were obtained. Changes in the prescriptions were more frequent for the respiratory syncytial virus patients compared to patients who had negative viral screening results (p =0.004), especially the discontinuation of antibiotics (p<0.001). The identification of respiratory syncytial virus was associated with the suspension of antibiotics (p= 0.003), even after adjusting for confounding variables (p = 0.004); however, it did not influence the suspension of beta-agonists or corticosteroids. CONCLUSION: The identification of respiratory syncytial virus in infants with bronchiolitis was independently associated with the discontinuation of antibiotics during hospitalization.

Molecular epidemiology of the SH (small hydrophobic) gene of human respiratory syncytial virus (HRSV), over 2 consecutive years.

Human respiratory syncytial virus (HRSV) strains were isolated from nasopharyngeal aspirates collected from 965 children between 2004 and 2005, yielding 424 positive samples. We sequenced the small hydrophobic protein (SH) gene of 117 strains and compared them with other viruses identified worldwide. Phylogenetic analysis showed a low genetic variability among the isolates but allowed us to classify the viruses into different genotypes for both groups, HRSVA and HRSVB. It is also shown that the novel BA-like genotype was well segregated from the others, indicating that the mutations are not limited to the G gene.

Gravidade das coinfecções virais em lactentes hospitalizados com infecção por vírus sincicial respiratório / Severity of viral coinfection in hospitalized infants with respiratory syncytial virus infection

OBJETIVO: Comparar a gravidade de infecções causadas por um único vírus (VSR) com a gravidade de coinfecções. MÉTODOS: Este estudo avaliou uma coorte histórica de lactentes com infecção aguda por VSR. Secreção de nasofaringe foi coletada de todos os pacientes rotineiramente para pesquisa viral usando técnicas de biologia molecular. Os seguintes desfechos foram analisados: tempo total de internação, duração da oxigenioterapia, admissão em unidade de terapia intensiva e uso de ventilação mecânica. Os resultados foram ajustados para os fatores confundidores (prematuridade, idade e aleitamento materno). RESULTADOS: Foram incluídos no estudo 176 lactentes com idade média de 4,5 meses e diagnósticos de bronquiolite e/ou pneumonia. Cento e vinte e um tinham infecção única por VSR, e 55 tinham coinfecções (24 VSR + adenovírus, 16 VSR + metapneumovírus humano e 15 outras associações menos frequentes). Os quatro desfechos de gravidade avaliados foram semelhantes entre o grupo com infecção única por VSR e os grupos com coinfecções, independente do tipo de vírus associado com o VSR. CONCLUSÃO: As coinfecções virais não parecem alterar o prognóstico de lactentes hospitalizados com infecção aguda por VSR.

OBJECTIVE: To compare the severity of single respiratory syncytial virus (RSV) infections with that of coinfections. METHODS: A historical cohort was studied, including hospitalized infants with acute RSV infection. Nasopharyngeal aspirate samples were collected from all patients to detect eight respiratory viruses using molecular biology techniques. The following outcomes were analyzed: duration of hospitalization and of oxygen therapy, intensive care unit admission and need of mechanical ventilation. Results were adjusted for confounding factors (prematurity, age and breastfeeding). RESULTS: A hundred and seventy six infants with bronchiolitis and/or pneumonia were included in the study. Their median age was 4.5 months. A hundred and twenty one had single RSV infection and 55 had coinfections (24 RSV + adenovirus, 16 RSV + human metapneumovirus and 15 other less frequent viral associations). The four severity outcomes under study were similar in the group with single RSV infection and in the coinfection groups, independently of what virus was associated with RSV. CONCLUSION: Virus coinfections do not seem to affect the prognosis of hospitalized infants with acute RSV infection.

Severity of viral coinfection in hospitalized infants with respiratory syncytial virus infection.

OBJECTIVE: To compare the severity of single respiratory syncytial virus (RSV) infections with that of coinfections. METHODS: A historical cohort was studied, including hospitalized infants with acute RSV infection. Nasopharyngeal aspirate samples were collected from all patients to detect eight respiratory viruses using molecular biology techniques. The following outcomes were analyzed: duration of hospitalization and of oxygen therapy, intensive care unit admission and need of mechanical ventilation. Results were adjusted for confounding factors (prematurity, age and breastfeeding). RESULTS: A hundred and seventy six infants with bronchiolitis and/or pneumonia were included in the study. Their median age was 4.5 months. A hundred and twenty one had single RSV infection and 55 had coinfections (24 RSV + adenovirus, 16 RSV + human metapneumovirus and 15 other less frequent viral associations). The four severity outcomes under study were similar in the group with single RSV infection and in the coinfection groups, independently of what virus was associated with RSV. CONCLUSION: Virus coinfections do not seem to affect the prognosis of hospitalized infants with acute RSV infection.

Infecção urinária em menores de 15 anos: etiologia e perfil de sensibilidade antimicrobiana em hospital geral de pediatria / Urinary tract infection in children under 15 years: etiology and antimicrobial susceptibility in a children's hospital

OBJETIVO: Descrever a prevalência dos principais agentes etiológicos de infecção urinária comunitária em crianças menores de 15 anos e analisar o perfil de sensibilidade antimicrobiana do principal agente, Escherichia coli. MÉTODOS: Estudo retrospectivo conduzido a partir de uroculturas com crescimento de agente único, com unidades formadoras de colônia maior ou igual a 10(5)/mL. A população selecionada foi atendida no Pronto Atendimento de Pediatria do Hospital Universitário da Universidade de São Paulo entre janeiro de 2006 e dezembro de 2007. Para analisar o perfil de sensibilidade de E. coli, foram excluídos casos com infecção urinária de repetição e/ou portadores de uropatias. RESULTADOS: Dos 176 casos de infecção urinária, 133 (76 por cento) ocorreram no sexo feminino e 43 (24 por cento) no masculino. A faixa etária de maior prevalência das infecções urinárias foi a de menores de dois anos, com 84 casos (48 por cento). Escherichia coli foi o principal agente isolado (122 culturas - 69 por cento do total). Foram encontrados altos índices de sensibilidade antimicrobiana de E. coli às cefalosporinas de segunda e terceira geração (cefuroxima e ceftriaxona, 100 por cento), aos aminoglicosídeos (amicacina, 100 por cento; gentamicina, 96,4 por cento), ao ácido nalidíxico (97,3 por cento), à nitrofurantoina (98,2 por cento) e às quinolonas (ciprofloxacina e norfloxacina, 98,2 por cento); sensibilidade moderada à cefalosporina de primeira geração (cefalotina, 78,4 por cento); baixa sensibilidade à ampicilina (38,7 por cento) e ao sufametoxazol-trimetoprim (55 por cento). CONCLUSÕES: E. coli continua sendo a bactéria mais prevalente das infecções urinárias comunitárias. Conhecendo a baixa sensibilidade in vitro dessa bactéria à sulfametoxazol-trimetoprim e à ampicilina, recomenda-se que tais drogas não sejam eleitas para a terapêutica inicial.

OBJECTIVE: To describe the prevalence of the most frequent etiological agents of community acquired urinary tract infection in children under the age of 15 years, as well as to analyse the antimicrobial susceptibility patterns of the most prevalent pathogen, Escherichia coli. METHODS: Retrospective study conducted from urine cultures of a single bacterial species, at a concentration > 10(5) colonies forming units/mL. The children included in the study were treated in the Pediatric Emergency Care Unit of the University Hospital of the University of Sao Paulo from January, 2006 to December, 2007. In order to analyze Escherichia coli antimicrobial susceptibility patterns, cases with recurrent urinary tract infection and/or carriers of uropathy were excluded. RESULTS: Among 176 urinary tract infection patients, 133 (76 percent) were females. Children less than two years old presented the highest prevalence of urinary tract infection (84 cases; 48 percent). E. coli was the main agent (122 cultures - 69 percent of the total). There were high rates of E. coli antimicrobial susceptibility to second and third-generation cephalosporins (cefuroxime and ceftriaxone, 100 percent), aminoglycosides (amikacin, 100 percent, gentamicin, 96.4 percent), nalidixic acid (97.3 percent), nitrofurantoin (98.2 percent) and quinolones (ciprofloxacin and norfloxacin, 98.2 percent); moderate susceptibility to first-generation cephalosporin (cephalothin, 78.4 percent); low susceptibility to ampicillin (38.7 percent) and sufamethoxazole-trimethoprim (55 percent). CONCLUSIONS: E. coli remains the most prevalent bacterial pathogen of community acquired urinary tract infection. Given the low in vitro susceptibility of these bacteria to sulfamethoxazole-trimethoprim and ampicillin, these drugs should not be elected as the initial choice for treatment.