Emergence of acute/subacute infant-juvenile paracoccidioidomycosis in Northeast Argentina: Effect of climatic and anthropogenic changes?

Argentina has two endemic areas of paracoccidioidomycosis (PCM). Bordering Paraguay and Brazil, Northeast Argentina (NEA) comprises the area with the highest incidence where the chronic adult clinical form has historically been reported. Juvenile form in children and adolescents is rare in this area since only one case was reported in the last 10 years. Despite this, between 2010 and 2012, several cases of acute/subacute clinical forms in children aged 10 to 16 (median 12) were detected. In the last decade, the NEA region has been exposed to ecological variations as consequences of certain climatic and anthropogenic changes, including El Niño-Southern Oscillation phenomenon during 2009, and deforestation. The region has also suffered from the significant ecological effects of the construction of one of the biggest hydroelectric dams of South America. This study aims to describe clinical and epidemiological aspects of acute/subacute PCM cases detected in children from NEA and to discuss climatic and anthropogenic changes as possible contributing factors in the emergence of this disease in children. This acute/subacute PCM cluster was characterized by severe disseminated and aggressive presentations to localized form, with a high spectrum of clinical manifestations uncommonly observed. Due to the lack of experience in acute/subacute PCM in children in the studied area and the atypical clinical manifestations observed, the diagnosis was delayed. In order to avoid misdiagnosis, a higher level of suspicion is now required in NEA and countries bordering the southern part of the endemic area, which are affected by the changes discussed in this article.

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

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

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

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

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

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

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

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

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

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

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