[Clostridium difficile associated diarrhea in children]. / Diarrea asociada a Clostridium difficile en niños.

INTRODUCTION: Clostridium difficile is the most commonly isolated organism in antimicrobial and health care-associated diarrhea and is growing in relevance in community-acquired infections. It is a Gram-positive bacillus acquired via the fecal-oral route in the community and in hospital setting. EPIDEMIOLOGY: 0.6 to 2.1% worldwide incidence, mortality ~ 1-5%. COLONIZATION: High rates of asymptomatic colonization in healthy people, 37% in children: its presence in stools is of controversial significance. Risk factors in children are prior exposure to antibiotics, recent hospitalization, immunosuppression or inflammatory bowel disease. CLINICAL MANIFESTATIONS: Secondary to intestinal involvement due to toxin production, ranging from asymptomatic colonization to fulminant disease. DIAGNOSIS: Clinical diagnostic criteria plus high sensitivity and specificity laboratory certification. Recommendations AAP (American Academy of Pediatrics): under 1 year, avoid routine study, only in Hirschsprung disease and/or nosocomial outbreak, 1-3 year, a (+) result suggests C. difficile associated diarrhea (CDAD) is possible, and in children older than 3 years interpretation is equal to adults. MANAGEMENT: Antimicrobial suspension, oral metronidazole as first line in mild to moderate CDAD, and oral or enema vancomycin or associated with intravenous metronidazole only in severe cases. Duration 10 days. PREVENTION: Antimicrobial control programs and environmental management. CONCLUSION: Given the increasing complexity of pediatric patients it is important to deepen the knowledge on this microorganism and its clinical manifestations, as its incidence, morbidity and mortality are increasing.

Diarrea asociada a Clostridium difficile en niños / Clostridium difficile associated diarrhea in children

Introduction: Clostridium difficile is the most commonly isolated organism in antimicrobial and health care-associated diarrhea and is growing in relevance in community-acquired infections. It is a Gram-positive bacillus acquired via the fecal-oral route in the community and in hospital setting. Epidemiology: 0.6 to 2.1% worldwide incidence, mortality ~ 1-5%. Colonization: High rates of asymptomatic colonization in healthy people, 37% in children: its presence in stools is of controversial significance. Risk factors in children are prior exposure to antibiotics, recent hospitalization, immunosuppression or inflammatory bowel disease. Clinical manifestations: secondary to intestinal involvement due to toxin production, ranging from asymptomatic colonization to fulminant disease. Diagnosis: Clinical diagnostic criteria plus high sensitivity and specificity laboratory certification. Recommendations AAP (American Academy of Pediatrics): under 1 year, avoid routine study, only in Hirschsprung disease and/or nosocomial outbreak, 1-3 year, a (+) result suggests C. difficile associated diarrhea (CDAD) is possible, and in children older than 3 years interpretation is equal to adults. Management: antimicrobial suspension, oral metronidazole as first line in mild to moderate CDAD, and oral or enema vancomycin or associated with intravenous metronidazole only in severe cases. Duration 10 days. Prevention: Antimicrobial control programs and environmental management. Conclusion: Given the increasing complexity of pediatric patients it is important to deepen the knowledge on this microorganism and its clinical manifestations, as its incidence, morbidity and mortality are increasing.

Introducción: Clostridium difficile, microorganismo más común en diarrea asociada a antimicrobianos, a atención de salud y en aumento en la comunidad es un bacilo grampositivo adquirido vía fecal oral en la comunidad y en el ambiente hospitalario. Epidemiología: Incidencia mundial 0,6-2,1%, mortalidad~1-5%. Colonización: Alta colonización asintomática en personas sanas, niños 37%, su presencia en las deposiciones es controversial. Factores de riesgo en niños: exposición previa a antimicrobianos, hospitalización reciente, inmunosupresión o enfermedad inflamatoria intestinal. Clínica: Compromiso intestinal secundario a la producción de toxinas. Puede variar desde una colonización asintomática hasta enfermedad fulminante. Diagnóstico: La certificación diagnóstica requiere de un criterio clínico más laboratorio rápido, con elevada sensibilidad y especificidad. Recomendaciones de American Academy of Pediatrics son en lactantes bajo un año, evitar estudio rutinario, sólo enfermedad de Hirschprung y/o brote nosocomial, entre 1-3 años; un resultado (+) indica DACD posible y en mayores de 3 años los criterios son igual a adultos. Manejo: Suspensión de antimicrobianos, metronidazol ev como primera línea en niños con DACD leve a moderada y vancomicina oral, enema o asociada a metronidazol intravenoso sólo en casos graves. Duración 10 días. Prevención: Control de antimicrobianos y manejo ambiental. Conclusión: Dada la creciente complejidad de pacientes pediátricos, es importante profundizar sobre este microorganismo y el desarrollo de enfermedad, ya que su incidencia y morbi-mortalidad van en aumento.

Penicillin resistance is not extrapolable to amoxicillin resistance in Streptococcus pneumoniae isolated from middle ear fluid in children with acute otitis media.

OBJECTIVES: We evaluated the in vitro antibacterial activity of amoxicillin against penicillin-susceptible and -nonsusceptible Streptococcus pneumoniae strains isolated from children with acute otitis media (AOM). METHODS: Children more than 3 months of age with AOM who were seen in the Dr Sótero del Rio and Luis Calvo Mackenna Hospitals in Santiago, Chile, between July 1998 and December 2002 were subjected to tympanic puncture for middle ear fluid culture. The penicillin and amoxicillin susceptibilities of the S pneumoniae isolates were determined by epsilometer test (E test). RESULTS: A bacterial pathogen was isolated in 432 of 543 children (80%) as follows: S pneumoniae, 40%; Haemophilus influenzae, 29%; Moraxella catarrhalis, 7%; and Streptococcus pyogenes, 4%. Penicillin-susceptible S pneumoniae strains were less common than amoxicillin-susceptible strains (60% versus 95%; odds ratio [OR], 0.08; 95% confidence interval [CI], 0.04 to 0.18). Both intermediate- and high-resistance strains were more common for penicillin (22% versus 4.5%; OR, 5.6; 95% CI, 2.5 to 12.7) than for amoxicillin (18% versus 0.5%; OR, 41.3; 95% CI, 6.0 to 821). CONCLUSIONS: Penicillin resistance is not extrapolable to amoxicillin among S pneumoniae strains isolated from middle ear fluid of children with AOM. Our results support the recommendation to evaluate the minimal inhibitory concentrations of penicillin-nonsusceptible S pneumoniae for amoxicillin and to continue use of this antimicrobial as a first-line antimicrobial choice for children with AOM.