Early impact of 13-valent pneumococcal conjugate vaccine on community-acquired pneumonia in children.

BACKGROUND: Pneumococcal serotypes 1, 3, 5, 7F, and 19A were the most implicated in community-acquired pneumonia (CAP) after implementation of 7-valent pneumococcal conjugate vaccine (PCV7). In France, the switch from PCV7 to 13-valent pneumococcal conjugate vaccine (PCV13) occurred in June 2010. An active surveillance network was set up to analyze the impact of PCV13 on CAP. METHODS: An observational prospective study performed in 8 pediatric emergency departments from June 2009 to May 2012 included all children between 1 month and 15 years of age with chest radiography-confirmed pneumonia. Three 1-year periods were defined: pre-PCV13, transitional, and post-PCV13. RESULTS: During the 3-year study period, among the 953 274 pediatric emergency visits, 5645 children with CAP were included. CAP with pleural effusion and documented pneumococcal CAP were diagnosed in 365 and 136 patients, respectively. Despite an increase (4.5%) in number of pediatric emergency visits, cases of CAP decreased by 16% (2060 to 1725) between pre- and post-PCV13 periods. The decrease reached 32% in infants in the same periods (757 to 516; P < .001). Between pre- and post-PCV13 periods, the proportion of CAP patients with a C-reactive protein level >120 mg/dL decreased from 41.3% to 29.7% (P < .001), the number of pleural effusion cases decreased by 53% (167 to 79; P < .001) and the number of pneumococcal CAP cases decreased by 63% (64 to 24; P = .002). The number of additional PCV13 serotypes identified decreased by 74% (27 to 7). CONCLUSIONS: Our data suggest a strong impact of PCV13 on CAP, pleural effusion, and documented pneumococcal pneumonia, particularly cases due to PCV13 serotypes.

Multiple health care visits related to a pediatric emergency visit for young children with common illnesses.

UNLABELLED: We aim to describe the number of health care visits before and after pediatric emergency department (PED) visits for common illnesses in a French tertiary pediatric hospital. This was a prospective cohort study with 501 children under 6 years of age who were evaluated and discharged from a tertiary care PED. Enrollment occurred on eight randomly selected study days between November 2010 and June 2011. The caregivers were then contacted via telephone 8 days later to obtain follow-up data, including information about return visits to health care facilities. Multiple visits were made by 206 (41 %) children, previous visits had occurred for 139 (28 %) children, and return visits had occurred for 94 (19 %) children. Previous and return visits were made at the PED as well as in general practitioners' offices and private pediatric offices. The median age of the subjects was 18 months. Fever was the most common complaint and was associated with more frequent multiple heath care visits. CONCLUSION: Multiple heath care visits for the same illness are frequent, especially for febrile children. Interestingly, this phenomenon concerns every type of health care facility, including the PED, general practitioners' offices, and private pediatric offices. Further studies should be performed to achieve a better understanding of this phenomenon and to test specific interventions, such as parental education and improvement of the information system.

Impact of implementing French antibiotic guidelines for acute respiratory-tract infections in a paediatric emergency department, 2005-2009.

Acute respiratory tract infections (ARTIs) are the main reason for antibiotic prescription in children. In 2005, the French Drug Agency published guidelines to minimise inappropriate use of antibiotics for ARTI. The purpose of this study was to assess the impact of implementing these guidelines in a paediatric emergency department. We retrospectively analysed data collected prospectively in a French paediatric emergency department from November 2005 (date of guideline implementation) to October 2009. For each child diagnosed with ARTI, we collected age, diagnosis, and prescribed antibiotics. We computed antibiotic prescription rates in the study population. During the study period, 53,055 children were diagnosed with ARTI and 59% of the 22,198 antibiotic prescriptions given at discharge were related to ARTI. The proportion of ARTI patients given antibiotic prescriptions fell from 32.1% during the first year to 21% in year 4 (p<10(-4), Cochran-Armitage test). Amoxicillin-clavulanic acid and amoxicillin accounted for 50% and 34% of antibiotic prescriptions for ARTI, respectively. French antibiotic guidelines led to significant decreases in antibiotic prescription for ARTI in our paediatric emergency department.

From the original SARS-CoV-2 strain to the Omicron variant: Predictors of COVID-19 in ambulatory symptomatic children.

OBJECTIVES: To determine the predictors of a positive SARS-CoV-2 test in a pediatric ambulatory setting. PATIENTS AND METHODS: We performed a cross-sectional prospective study (November 2020-February 2022) of 93 ambulatory settings in France. We included symptomatic children < 15 years old tested for SARS-CoV-2. For each period corresponding to the spread of the original strain and its variants (period 1: original strain; period 2: Alpha, period 3: Delta; period 4: Omicron), we used a multivariate analysis to estimate adjusted odds ratios (aORs) associated with COVID-19 among age, signs, symptoms or contact, and 95 % confidence intervals (95CIs). RESULTS: Of 5,336 children, 13.9 % (95CI 13.0-14.8) had a positive test. During the first three periods, the positivity rate ranged from 5.6 % (95CI 4.6-6.7) to 12.6 % (95CI 10.8-14.6). The main factors associated with a positive test were contact with an infected adult at home or outside the home (aOR 11.5 [95CI 4.9-26.9] to 38.9 [95CI 19.3-78.7]) or an infected household child (aOR 15.0 [95CI 4.8-47.1] to 28.4 [95CI 8.7-92.6]). By contrast, during period 4, aORs for these predictors were substantially lower (2.3 [95CI 1.1-4.5] to 5.5 [95CI 3.2-7.7]), but the positivity rate was 45.7 % (95CI 42.3-49.2). CONCLUSIONS: In pediatric ambulatory settings, before the Omicron period, the main predictor of a positive test was contact with an infected person. During the Omicron period, the odds of these predictors were substantially lower while the positivity rate was higher. An accurate diagnostic strategy should only rely on testing and not on age, signs, symptoms or contact.

Sensitivity and specificity of a rapid influenza diagnostic test in children and clinical utility during influenza A (H1N1) 2009 outbreak.

INTRODUCTION: The influenza A (H1N1) 2009 outbreak caused death and a disruption of public health services. Rapid influenza diagnostic tests (RIDT) could be helpful to ease the triage of patients and prevent an overload of emergency and laboratory facilities. OBJECTIVES: To compare the sensitivity and specificity of the Clearview Exact Influenza A&B test and real-time reverse transcription(RT)-PCR to detect influenza A (H1N1) 2009 in a paediatric emergency department of a paediatric teaching hospital in Paris, France. METHODS: 76 children with an influenza-like illness and either severe symptoms or an underlying medical condition were prospectively recruited between July 2009 and October 2009. RIDT and RT-PCR were simultaneously performed and compared. RESULTS: Among 39 influenza A (H1N1) 2009 RT-PCR-positive children (median age 5 years), 23 Clearview Exact Influenza A&B tests were positive. Sensitivity was 59% (95% CI 42.2 to 74) and specificity was 94.6% (95% CI 80.5 to 99.1). CONCLUSIONS: This study shows a sensitivity of RIDT of 59%, in agreement with other prospective studies, which could be useful in clinical practice for diagnosis influenza A (H1N1) 2009 in children. In outbreaks of a high prevalence, such as the 2009 outbreak, this test can help to prevent an overload of public health services.

Efficacy of fascia iliaca nerve block in daily routine for children with femoral fractures in a pediatric emergency department.

OBJECTIVES: We aimed to evaluate the efficacy of fascia iliaca nerve block (FINB), routinely used for children with femoral fractures, in a pediatric emergency department (PED). METHODS: This retrospective, single-center, observational study examined FINB using ropivacaine and a 1% lidocaine hydrochloride solution, in all patients under 18 years of age admitted with a femoral fracture from January 2012 to December 2016. Pain was assessed using two validated pediatric pain scales: EVENDOL or a visual analog scale. A level of ≥ 4 on either scale indicates the need for an analgesic. The primary outcome was the percentage of patients who were pain free after the FINB procedure defined by a pain score of < 4. Secondary outcomes were the time spent between PED admission and FINB, the need of additional analgesics, side effects, and the success rate of FINB. RESULTS: Of 161 patients screened, 144 were included. The median age was 3.2 years (range 2 months to 16 years) and 74% were boys. The number of children determined to be pain free (pain score < 4) increased from 36 (25%) before the FINB to 123 (85%) after the FINB (absolute risk difference 60%, 95% CI: 51%-70%). Overall, 21 children (15%) required a second analgesic after the FINB. CONCLUSION: The routine use of FINB with ropivacaine and lidocaine by pediatric ED physicians provided effective pain relief for children admitted for a femoral fracture in the emergency department. Our data support the efficiency and feasibility of FINB for the antalgic management of children with femoral fracture.

Invasive group A streptococcal infection in children: clinical manifestations and molecular characterization in a French pediatric tertiary care center.

Invasive group A streptococcal (GAS) infections have a broad and evolving clinical spectrum, associated with various GAS genotypes and/or virulence factors that are only poorly described in children. We aimed to assess the clinical and molecular characteristics of invasive GAS infections in 28 children admitted from 2000 to 2007 at a large French pediatric tertiary care center. The GAS isolates were characterized molecularly by emm-typing and by the determination of the main virulence factors: speA, speB, speC, smeZ-1, ssa, sic, and silC. The median age of the children was 2.9 years. Osteoarticular infection (OAI) was the main clinical manifestation (n=15/28, 53%). emm-1 predominated (n=10/28), followed by emm-12, 3, and 4. No significant correlation was found between emm type and clinical manifestations, but emm-1 predominated in cases of OAI (n=7/15) and was associated with speA, speB, smeZ-1, and sic virulence factor genes. In this pediatric study, we describe a predominance of OAI associated with emm-1 GAS. Further larger international pediatric studies, including host immunity evaluation, are needed in order to better assess the pathogenesis of GAS infection in children.

Severe and fatal forms of COVID-19 in children.

OBJECTIVES: The aim of this study was to describe severe forms of novel coronavirus disease 2019 in children, including patient characteristics, clinical, laboratory, and imaging findings, as well as the disease management and outcomes. METHODS: This was a retrospective, single-center, observational study conducted in a pediatric intensive and high-dependency care unit (PICU, HDU) in an urban hospital in Paris. All patients, aged from 1 month to 18 years, admitted for confirmed or highly suspected SARS-CoV-2 were included. RESULTS: We analyzed the data of 27 children. Comorbidities (n=19, 70%) were mainly neurological (n=7), respiratory, (n=4), or sickle cell disease (n=4). SARS-CoV-2 PCR results were positive in 24 children (nasopharyngeal swabs). The three remaining children had a chest CT scan consistent with COVID-19. Respiratory involvement was observed in 24 patients (89%). Supportive treatments were invasive mechanical ventilation (n=9), catecholamine (n=4), erythropheresis (n=4), renal replacement therapy (n=1), and extracorporeal membrane oxygenation (n=1). Five children died, of whom three were without past medical history. CONCLUSION: This study highlighted the large spectrum of clinical presentation and time course of disease progression as well as the non-negligible occurrence of pediatric life-threatening and fatal cases of COVID-19 mostly in patients with comorbidities. Additional laboratory investigations are needed to further analyze the mechanism underlying the variability of SARS-Cov-2 pathogenicity in children.

Cervical trauma in children: Be aware of the risk of infection.

Neck abscesses after a cervical trauma rarely occur, especially in children. Cervical abscesses are more generally complications of otolaryngological infections. Progression to severe complication or death may be rapid. We describe a case of a sternocleidomastoid muscle and retropharyngeal abscess that developed after a minor cervical trauma from being struck in the neck. The patient was surgically treated and received antibiotics, but returned with a recurrence of the cervical infection. We discuss the superinfection of the hematoma, cervical abscess management, and its treatment in children.

[Tolerance and efficacy of atovaquone-proguanil for the treatment of paediatric imported Plasmodium falciparum malaria in France: clinical practice in a university hospital in Paris]. / Tolérance et efficacité de l'atovaquone-proguanil dans le traitement du paludisme d'importation àPlasmodium falciparum de l'enfant en France métropolitaine: expérience d'un centre hospitalier parisien.

UNLABELLED: Only few drugs for uncomplicated Plasmodium falciparum malaria are available in children. Atovaquone-proguanil is a recent antimalarial drug licensed in France for the uncomplicated P. falciparum malaria in adults. Few paediatric studies have evaluated atovaquone-proguanil in children for uncomplicated malaria in endemic area, but no study have evaluated this treatment for imported malaria. OBJECTIVE: To evaluate treatment by atovaquone-proguanil for uncomplicated and imported P. falciparum malaria in children. METHODS: We retrospectively evaluated the tolerance and the efficacy of atovaquone-proguanil in the children admitted in Robert-Debré Hospital (Paris) for a P. falciparum malaria. From January 2004 to December 2005, 48 children with a median age of 7,5 years (IQR 4-11) were treated with atovaquone-proguanil for a uncomplicated P. falciparum malaria, except for 5 children who had an isolated hyperparasitemia greater or equal to 5%. RESULTS: Atovaquone-proguanil was stopped for 3/48 children because of vomiting. Fever resolved in all the children between Day 3 and 7, following the beginning of the treatment. One child, with a favourable outcome, had a positive parasitemia at Day 4 equal to the initial parasitemia (0,1%). No late therapeutic failure was observed among the 24 children evaluated up to one month after starting treatment. CONCLUSION: Atovaquone-proguanil is an efficient and well-tolerated antimalarial treatment for uncomplicated P. falciparum malaria in children. The risk of vomiting should lead to a systematic initial hospitalisation of children treated with atovaquone-proguanil.

Extended-spectrum ß-lactamase-producing Enterobacteriaceae, national study of antimicrobial treatment for pediatric urinary tract infection.

OBJECTIVE: To evaluate clinical practices for ESBL-producing urinary tract infection (UTI) in France. METHODS: We performed an observational, retrospective, cross-sectional, hospital-based study in 22 pediatric departments of university or secondary care hospitals. We collected data of the last five patients presenting with ESBL-producing UTI in 2012 and the physicians' therapeutic approach to two case vignettes of acute non-septic ESBL-producing pyelonephritis (7-month-old girl) and cystitis (30-month-old girl). The adequacy of the therapeutic decision was analyzed by a panel of independent infectious disease experts. RESULTS: A total of 80 case patients of ESBL-producing UTI were collected: 54 with acute pyelonephritis (mean age: 28 months, female: 66%), of whom 98% received an intravenous ESBL-adapted antibiotic treatment and 55% a two-drug antibiotic therapy. Carbapenems were used in 56% of cases and aminoglycosides in 36%. Of the 26 cystitis patients (mean age: 5 years, female: 73%), 85% were treated with antibiotics, including three intravenously (carbapenems=2). For the case vignettes, physicians (n=85) would have treated the pyelonephritis patient with carbapenems (76%) and/or aminoglycosides (68%); 71% would have used a two-drug antibiotic treatment. The cystitis patient would have been treated intravenously by 29% of physicians; 8% would have used a two-drug antibiotic treatment, 16% would have prescribed carbapenems, and 11% aminoglycosides. Antibiotic treatments were deemed appropriate in 37% of cases. CONCLUSIONS: Antimicrobial treatment for ESBL-producing UTI greatly varies, and carbapenems are excessively prescribed. Specific guidelines for ESBL infections are required.

Antibiotic treatment of lower respiratory tract infections.

Lower respiratory tract infections, i.e., bronchitis, bronchiolitis, and pneumonia, are the second leading cause of antibiotic prescriptions. The vast majority of these infections are due to viruses and are self-limited diseases: most patients recover spontaneously. These two facts explain that antibiotic prescriptions must be limited to some clinical situations for which the diagnosis has to be done early. The first message of this manuscript is to strengthen non-antibiotic prescriptions in many situations such as bronchitis and bronchiolitis. Implementation of pneumococcal conjugate vaccines (PCVs) has reduced the incidence of pneumonia and empyema, and induced a dramatic decrease in the proportion of pneumococcus in these diseases. However, pneumococcus remains probably the leading cause of bacterial pneumonia and empyema and the main target of antibiotic treatment. Furthermore, the implementation of PCVs has reduced resistance to antibiotics including penicillins and macrolides antibiotics, explaining the de-escalation proposed in the last few years, with the reduction of the use if third generation cephalosporins and vancomycin. The therapeutic choices proposed in this article follow the previous official guidelines in France. Serious infections represented by empyema and severe pneumonia remain therapeutic emergencies, most often warranting hospitalization and IV antibiotics.

[Chronic otitis and hearing loss revealing a disseminated tuberculosis in a child]. / Otorrhée chronique et hypoacousie révélant une tuberculose disséminée chez l'enfant: à propos d'un cas.

UNLABELLED: Ear localization is sometimes the first symptom of tuberculosis. CASE REPORT: We report a case of a teen with a chronic otitis revealing a disseminated tuberculosis. The investigations showed ear, bones and pulmonary localisations. The outcome with treatment showed a persistent hearing loss. CONCLUSION: Middle ear tuberculosis should be suspected in patients with chronic otitis and risk factors of tuberculosis. A disseminated tuberculosis should be investigated and an early treatment is necessary to prevent hearing loss.

[Influenza vaccination coverage rate in children with underlying chronic disorders in 7 French pediatric wards]. / Couverture vaccinale vis-à-vis de la grippe chez les enfants de la région parisienne atteints d'une affection de longue durée.

UNLABELLED: In France, annual influenza vaccination is recommended and free of charge for children with chronic disease (chronic lung, heart or kidney disease, diabetes, haemoglobinopathy, immune deficiency). The national goal is to reach 75% influenza vaccination coverage by 2008, but data on coverage in high risk children are limited. OBJECTIVES: To estimate the influenza vaccination coverage in children with an underlying chronic health condition in the Paris region, during in- or out-patient visit at hospital. METHODS: A multicentre cross-sectional descriptive study was carried out over 2 months before the 2004-2005 flu vaccination campaign in 7 French paediatric hospitals (Paris region). Inclusion criteria for this survey were: children aged 6 months to 18 years, with an underlying chronic disease requiring annual influenza vaccination, with a vaccination card available, so as to check their vaccination status. Reasons for non vaccination were recorded. RESULTS: Data from 239 children were analysed. 56% of patients were males (mean age: 8.1 years). Two patients had 2 separate underlying chronic disorders; 69% had a haemoglobinopathy, 16.3% had a chronic respiratory disease, and 7.5% had diabetes. The influenza vaccination rate for 2003-2004 was 43.7% (haemoglobinopathy: 55.5%; chronic respiratory diseases: 12.8%). This rate increased from 20.4% to 43.7% between 1999 and 2003. Less than 16% of parents remembered having received a voucher for free vaccination from the National Health Insurance Agency. CONCLUSION: Efforts are still needed to achieve the 2008 objectives of 75% coverage.

Traumatic spinal epidural hematoma in a 1-year-old boy.

Traumatic spinal epidural hematoma is uncommon in children, making rapid diagnosis difficult. In this report, we present a case of traumatic cervical epidural hematoma in a 1-year-old boy, diagnosed with computed tomography scanning and magnetic resonance imaging (MRI). Management was conservative and the lesion regressed spontaneously. The presentation in childhood is often nonspecific. MRI is the imaging modality of choice for diagnosing these lesions. Conservative treatment has to be considered in cases with a benign clinical course and provided that the patient is followed up neurologically with repeated MRI.

[Consensus validation of a tool to identify inappropriate prescribing in pediatrics (POPI)]. / Validation par consensus d'un outil d'identification de prescriptions inappropriées en pédiatrie (POPI).

OBJECTIVE: Medication errors including inappropriate prescriptions and drug omissions are one of the causes of adverse drug events in children. Our aim was to develop a preliminary screening tool to detect omissions and inappropriate prescriptions in pediatrics based on French and international guidelines. MATERIEL AND METHODS: Disease classification was based on the prevalence rate of pathology and hospital statistics. The criteria were obtained by reviewing many French and international references. The Delphi consensus technique was used to establish the content validity of POPI. The level of agreement and the proposals of healthcare professionals was noted on a nine-point Likert scale. RESULTS: The criteria were categorized according to the main physiological systems (gastroenterology, respiratory infections, pain, neurology, dermatology, and miscellaneous). They were distributed to 16 French pediatric panelists (eight pharmacists, eight pediatricians who were hospital-based [50%] or working in the community [50%]). After two rounds of the Delphi process, 101 of 108 criteria were chosen with strong consensus (76 inappropriate prescriptions and 25 omissions). CONCLUSIONS: POPI is the first screening tool to detect inappropriate prescriptions and omissions in pediatrics. It is now necessary to conduct a prospective study to determine inter-rater reliability and the tool's detection capacity.

[Nationwide survey on pediatric infectious disease organisation and antibiotic management in French hospitals]. / Enquête nationale sur l'organisation des activités de référence en maladies infectieuses et antibiothérapie de l'enfant dans les centres hospitaliers français.

UNLABELLED: Skills in pediatric infectious disease (PID) and antibiotic management are of critical importance in hospitals. This nationwide survey aimed to assess the characteristics, training, and tasks of PID consultants in French hospitals. The management of PID and antibiotic therapy was also analyzed in hospitals lacking PID consultants. METHODS: An electronic survey linked to a dedicated website was sent to French hospitals with a pediatric department in June 2012. In hospitals where PID consultants were available, they were asked to answer the questionnaire. In hospitals lacking PID consultants, pediatricians were asked to send the questionnaire to their infectious disease consultant, if available. RESULTS: A total of 86 individual responses were received from 76 hospitals (including 26 academic hospitals). The existence of a PID consultant was declared in 53 hospitals. Responses were received from the person claiming to be "the" or "one of the" PID consultants in 46 cases, representing 39 centers. PID consultants had a degree in PID (46%) or antibiotic therapy (37%), or a complementary qualification as a specialist in infectious diseases (13%). The PID consultants worked in departments of general pediatrics (61%) and emergency medicine (15%), or neonatology (15%). They were involved in the Nosocomial Infection Prevention Committee (43%) or the Antimicrobial Therapy Committee (63%) and had teaching activities (65%). There was a specific unit with a PID label in 10% of the 39 centers reporting at least one consultant and consultations of infectious diseases took place in 28%. CONCLUSION: PID consultants are rare. Their important role in patient care should be recognized. Efforts should focus on recruiting and training such specialists.

Impact of 2011 French guidelines on antibiotic prescription for acute otitis media in infants.

OBJECTIVE: In 2011, new guidelines on antibiotic prescription for acute otitis media (AOM) were published in France to decrease the use of third generation cephalosporins that promote the carriage of extended-spectrum beta-lactamase producing Escherichia coli. Our objective was to assess the impact of the 2011 French recommendations on the type of antibiotics prescribed for AOM. METHODS: Fourteen thousand six hundred and sixty-one children, 6 to 24 months of age, presenting with AOM were included in 2 studies, between November 1, 2009 and October 31, 2012. The first one was conducted with the support of 62 private practice pediatricians; the second one was conducted in 7 pediatric emergency departments. Three periods of 1 year each were defined. RESULTS: Antibiotics were prescribed in 12,471 (85.1%) of cases of AOM during the study period. Amoxicillin prescriptions was multiplied by 25, between the first year (2.6%) and the last year (66.1%). Conversely, prescriptions of cefpodoxime proxetil and amoxicillin-clavulanic acid decreased from 33.6% and 62.0% in the first year to 5.2% and 27.7% in the last year, respectively. This trend was observed in both private practices and in the pediatric emergency departments. CONCLUSION: Amoxicillin became the most frequently prescribed antibiotic for AOM in 2012, complying with the 2011 French guidelines, while the proportion of prescribed broad-spectrum antibiotics decreased. Our study highlights the importance of guidelines to decrease the prescription of broad-spectrum antibiotics, a crucial factor in the prevention of antibiotic resistance.

[Recommendations for the use of diagnostic testing in low respiratory infections in children older than three months]. / Recommandations sur l'utilisation des nouveaux outils diagnostiques étiologiques des infections respiratoires basses de l'enfant de plus de trois mois.

Recommendations for the use of diagnostic testing in low respiratory infection in children older than 3 months were produced by the Groupe de Recherche sur les Avancées en Pneumo-Pédiatrie (GRAPP) under the auspices of the French Paediatric Pulmonology and Allergology Society (SP(2)A). The Haute Autorité de santé (HAS) methodology, based on formalized consensus, was used. A first panel of experts analyzed the English and French literature to provide a second panel of experts with recommendations to validate. Only the recommendations are presented here, but the full text is available on the SP(2)A website.