Pediatric ambulatory pertussis epidemiology in France, recent updates.

OBJECTIVES: Following various changes in the vaccine strategy in 2013 and the mandatory vaccination in 2018, we aimed to analyze the vaccination status, age, and source of contamination of pertussis and parapertussis cases in outpatient surveillance. PATIENTS AND METHODS: Confirmed pertussis and parapertussis cases were enrolled by 35 pediatricians. RESULTS: From 2014 to 2022, 73 confirmed cases of pertussis (n = 65) and parapertussis (n = 8) were reported. For children below 6 years of age, the number of cases with a 2 + 1 schedule (n = 22) was higher than that of those with a 3 + 1 schedule (n = 7). The age of cases with a 3 + 1 or a 2 + 1 schedule was not significantly different (3.8y ± 1.4 vs 4.2y ± 1.5). The main source of contamination was either adults or adolescents. CONCLUSION: Vaccination status and source of contamination are crucial to study the impact of vaccination recommendations.

[Inhaled therapies in cystic fibrosis]. / Aérosolthérapie dans la mucoviscidose.

INTRODUCTION: Delivery of drugs by the inhaled route is particularly attractive in cystic fibrosis despite heterogeneous and variable deposition in the lungs. STATE OF THE ART: Proposed therapies include drugs aimed at improving the mucus quality (nebulised hypertonic saline or RhDNase and, in the future, mannitol as a dry powder) or treating chronic colonization and early infection with Pseudomonas aeruginosa (nebulised tobramycine and colistine and, soon, aztreonam lysate, ciprofloxacin and liposomal amikacine). Bronchodilators need to be tested. Corticosteroids have no proven benefit. Other drugs (gene therapy, L-arginine, anti-proteases, etc...) are under development or on trial. In practice, mixtures of drugs should be avoided and the chronological order between drugs observed to achieve correct delivery. VIEWPOINT: Developments in pharmaceutics and device technology allow us to consider new therapeutic approaches in cystic fibrosis. CONCLUSION: More and more efficacious but expensive inhaled treatments are now, and will in the next future, be available for cystic fibrosis patients. Teaching of good inhalational technique and proper hygiene concerning the devices is an absolute necessity before any inhaled treatment is prescribed.

[Patient education in cystic fibrosis: what skills for the patient?]. / L'éducation thérapeutique dans la mucoviscidose: quelles compétences pour le patient? Présentation du référentiel des compétences adulte-enfant.

INTRODUCTION: In France since 2002 two major changes have occurred in the management of patients with cystic fibrosis: systematic neonatal screening and the establishment of specialised CF centres. One of the roles of the CF centres is therapeutic education of the patients and their families. METHODS: The proposed educational approach consists of 4 steps: an educational diagnosis to assess the patient; an educational contract based on the capabilities and objectives previously identified by the team; implementation of the education programme which organises the teaching of the patient and, finally, evaluation. RESULTS: With the goal of facilitating the establishment of patient education in the CF centres we present the learning objectives for patients suffering from cystic fibrosis, based on the capabilities that the patients need to acquire in the course of the education programme. CONCLUSION: Based on the capabilities and learning objectives of the patients the working party are developing valid tools for the instructor/carer. They present the outcomes of the meetings, the educational principles of implementation and the respective roles of the patient and the carer.

End-of-life care in cystic fibrosis.

OBJECTIVE: End-of-life clinical care in cystic fibrosis (CF) differs substantially from terminal care in childhood cancer. To examine this difference, we reviewed the medical care of a cohort of CF patients treated at Children's Hospital, Boston, to document the use of preventive, therapeutic, and palliative care in the month preceding death. PATIENTS: We reviewed the medical records of 44 patients older than 5 years who died of CF-related respiratory failure for the years 1984 to 1993. RESULTS: Thirty-eight patients (86%) received opiates for the treatment of severe dyspnea and pain; the duration of opiate use varied from less than 1 hour to greater than 1 month. The dose of opiates varied from less than 5 mg per hour to greater than 30 mg per hour. Thirty-three patients (75%) continued to receive intravenous antibiotics in the last 12 hours of life; 32 (72%) continued to receive preventive or therapeutic oral medications in the last 12 hours of life. All patients were designated as do not resuscitate at the time of death; 43 of the patients died in the hospital with 1 patient dying at home under hospice care. CONCLUSIONS: The model of comfort care developed in childhood cancer does not adequately describe the combination of preventive, therapeutic, and palliative care given at the end of life for CF at our institution. The majority of CF patients continued to receive intravenous antibiotics and/or oral vitamin preparations while being treated with opiates for terminal pain and dyspnea. Small doses of opiates seem to be effective in the treatment of the pain and dyspnea at the end of life in CF.

Chronic pain in cystic fibrosis.

OBJECTIVE: The objective of this study was to examine the incidence and therapy of chronic pain in a group of older patients with cystic fibrosis (CF). PATIENTS: We identified two groups of patients followed at the CF Center at Children's Hospital (Boston); the first group consisted of all patients above the age of 5 years who died between 1984 and 1993, and the second was a cohort of 23 additional CF patients who had been referred to the Pain Treatment Service. DESIGN: Medical charts were reviewed for the etiology and therapy of all pain episodes requiring medical intervention. RESULTS: The incidence of chronic pain in this population increased sharply in the last 6 months of life. Headaches (55% of patients) and chest pain (65%) were frequently reported, although back pain (19%), abdominal pain (19%), and limb pain (16%) were also reported. In patients with headache, the main etiologies were hypercarbia or hypoxia, migraine, and sinusitis. The majority of chest pain was musculoskeletal, with pleuritis, pneumothorax, and rib fracture also reported as the cause of chest pain. INTERVENTIONS: A variety of nonpharmacological and pharmacological therapies were reported. Forty-one patients (53%) had pain severe enough to require opioid treatment, and 10 patients (13%) received opioids for more than 3 months. In eight patients with more severe pain, regional analgesia was found to be particularly effective. CONCLUSIONS: Chronic pain is a common problem in CF, particularly as the patient population ages. When administered with caution, opioids have proven to be effective and safe in this population; regional anesthesia can be used to preserve pulmonary toilet while adequately treating severe pain.

Serum alpha-interferon in lower respiratory tract infections of children.

BACKGROUND: Serum alpha-interferon (IFN-alpha) concentrations are high in some children with viral meningitis and other viral infections. We have tried to assess the utility of determining serum IFN-alpha concentrations as a marker of acute viral respiratory infections. METHODS: Measurement of IFN-alpha via a biologic assay on Madin-Darby bovine kidney cells was performed in 138 patients with lower respiratory tract infection in whom a pathogen was identified. RESULTS: Serum IFN-alpha was detectable at the early stage of respiratory infections in the era of 59 of 75 (78.7%) of patients with a viral infection and in 4 of 63 (6.3%) of those with bacterial infection (P < 0.001). In the 4 patients with positive IFN-alpha and bacterial infection, a concomitant viral infection was found. The production of IFN-alpha is independent of age, and detectable levels are found in young infants, including the first 3 months of life, and in children with an acute viral disease. CONCLUSION: This test could be useful in distinguishing between bacterial and viral origins in lower respiratory tract infection (the specificity was 94% and the sensitivity was 79%) and could help guide the use of antibiotics, but more rapid techniques, available in a matter of hours, are required.

Comparison of procalcitonin with C-reactive protein, interleukin 6 and interferon-alpha for differentiation of bacterial vs. viral infections.

BACKGROUND: Procalcitonin (PCT) concentration increases in bacterial infections but remains low in viral infections and inflammatory diseases. The change is rapid and the molecule is stable, making it a potentially useful marker for distinguishing between bacterial and viral infections. METHODS: PCT concentration was determined with an immunoluminometric assay on plasma collected at admission in 360 infants and children hospitalized for bacterial or viral infection. It was compared with C-reactive protein (CRP), interleukin 6 and interferon-alpha measured on the same sample. RESULTS: The mean PCT concentration was 46 microg/l (median, 17.8) in 46 children with septicemia or bacterial meningitis. PCT concentration was > 1 microg/l in 44 of 46 in this group and in 59 of 78 children with a localized bacterial infection who had a negative blood culture (sensitivity, 83%). PCT concentration was > 1 microg/l in 16 of 236 children with a viral infection (specificity, 93%). PCT concentration was low in 9 of 10 patients with inflammatory disease and fever. A CRP value > or =20 mg/l was observed in 61 of 236 patients (26%) with viral infection and in 105 of 124 patients (86%) with bacterial infection. IL-6 was > 100 pg/ml in 14% of patients infected with virus and in 53% with bacteria. A secretion of interferon-alpha was found in serum in 77% of viral infected patients and in 8.6% of bacterial infected patients. CONCLUSIONS: In this study a PCT value of 1 microg/l or greater had better specificity, sensitivity and predictive value than CRP, interleukin 6 and interferon-alpha in children for distinguishing between viral and bacterial infections. PCT values are higher in invasive bacterial infections, but the cutoff value of 1 microg/l indicates the severity of the disease in localized bacterial infection and helps to decide antibiotic treatment in emergency room. PCT may be useful in an emergency room for differentiation of bacterial vs. viral infections in children and for making decisions about antibiotic treatments.

Thoracoabdominal asynchrony and ratio of time to peak tidal expiratory flow over total expiratory time in adolescents with cystic fibrosis.

Thoracoabdominal asynchrony (TAA) and the ratio of time to peak tidal expiratory flow over total expiratory time (TME/TE) have been used to assess airway obstruction in infants and adults. We obtained these measurements using calibrated respiratory inductance plethysmography (RIP) on 15 adolescents and young adults with cystic fibrosis (CF) and varying disease severity. The measurements were then compared to 15 normal age-matched controls. TAA was expressed as a phase angle (phi) calculated from the abdominal (AB) and ribcage (RC) signals acquired from scalar strip chart recordings. Using CODAS (DATAQ Instruments, Akron, OH) software, the analog signals were digitized, and the differentiated sum (AB + RC) signal was used to calculate TME/TE. Forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1) were obtained using RIP in all subjects. Subjects with CF had a significantly higher mean phi than the control subjects (15 degrees vs. 8 degrees, respectively, P = 0.01). In the CF patients the specificity of a high phi as an indicator of abnormality was 80%, while the sensitivity was 65%. There was no correlation in the magnitude of phi and disease severity as assessed by FVC or FEV1. There was no significant difference in TME/TE between the groups. We conclude that RIP-acquired phi, but not TME/TE, is a simple and useful method to detect the presence of airway obstructive disease. We speculate that the sensitivity of this method will increase in younger patients with more compliant chest walls and less air trapping. Longitudinal studies of phi in infants and young children with lung disease could help in assessing disease severity and progression in this population, in whom repeated measures are few and complex.

[Hospitalization for acute community-acquired rotavirus gastroenteritis: a 4-year survey]. / Hospitalisations pour gastroentérites aiguës communautaires à rotavirus: une enquête de quatre ans.

OBJECTIVE: To evaluate the number of hospitalizations due to community-acquired rotavirus acute gastroenteritis in a general pediatric unit during a four-year survey. RESULTS: From January 1997 to December 2000, 725 patients were admitted for acute gastro-enteritis to the general paediatric unit of a Parisian children hospital (nosocomial diarrhoea excluded) and 706 (97.5%) of these patients had had a stool microbiologic examination. Diarrhoea was caused by rotavirus in 359 patients (50.89%) and Salmonella sp in 61 (8.6%). Children and infants hospitalized for rotavirus acute gastroenteritis were younger (26% had three months or less, and 50.03% had six months or less) than in other European studies. CONCLUSION: This study is the first in France reporting a systematic survey of hospitalized gastroenteritis during four years. More than half of hospitalized community-acquired gastroenteritis were due to rotavirus in this Parisian area. The young age of patients should be investigated in other French areas, searching for risk factors and rotavirus strains.

[Ciprofloxacin after clinical failure of beta-lactam antibiotics in children with salmonellosis]. / Ciprofloxacine après échec des beta-lactamines dans les salmonelloses de l'enfant.

BACKGROUND: Children with enteric fever or severe salmonella infections are usually treated with beta-lactam antibiotics, particularly ceftriaxone. Due to their poor penetration into cells, beta-lactam antibiotics, even if active in vitro, are sometimes clinically ineffective because they cannot reach the intracellular sites of Salmonella multiplication. OBJECTIVES: To evaluate in a retrospective study usefulness, efficacy and safety of oral ciprofloxacin in patients with severe salmonellosis and clinical failure of ceftriaxone or beta-lactam antibiotics. PATIENTS AND METHODS: From July 1, 1995 to 2000, the bacteriology laboratory of a French pediatric hospital had identified 215 patients aged between 1 month and 15 years with positive blood or stools for Salmonella sp, 113 of them requiring hospitalization due to their clinical symptoms. Three were excluded for sickle-cell disease or poor nutritional status. None of the 110 strains (including 4 S. typhi, 51 S. typhimurium, 25 S. enteritidis, 6 S. hadar and 5 S. heidelberg) isolated was resistant to ceftriaxone or ciprofloxacin. Forty-one of the 110 strains (37.3%) produced a beta-lactamase. Twelve patients had a rapid recovery without antibiotic treatment, and 98 (mean age 3.9 years) were given antibiotics (ceftriaxone in 91 and amoxicillin in 7) for dysentery (43%), shock (15%) or persistent high fever and severe diarrhea (42%). RESULTS: In 72 children (mean age = 3.6 years) ceftriaxone treatment (amoxicillin in 5) for 5 or 7 days was rapidly effective: apyrexia was obtained in 1.5 day after the start of treatment and the number of stools per day was 4 or less in 2.2 days. Two to 3 weeks after clinical recovery, asymptomatic carriage was present in 22/38 patients. In the 26 other patients ceftriaxone (amoxicillin in 2) treatment was clinically ineffective, despite good in vitro activity, and was switch for oral ciprofloxacin (20 mg kg(-1) d(-1), 5 days) after 2 to 7 days of lasted fever and/or severe diarrhea. Clinical improvement with ciprofloxacin was obtained in less than 48 h. The strains involved in these 26 patients included the 4 S. typhi and 15 S. typhimurium (P < 0.05), 13/15 (P < 0.01) producing beta-lactamase. Asymptomatic carriage was found in 5/22 patients (P < 0.05) after recovery. None of the patient treated with ciprofloxacin had side effect. CONCLUSION: In severe salmonellosis, the clinical failure of treatment with ceftriaxone is not rare, particularly in S. typhimurium producing beta-lactamase infection and short treatment with oral ciprofloxacin is safe and allows to obtain a rapid recovery.

[Coincidental outbreaks of rotavirus and respiratory syncytial virus in Paris: a survey from 1993 to 1998]. / Coïncidence des épidémies de rotavirus et de virus respiratoire syncytial à Paris: une enquête de 1993 à 1998.

PATIENTS AND METHODS: In a pediatric hospital of Paris, from 1993 to 1998, respiratory secretions were positive for respiratory syncytial virus (RSV) in 26.3% of 4,738 children (0-5 years) examined or hospitalized for lower respiratory tract infections. Rotavirus detection was positive in stools of 23.7% of the 8,537 children of the same age with acute diarrhea. RESULTS: The RSV epidemic peak occurred annually in Paris in December and the rotavirus outbreak peaks were observed in December/January. The winter seasonal peaks remained constant for both pathogens and the temporal appearance of these peaks was constant from 1993 to 1998. Fifty to sixty-one percent of rotavirus and 77 to 92% of RSV infections were observed in November, December or January. These simultaneous outbreaks provoked important problems in hospital organization and prevention of nosocomial infections. CONCLUSION: The coincidence of RSV and rotavirus peaks is not found in all countries. The epidemic patterns have to be checked in other parts of France and Europe because this could be important when active immunization programs will be available for these two pathogens.

[Procalcitonin in pediatric emergencies: comparison with C-reactive protein, interleukin-6 and interferon alpha in the differentiation between bacterial and viral infections]. / Procalcitonine aux urgences pédiatriques. Comparaison avec la protéine C-réactive, l'interleukine-6 et l'interféron-alpha pour la différenciation des infections bactériennes et virales.

OBJECTIVE: Procalcitonin concentration increases in bacterial infections but remains low in viral infections and inflammatory diseases. The change is rapid and the molecule is stable making it a potentially useful marker for distinguishing between bacterial and viral infections. PATIENTS AND METHODS: Procalcitonin (PCT) was determined with an immunoluminometric assay on plasma collected at admission in 436 infants and children hospitalized for bacterial or viral infection. It was compared with C reactive protein, interleukin-6 and interferon-alpha measured on the same sample. RESULTS: PCT was 41.3 +/- 77.4 micrograms/l in children with septicemia or bacterial meningitis (n = 53), 0.39 +/- 0.57 microgram/l in children with viral infection (n = 274) and 3.9 +/- 5.9 micrograms/l in children with a localized bacterial infection who had a negative blood culture (n = 109). PCT was > 1 microgram/l in 126 children with a localized or systemic bacterial infection (sensitivity 78%). PCT was < 1 microgram/l in 258 children with a viral infection (specificity 94%). For differenciation between viral and bacterial infections, CRP value > or = 20 mg/l, IL-6 > 100 pg/ml and interferon-alpha > 0 Ul/ml have 85, 48 and 76% sensitivity and 73, 85 and 92% specificity respectively. CONCLUSIONS: In this study, a PCT value of 1 microgram/l or greater had better specificity, sensitivity and predictive value than CRP, IL-6 and interferon-alpha in children for distinguishing between viral and bacterial infections. PCT may be useful in pediatric emergency room for making decision about antibiotic treatments.

[Procalcitonin, C-reactive protein and interleukin 6 in bacterial and viral meningitis in children]. / Procalcitonine, protéine C-réactive et interleukine 6 dans les méningites bactériennes et virales de l'enfant.

OBJECTIVES: In young children with meningitis, blood or cerebrospinal fluid (CSF) analysis cannot differentiate all cases of viral meningitis (VM) from bacterial meningitis (BM). Empirical antibiotic therapy is often given. As new markers are needed, we compared serum proCalcitonin (PCT) with CSF analysis for C-reactive protein (CRP) and interleukin-6 (IL6). PATIENTS AND METHODS: PCT was measured with a chemoluminescent assay in the sera of 23 children (aged 3 months to 14 years) hospitalized for BM and in 51 patients with VM. RESULTS: Initial CRP (mean 143.3 mg/l, range 28-351 and mean 13.9, range 1-48), CSF proteins (mean 2.2, range 0.4-4.74 and mean 0.57, range 0.12-2.72) and white blood cell count in CSF (range 240-17500 and 20-3200) in BM and VM respectively, were not sufficiently discriminative to distinguish between BM and VM. Twenty-four of the 51 patients with VM were given antibiotics. IL6 values at admission showed an overlap zone (> 100 pg/ml in 7/19 patients with VM and < 100 pg/ml in 1/8 patients with BM. PCT was discriminative in all cases: mean PCT in BM was 61 micrograms/l (range 4.8-335) and 0.33 in VM (range 0-1.7; p < 0.001). No production of PCT was detected in CSF. After antibiotic therapy, PCT decreased and reached undetectable levels after recovery. CONCLUSION: PCT is a sensitive and specific marker for early diagnosis of viral meningitis versus bacterial meningitis in children.

[Community-acquired pneumonia in children: importance of Mycoplasma pneumoniae infections and efficacy of antibiotics]. / Pneumonies communautaires de l'enfant: importance des infections à Mycoplasma pneumoniae et efficacité des antibiotiques.

OBJECTIVES: Define a therapeutic management schema adapted to children with community-acquired pneumonia. METHODS: A prospective survey was conducted in 104 children over 18 months of age with community-acquired pneumonia. The pathogen was isolated in 85% of the cases. RESULTS: Viral infection alone was proven in 30 children (respiratory syncytial virus in 10). Pneumococci pneumonia was found in 12 patients; the isolated strains were sensitive to penicillin. Apyrexia was obtained in 11/12 cases with amoxicillin. Mycoplasma infections occurred in 42% of the cases (41 alone and in association with pneumococci in 2 cases). Pneumococci and mycoplasma infections could not be differentiated with standard radiography and laboratory tests. Initial treatment with beta lactamines was always unsuccessful in children with mycoplasma infections. Apyrexia was achieved when antibiotics were changed to macrolides. CONCLUSION: Since lower respiratory tract infections due to pneumococci are much more severe than those due to mycoplasma, beta lactamines should be given as first intention treatment for children over 18 months with pneumonia. Macrolides should be given in case of failure because mycoplasma would then be the most probable infectious agent.

[Perceptions of cystic fibrosis patients, patient relatives and physicians: barriers or motivations to lung transplantation]. / Motivations et freins à la greffe chez patients, aidants et médecins dans la mucoviscidose.

INTRODUCTION: The aims of this study are to describe qualitatively the perceptions of three groups involved in the cystic fibrosis transplant decision, looking for similarities and differences between groups, and to identify those that act as motivations or barriers to transplantation. METHODS: Thirty patients, 26 patient relatives and 27 physicians were interviewed, and concept maps were constructed from those interviews. Their degree of transplant acceptance at the time of the interview was measured. RESULTS: There were motivations and barriers in the pre-, peri- and post-transplant period. Analysis revealed similar perceptions regarding the risks and benefits of transplantation, but also different perceptions in the specific concerns of each group. Patients and patient relatives expressed many questions and fears in their concept maps, and physicians expressed difficulties. CONCLUSIONS: This study highlights the value of better understanding the perceptions of patients, relatives and physicians, in order to remove some of the barriers to transplantation. It also demonstrates the benefits of education and support activities for patients and patient relatives prior to transplantation, and continuing education and supervision for physicians.

[Inhalation therapy: inhaled generics, inhaled antidotes, the future of anti-infectives and the indications of inhaled pentamidine. GAT aerosolstorming, Paris 2012]. / Aérosolthérapie : les génériques par voie inhalée, les antidotes en aérosol, le futur des anti-infectieux et les indications de la pentamidine en aérosol. Aérosolstorming du GAT, Paris 2012.

The working group on aerosol therapy (GAT) of the Société de pneumologie de langue française (SPLF) organized its third "Aerosolstorming" in 2012. During the course of one day, different aspects of inhaled therapy were discussed, and these will be treated separately in two articles, this one being the first. Inhaled products represent a large volume of prescriptions both in the community and in hospital settings and they involve various specialties particularly ENT and respiratory care. Technical aspects of the development of these products, their mode of administration and compliance with their indications are key elements for the effective therapeutic use of inhaled treatments. In this first article, we will review issues concerning generic inhaled products, the existence of inhaled antidotes, new anti-infective agents and indications for inhaled pentamidine.

[Physical activity and exercise training for patients with cystic fibrosis]. / Activité physique et réentraînement à l'effort du patient atteint de mucoviscidose.

In France patients with cystic fibrosis benefit from a multidisciplinary follow-up in Cystic Fibrosis Centres. In this follow-up, despite the numerous therapeutic benefits of exercise in this disease, little emphasis is placed on the promotion of physical activity. The aim of this article is to improve this aspect of management, giving advice from a working group of experts, based on the medical literature and clinical experience. These proposals include quantification of physical activity, evaluation of exercise, training and rehabilitation programs and finally, modification of behaviour to include physical activity in the overall cystic fibrosis treatment strategy. It is intended to set up multicentre studies to evaluate the impact of these proposals.