Pediatric palliative care and end-of-life: a systematic review of economic health analyses.

OBJECTIVE: To perform a systematic review of the health economic evidence on the care of children and adolescents with complex clinical conditions, comparing groups included and not included (control group) in palliative care at the end of life. DATA SOURCE: The seven databases searched were PubMed, Embase, Web of Science, Cochrane Library, Virtual Health Library-Latin American and Caribbean Health Sciences Literature (VHL-LILACS), EBSCOhost, and Paediatric Economic Database Evaluation, following recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, from January 1979 to November 2020. The review included studies of patients under 18 years of age with complex clinical conditions that compared a palliative care group with a control group. The economic outcomes analyzed were length and place of stay at the end of life (home, hospice, ward, intensive care unit, emergency room), diagnostic and therapeutic procedures performed, and health-related costs. The exclusion criteria were: studies without a matched control group, conference/congress abstracts, letters to the editor, editorials, comments, qualitative studies, narrative reviews, studies with ten or fewer participants in each group, articles published in languages other than English, Portuguese, or Spanish. DATA SYNTHESIS: Out of the 518 articles identified, 4 met the inclusion criteria. We found evidence of direct economic benefits, such as reduced health costs, indirect savings, and protection of patients from undergoing invasive procedures, surgeries, and costly therapies, which cause greater suffering at the end of life. Therefore, participating in a palliative care program saved financial and technological resources, besides increasing the frequency of deaths at home and improving the quality of life. CONCLUSIONS: Public and private policies to promote palliative care represent better efficiency when allocating available health care resources.

Pediatric palliative care and end-of-life: a systematic review of economic health analyses / Cuidados paliativos pediátricos e no fim de vida: uma revisão sistemática da avaliação econômica em saúde

Abstract Objective: To perform a systematic review of the health economic evidence on the care of children and adolescents with complex clinical conditions, comparing groups included and not included (control group) in palliative care at the end of life. Data source: The seven databases searched were PubMed, Embase, Web of Science, Cochrane Library, Virtual Health Library-Latin American and Caribbean Health Sciences Literature (VHL-LILACS), EBSCOhost, and Paediatric Economic Database Evaluation, following recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, from January 1979 to November 2020. The review included studies of patients under 18 years of age with complex clinical conditions that compared a palliative care group with a control group. The economic outcomes analyzed were length and place of stay at the end of life (home, hospice, ward, intensive care unit, emergency room), diagnostic and therapeutic procedures performed, and health-related costs. The exclusion criteria were: studies without a matched control group, conference/congress abstracts, letters to the editor, editorials, comments, qualitative studies, narrative reviews, studies with ten or fewer participants in each group, articles published in languages other than English, Portuguese, or Spanish. Data synthesis: Out of the 518 articles identified, 4 met the inclusion criteria. We found evidence of direct economic benefits, such as reduced health costs, indirect savings, and protection of patients from undergoing invasive procedures, surgeries, and costly therapies, which cause greater suffering at the end of life. Therefore, participating in a palliative care program saved financial and technological resources, besides increasing the frequency of deaths at home and improving the quality of life. Conclusions: Public and private policies to promote palliative care represent better efficiency when allocating available health care resources.

Resumo Objetivo: Realizar revisão sistemática das evidências de economia da saúde no cuidado de crianças e adolescentes com condições clínicas complexas, comparando no fim de vida o grupo inserido em cuidados paliativos com o grupo não inserido (grupo controle). Fontes de dados: As sete bases de dados pesquisadas foram PubMed, Embase, Web of Science, Cochrane Library, Biblioteca Virtual da Saúde-Literatura Latino-Americana e do Caribe em Ciências da Saúde (BVS-LILACS), EBSCOhost e Paediatric Economic Database Evaluation, seguindo as recomendações do Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement, de janeiro/1979 a novembro/2020. A revisão incluiu estudos com pacientes com condições clínicas complexas, idade inferior a 18 anos, comparativos de um grupo inserido em cuidados paliativos com um grupo controle não inserido em cuidados paliativos. Os desfechos econômicos analisados foram tempo e local de permanência no fim de vida (casa, hospice, enfermaria, unidade de terapia intensiva, pronto-socorro), procedimentos diagnósticos e terapêuticos realizados e custos relacionados aos cuidados de saúde. Os critérios de exclusão foram: estudos sem grupo controle pareados, resumos de conferências/congressos, cartas ao editor, editoriais, comentários, estudos qualitativos, revisões narrativas, estudos com dez ou menos participantes, artigos publicados em outras línguas além de inglês, português e espanhol. Síntese dos dados: Do total de 518 artigos identificados, quatro preencheram os critérios de inclusão. Houve evidências de benefícios econômicos diretos de redução de custos monetários relacionados à saúde e também indiretos, de economia e proteção ao paciente de procedimentos invasivos, cirurgias e terapias onerosas, que geram maior sofrimento no fim de vida. Portanto, estar inserido em um programa de cuidados paliativos promoveu economia de recursos financeiros e tecnológicos, além de ter possibilitado maior frequência de óbitos no domicílio e maior qualidade de vida. Conclusões: Políticas públicas e privadas para promover cuidados paliativos representam melhor eficiência na alocação dos recursos disponíveis para cuidados em saúde.

Clinical and laboratory features of urinary tract infections in young infants.

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.

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.

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.

Acute Hemorrhagic Edema of Infancy: an unusual diagnosis for the general pediatrician.

Acute Hemorrhagic Edema of Infancy (AHEI) is a rare leukocytoclastic vasculitis, clinically characterized by the classical triad: palpable purpuric skin lesions, edema and fever, and is commonly misdiagnosed as Henoch-Schönlein purpura. In addition to its sudden onset, AHEI is also characterized by its self-limited course with complete and spontaneous recovery occurring between 1 and 3 weeks. Because of the scarcity of studies on therapy with corticosteroids, the conservative approach is usually recommended. The authors report an unusual case of an one-year-old boy who presented with typical cutaneous rash of AHEI and orchitis, the latter showing complete resolution after less than 24 hours of prednisolone therapy. The authors call attention to this entity mainly as a differential diagnosis of Henoch-Schönlein purpura and to the importance of new studies to establish the benefits of corticosteroid therapy for AHEI.

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.

High Frequency of Staphylococcus Saprophyticus Urinary Tract Infections Among Female Adolescents.

Staphylococcus saprophyticus is a rarely reported agent of urinary tract infection (UTI) in the pediatric population. In our retrospective 3-year study, S. saprophyticus comprised 24.5% of 106 isolates of UTIs in female adolescents 12-15 years of age who attended an emergency department. Clinicians should be aware of the high prevalence of this etiology when empirically treating UTIs in female adolescents.

[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.

Otomastoiditis caused by Sphingomonas paucimobilis: case report and literature review.

Sphingomonas paucimobilis is an aerobic Gram-negative bacillus that, although rare in humans, most commonly infects immunocompromised and hospitalized patients. Among the 59 pediatric cases of S. paucimobilis infection reported in the literature, the most common diagnosis involves isolated bacteremia. These cases are related to sporadic or epidemic infections. Death related to this infection occurred in only one case. The authors report a case of an 11-year-old boy with the diagnosis of Sphingomonas paucimobilis otomastoiditis and a thorough review of the literature on this infection in pediatrics. The patient presented a 20-day history of fever, otalgia, otorrhea, and progressive retroauricular swelling with protrusion of the left ear; despite 15 days of amoxicillin regimen. His past medical history included chronic bilateral otitis media, but no cause of immunosuppression was found. A brain computed tomography scan showed left otomastoiditis associated with a large circumscribed fluid collection with deep involvement of the soft tissues of the temporal region, including the subperiosteal space. Blood tests showed neutrophilia and elevated C-reactive protein. Surgical manipulation of the cited collection drained a large amount of a fetid purulent secretion. Ceftazidime and clindamycin were empirically initiated. The outcome was favorable, with fever defervescence and resolution of the scalp deformation. Culture of the drained secretion was positive for S. paucimobilis. Ciprofloxacin was scheduled for a further 10 days after discharge. The follow-up showed complete recovery. As far as we know, this is the first case of S. paucimobilis otomastoiditis, complicated with subperiosteal abscess in an immunocompetent child. The authors call attention to the increasing number of reports on S. paucimobilis infection over the years, and therefore to the importance of this pathogen, which was previously underestimated.

Cat-scratch disease presenting as multiple hepatic lesions: case report and literature review.

Although infectious diseases are the most prevalent cause of fevers of unknown origin (FUO), this diagnosis remains challenging in some pediatric patients. Imaging exams, such as computed tomography (CT) are frequently required during the diagnostic processes. The presence of multiple hypoattenuating scattered images throughout the liver associated with the history of cohabitation with cats should raise the suspicion of the diagnosis of cat-scratch disease (CSD), although the main etiologic agent of liver abscesses in childhood is Staphylococcus aureus. Differential diagnosis by clinical and epidemiological data with Bartonella henselae is often advisable. The authors report the case of a boy aged 2 years and 9 months with 16-day history of daily fever accompanied by intermittent abdominal pain. Physical examination was unremarkable. Abdominal ultrasound performed in the initial work up was unrevealing, but an abdominal CT that was performed afterwards disclosed multiple hypoattenuating hepatic images compatible with the diagnosis of micro abscesses. Initial antibiotic regimen included cefotaxime, metronidazole, and oxacillin. Due to the epidemiology of close contact with kittens, diagnosis of CSD was considered and confirmed by serologic tests. Therefore, the initial antibiotics were replaced by clarithromycin orally for 14 days followed by fever defervescence and clinical improvement. The authors call attention to this uncommon diagnosis in a child presenting with FUO and multiple hepatic images suggestive of micro abscesses.

Community-acquired urinary tract infection: age and gender-dependent etiology.

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: Cross-sectional 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.

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.

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.

Purpura trombocitopenica imunologica associada a hepatite A: relato de caso / Immune thrombocytopenic purpura associated to hepatitis A: a case report

Relatar um caso grave de purpura trombocitopenica imunologica apos infeccoes pelo virus da hepatite A...

Neuroesquistossomose medular: relato de um caso com sequelas graves / Report on a serious case of spinal cord schistosomiasis

Os autores apresentam o caso de um adolescente procedente do litoral sul do Estado de Säo Paulo, portador de esquistossomose com comprometimento medular. Säo discutidos os aspectos mais relevantes com relaçäo aos mecanismos fisiologicos desta doenäa, sua terapeutica e prognóstico. Enfatiza-se a importância do reconhecimento precoce da neuropatia esquistossomotica nas mielopatias da infância