Variation in paediatric hospital antibiotic guidelines in Europe.

OBJECTIVE: To assess the availability and source of guidelines for common infections in European paediatric hospitals and determine their content and characteristics. DESIGN: Participating hospitals completed an online questionnaire on the availability and characteristics of antibiotic prescribing guidelines and on empirical antibiotic treatment including duration of therapy for 5 common infection syndromes: respiratory tract, urinary tract, skin and soft tissue, osteoarticular and sepsis in neonates and children. RESULTS: 84 hospitals from 19 European countries participated in the survey of which 74 confirmed the existence of guidelines. Complete guidelines (existing guidelines for all requested infection syndromes) were reported by 20% of hospitals and the majority (71%) used a range of different sources. Guidelines most commonly available were those for urinary tract infection (UTI) (74%), neonatal sepsis (71%) and sepsis in children (65%). Penicillin and amoxicillin were the antibiotics most commonly recommended for respiratory tract infections (RTIs) (up to 76%), cephalosporin for UTI (up to 50%) and for skin and soft tissue infection (SSTI) and bone infection (20% and 30%, respectively). Antistaphylococcal penicillins were recommended for SSTIs and bone infections in 43% and 36%, respectively. Recommendations for neonatal sepsis included 20 different antibiotic combinations. Duration of therapy guidelines was mostly available for RTI and UTI (82%). A third of hospitals with guidelines for sepsis provided recommendations for length of therapy. CONCLUSIONS: Comprehensive antibiotic guideline recommendations are generally lacking from European paediatric hospitals. We documented multiple antibiotics and combinations for most infections. Considerable improvement in the quality of guidelines and their evidence base is required, linking empirical therapy to resistance rates.

Trends in the epidemiology of childhood tuberculosis in Greece.

SETTING: A hospital referral center for childhood tuberculosis (TB). OBJECTIVE: To evaluate the epidemiological and clinical features of childhood TB in the Greater Athens area in the last decade. DESIGN: We retrospectively reviewed the medical records of patients aged <14 years treated for active TB between January 2000 and December 2009 at our pediatric TB clinic and compared the results with the patient turnover during the previous decade (1990-1999). Data concerning demographic and clinical characteristics were analyzed. RESULTS: A total of 321 children (median age 5.57 years, 157 males) with active TB were identified. About one third originated from areas where TB was previously recognized to be highly endemic. Twenty-three children (7%) had extra-pulmonary TB, and 61% of them originated from TB-endemic areas. Bacteriological confirmation was obtained in 40% of patients from whom specimens were obtained: 1 of 26 (3.8%) strains was multidrug-resistant. Most cases with drug-resistant Mycobacterium tuberculosis were noted among immigrant children. The average annual TB incidence was estimated at 5.37 per 100 000 for children aged <14 years in the Greater Athens area. Time trend analysis for the 20-year period revealed a significant reduction in the total number of TB cases (P = 0.002) and in TB among children from low-incidence countries (P < 0.0001). CONCLUSIONS: In our settings, active TB is decreasing among children of Greek origin; disease epidemiology and drug resistance is influenced by the increasing influx of immigrants from areas where the disease is highly prevalent.

Impact of the Gen-Probe Amplified MTD® Test on tuberculosis diagnosis in children.

OBJECTIVE: To evaluate the performance of the Gen-Probe Amplified MTD® Test (AMTD) for childhood tuberculosis (TB) diagnosis compared to conventional culture. DESIGN: We retrospectively studied 121 childhood cases (73 males; median age 7 years, range 1-16). Pulmonary samples (104/152, 68%) included gastric aspirates (n = 53), induced sputum samples (n = 43), bronchial aspirates and bronchoalveolar lavage (n = 8). Extra-pulmonary samples (48/152, 32%) included lymph nodes (n = 34) and other sterile fluids (n = 14). Specimens were examined using acid-fast bacilli (AFB) microscopy, AMTD and bacterial culture using BACTEC™ MGIT™ 960 and Löwenstein-Jensen (LJ) media. RESULTS: A clinical diagnosis of TB was made in 50/121 (41%) children (43/50 pulmonary disease). AFB microscopy was positive in 6%; Mycobacterium tuberculosis was recovered by culture from 16/50 (32%) and AMTD was positive in 29/50 (58%). AMTD sensitivity, specificity, positive predictive value and negative predictive value compared to culture were respectively 100%, 85%, 50% and 100%. For pulmonary vs. extra-pulmonary disease, the performance of AMTD compared to culture was respectively 100%, 77%, 46% and 100% vs. 100%, 97.5%, 75% and 100%. CONCLUSIONS: Nucleic acid amplification tests are more sensitive and very specific methods for the rapid detection of M. tuberculosis. The AMTD technique increases TB detection in children compared to conventional culture.

Latent tuberculosis infection in children: diagnostic approaches.

Tuberculosis (TB) remains an important public health problem and a leading infectious cause of death. Diagnosis and treatment of latent tuberculosis infection (LTBI) is important for TB control and elimination. Nevertheless, the diagnosis of LTBI in both adults and children remains complex, since there is no gold standard. The development of interferon gamma release assays was a major breakthrough in the diagnosis of LTBI. The evaluation of IGRAs in the diagnosis of LTBI in children is proven to be difficult since childhood TB differs from adults as immune responses vary with age. Separate studies assessing IGRAs performance in children are still limited, and only a few of them divide results by narrow age groups Nevertheless, new approaches are being exploited by the ongoing research for the development of more efficient diagnostic tools. It is likely that many changes in both the diagnosis and management of LTBI will occur in the near future. We believe that better understanding of the immunopathology of latency can ultimately lead to the development of more effective strategies in TB control. In the present review we summarize current data on diagnosis of LTBI in children, underscoring the existing challenges and limitations.

Association of hypospadias and cardiac defect in a Parvovirus B19-infected stillborn: a causality relation?

Parvovirus B19 intrauterine infection is a known cause of hydrops fetalis and fetal death. It is also associated with congenital malformations, although the teratogenic potential seems to be low. Postmortem examination of a male stillborn of 29 gestational weeks revealed mild subcutaneous edema, malformed micropenis, perineoscrotal hypospadias and atrial septal defect, along with fetal erythroblastosis and villitis. Polymerase chain reaction detected Parvovirus B19 DNA genome in tissues from the fetus and the placenta, confirming the hypothesis of an intrauterine infection.