Use of Dexamethasone to Prevent Extubation Failure in Pediatric Intensive Care Unit: A Randomized Controlled Clinical Trial.

Extubation failure is a common event in intensive care units. Corticosteroids are effective in preventing failure in adults, but no consensus has been reached on this matter in pediatrics. We assessed the efficacy of intravenous dexamethasone in mechanically ventilated children and adolescents for more than 48 hours, with at least one risk factor for failure. Extubations were scheduled 24 hours in advance when possible, and patients were randomly assigned into two groups: one group received a loading dose followed by up to four doses of dexamethasone, and the other group received no corticosteroids. Need for reintubation and length of stay in the pediatric intensive care unit were similar in both groups, and frequency of reintubation was 12.9%.

Diagnóstico e tratamento da síndrome do choque tóxico estreptocócico em unidade de terapia intensiva pediátrica: relato de caso / Diagnosis and treatment of streptococcal toxic shock syndrome in the pediatric intensive care unit: a case report

RESUMO Dentre as infecções causadas por Streptococcus β hemolyticus do grupo A de Lancefield, talvez a síndrome do choque tóxico seja a mais grave, com alto índice de mortalidade. A semelhança clínica com outras formas de choque, principalmente séptico, pode, muitas vezes, confundir o avaliador e interferir na escolha da terapêutica mais adequada. Esse relato tem o objetivo de auxiliar seus leitores quanto à necessidade de adicionar tal síndrome como diagnóstico diferencial, frente a quadros de choque, principalmente aqueles que não apresentam manifestações clínicas bem definidas. Para isso, apresentamos o quadro de um lactente com sintomas gripais comuns, que evoluiu rapidamente com exantema, rebaixamento do nível de consciência, sinais clínicos e laboratoriais de choque, com necessidade de suporte intensivo. Além de culturas indicando o agente etiológico, o aparecimento de exantema e fasciíte necrosante levou ao diagnóstico, mas, em menos de 50% dos casos temos sinais clínicos clássicos dessa entidade. As penicilinas em terapia combinada com aminoglicosídeos ainda são a terapia de escolha e possuem alto nível de evidência. Apesar da gravidade a evolução foi satisfatória.

ABSTRACT Among the infections caused by Streptococcus β hemolyticus from the Lancefield serogroup A, toxic shock syndrome is perhaps the most severe, and its mortality rate is high. Its clinical similarity to other forms of shock, especially septic shock, can often confuse the evaluator and interfere with the selection of the most appropriate therapy. This report aims to inform readers of the need to add this syndrome as a differential diagnosis in cases of shock, especially those with no well-defined clinical manifestations. For this purpose, we present the case of an infant with common flu-like symptoms who progressed rapidly with a rash, a reduced level of consciousness and clinical and laboratory signs of shock that required intensive support. In addition to cultures indicating the etiological agent, the appearance of exanthema and necrotizing fasciitis led to the diagnosis. However, less than 50% of cases present classic clinical signs of this entity. Penicillins combined with aminoglycosides are still the therapy of choice and are supported by a high level of evidence. Despite the severity of this patient's presentation, the progression was satisfactory.

Diagnosis and treatment of streptococcal toxic shock syndrome in the pediatric intensive care unit: a case report. / Diagnóstico e tratamento da síndrome do choque tóxico estreptocócico em unidade de terapia intensiva pediátrica: relato de caso.

Among the infections caused by Streptococcus ß hemolyticus from the Lancefield serogroup A, toxic shock syndrome is perhaps the most severe, and its mortality rate is high. Its clinical similarity to other forms of shock, especially septic shock, can often confuse the evaluator and interfere with the selection of the most appropriate therapy. This report aims to inform readers of the need to add this syndrome as a differential diagnosis in cases of shock, especially those with no well-defined clinical manifestations. For this purpose, we present the case of an infant with common flu-like symptoms who progressed rapidly with a rash, a reduced level of consciousness and clinical and laboratory signs of shock that required intensive support. In addition to cultures indicating the etiological agent, the appearance of exanthema and necrotizing fasciitis led to the diagnosis. However, less than 50% of cases present classic clinical signs of this entity. Penicillins combined with aminoglycosides are still the therapy of choice and are supported by a high level of evidence. Despite the severity of this patient's presentation, the progression was satisfactory.

Dentre as infecções causadas por Streptococcus ß hemolyticus do grupo A de Lancefield, talvez a síndrome do choque tóxico seja a mais grave, com alto índice de mortalidade. A semelhança clínica com outras formas de choque, principalmente séptico, pode, muitas vezes, confundir o avaliador e interferir na escolha da terapêutica mais adequada. Esse relato tem o objetivo de auxiliar seus leitores quanto à necessidade de adicionar tal síndrome como diagnóstico diferencial, frente a quadros de choque, principalmente aqueles que não apresentam manifestações clínicas bem definidas. Para isso, apresentamos o quadro de um lactente com sintomas gripais comuns, que evoluiu rapidamente com exantema, rebaixamento do nível de consciência, sinais clínicos e laboratoriais de choque, com necessidade de suporte intensivo. Além de culturas indicando o agente etiológico, o aparecimento de exantema e fasciíte necrosante levou ao diagnóstico, mas, em menos de 50% dos casos temos sinais clínicos clássicos dessa entidade. As penicilinas em terapia combinada com aminoglicosídeos ainda são a terapia de escolha e possuem alto nível de evidência. Apesar da gravidade a evolução foi satisfatória.

Antibiotic treatment schemes for very severe community-acquired pneumonia in children: a randomized clinical study.

OBJECTIVE: To compare clinical response to initial empiric treatment with oxacillin plus ceftriaxone and amoxicillin plus clavulanic acid in hospitalized children diagnosed with very severe community-acquired pneumonia (CAP). METHODS: A prospective randomized clinical study was conducted among children 2 months to 5 years old with a diagnosis of very severe CAP in the pediatric ward of São Paulo State University Hospital in Botucatu, São Paulo, Brazil, from April 2007 to May 2008. Patients were randomly divided into two groups by type of treatment: an oxacillin/ceftriaxone group (OCG, n = 48) and an amoxicillin/clavulanic acid group (ACG, n = 56). Analyzed outcomes were: time to clinical improvement (fever and tachypnea), time on oxygen therapy, length of stay in hospital, need to widen antimicrobial spectrum, and complications (including pleural effusion). RESULTS: The two groups did not differ statistically for age, sex, symptom duration before admission, or previous antibiotic treatment. Time to improve tachypnea was less among ACG patients than OCG patients (4.8 ± 2.2 versus 5.8 ± 2.4 days respectively; P = 0.028), as was length of hospital stay (11.0 ± 6.2 versus 14.4 ± 4.5 days respectively; P = 0.002). There were no statistically significant differences between the two groups for fever improvement time, time on oxygen therapy, need to widen antimicrobial spectrum, or frequency of pleural effusion. CONCLUSIONS: Both treatment plans are effective in treating very severe CAP in 2-month-to 5-year-old hospitalized children. The only analyzed outcome that favored amoxicillin/clavulanic acid treatment was time required to improve tachypnea. TRIAL REGISTRATION: ClinicalTrials.gov ID: NCT01166932.

Antibiotic treatment schemes for very severe community-acquired pneumonia in children: a randomized clinical study / Esquemas de tratamiento antibiótico para la neumonía extrahospitalaria muy grave en niños: estudio clínico aleatorizado

OBJECTIVE: To compare clinical response to initial empiric treatment with oxacillin plus ceftriaxone and amoxicillin plus clavulanic acid in hospitalized children diagnosed with very severe community-acquired pneumonia (CAP). METHODS: A prospective randomized clinical study was conducted among children 2 months to 5 years old with a diagnosis of very severe CAP in the pediatric ward of São Paulo State University Hospital in Botucatu, São Paulo, Brazil, from April 2007 to May 2008. Patients were randomly divided into two groups by type of treatment: an oxacillin/ceftriaxone group (OCG, n = 48) and an amoxicillin/clavulanic acid group (ACG, n = 56). Analyzed outcomes were: time to clinical improvement (fever and tachypnea), time on oxygen therapy, length of stay in hospital, need to widen antimicrobial spectrum, and complications (including pleural effusion). RESULTS: The two groups did not differ statistically for age, sex, symptom duration before admission, or previous antibiotic treatment. Time to improve tachypnea was less among ACG patients than OCG patients (4.8 ± 2.2 versus 5.8 ± 2.4 days respectively; P = 0.028), as was length of hospital stay (11.0 ± 6.2 versus 14.4 ± 4.5 days respectively; P = 0.002). There were no statistically significant differences between the two groups for fever improvement time, time on oxygen therapy, need to widen antimicrobial spectrum, or frequency of pleural effusion. CONCLUSIONS: Both treatment plans are effective in treating very severe CAP in 2-month-to 5-year-old hospitalized children. The only analyzed outcome that favored amoxicillin/clavulanic acid treatment was time required to improve tachypnea.

OBJETIVO: Comparar la respuesta clínica al tratamiento empírico inicial con oxacilina más ceftriaxona frente a amoxicilina más ácido clavulánico en niños hospitalizados con diagnóstico de neumonía extrahospitalaria muy grave. MÉTODOS: Se llevó a cabo un estudio clínico prospectivo aleatorizado en niños de 2 meses a 5 años de edad con diagnóstico de neumonía extrahospitalaria muy grave en la sala de pediatría del Hospital Universitario del Estado de São Paulo en Botucatu, São Paulo, Brasil, entre abril del 2007 y mayo del 2008. Los pacientes se dividieron aleatoriamente en dos grupos según el tratamiento administrado: un grupo recibió oxacilina/ceftriaxona (n = 48) y otro amoxicilina/ácido clavulánico (n = 56). Los criterios de valoración analizados fueron el tiempo hasta la mejoría clínica (de la fiebre y la taquipnea), el tiempo de administración de oxigenoterapia, la duración de la internación, la necesidad de ampliar el espectro antibiótico y las complicaciones (como el derrame pleural). RESULTADOS: Los dos grupos no presentaban diferencias estadísticas con respecto a la edad, el sexo, la duración de los síntomas antes de la internación o el tratamiento previo con antibióticos. El tiempo hasta la mejoría de la taquipnea fue menor en los pacientes tratados con amoxicilina/ácido clavulánico que en los que recibieron oxacilina/ceftriaxona (4,8 ± 2,2 días frente a 5,8 ±2,4 días, respectivamente; P = 0,028), y también fue menor la duración de la internación (11,0 ± 6,2 días frente a 14,4 ± 4,5 días, respectivamente; P = 0,002). No hubo diferencias estadísticamente significativas entre los dos grupos en relación con el tiempo hasta la mejoría de la fiebre, el tiempo de administración de oxigenoterapia, la necesidad de ampliar el espectro antibiótico ni la frecuencia de derrame pleural. CONCLUSIONES: Ambos esquemas de tratamiento son eficaces para tratar la neumonía extrahospitalaria muy grave en niños de 2 meses a 5 años de edad hospitalizados. El único criterio de valoración analizado que favoreció el tratamiento con amoxicilina/ ácido clavulánico fue el tiempo hasta la mejoría de la taquipnea.