Tuberculosis en el adolescente; reto y oportunidad de evitar el contagio a la comunidad / Adolescent tuberculosis; a challenge and opportunity to prevent community transmission

INTRODUCCIÓN: La tuberculosis (TB) en el adolescente puede presentar formas radiológicas cavitadas en los lóbulos superiores, con esputos bacilíferos, en lo que se ha llamado TB pulmonar tipo adulto, que implica un importante riesgo de contagio en el entorno social y familiar del paciente. PACIENTES Y MÉTODOS: Estudio observacional retrospectivo (2007-2012) en una serie pediátrica (< 18 años) con TB en un hospital pediátrico de referencia en Barcelona. Se compara a los pacientes ≤ 12 y > 12 años. RESULTADOS: Se incluyeron 124 pacientes (56,5% hombres, edad mediana: 4,0 años). En la mitad, la TB afectó a pacientes de origen inmigrante y se diagnosticó por sospecha clínico-radiológica. La TB intratorácica fue la forma clínica predominante (91,9%), los cultivos fueron positivos en un tercio de los casos (37,9%) y sensibles a los fármacos orales de primera línea en su totalidad. El tiempo mediano (rango intercuartil) de tratamiento fue de 6 (6-9) meses; solo 10 pacientes precisaron tratamiento directamente observado y la evolución fue satisfactoria en la mayoría (98,4%). Entre los adolescentes, la TB fue más prevalente en mujeres (63,2%) e inmigrantes (68,4%), la comorbilidad al diagnóstico y las formas pulmonares cavitadas fueron más comunes y se identificó el caso índice solo en el 21,1% de los pacientes. CONCLUSIÓN: En el adolescente, la TB pulmonar tipo adulto es común, y a menudo asocia comorbilidad y se diagnostica más tarde, implicando un mayor riesgo de contagio a la comunidad

INTRODUCTION: Adolescents may present with adult-type pulmonary tuberculosis (TB), including cavity disease in upper lobes and smear-positive sputum, which involves a significant transmission risk for social and family contacts. PATIENTS AND METHODS: A retrospective (2007-2012) observational study of a case series of TB was conducted in children and adolescents (< 18 years) in a paediatric referral centre in Barcelona. Patients aged ≤ 12 and > 12 years at diagnosis are compared. RESULTS: The series consisted of 124 patients (56.5% males, median age: 4.0 years). In half of the cases, the patient was of immigrant origina and TB was diagnosed after clinical-radiological suspicion, intra-thoracic disease being the most common (91.9%). Cultures yielded positive results in one third of cases (37.9%) and isolates were sensitive to oral first-line anti-TB agents in 100%. Median (interquartile range) duration of treatment was 6 (6-9) months, directly observed therapy was needed in 10 patients, and there was a satisfactory outcome after treatment in 98.4%. Among adolescents, TB was more prevalent in females (63.2%) and immigrant patients (68.4%), comorbidity at diagnosis and lung cavity forms were more common, and the source case was identified only in 21.1% of the patients. CONCLUSION: Adult-type pulmonary TB is common among adolescents, may be associated with underlying medical conditions, and is often diagnosed late, posing a significant transmission risk to the community

[Adolescent tuberculosis; a challenge and opportunity to prevent community transmission]. / Tuberculosis en el adolescente; reto y oportunidad de evitar el contagio a la comunidad.

INTRODUCTION: Adolescents may present with adult-type pulmonary tuberculosis (TB), including cavity disease in upper lobes and smear-positive sputum, which involves a significant transmission risk for social and family contacts. PATIENTS AND METHODS: A retrospective (2007-2012) observational study of a case series of TB was conducted in children and adolescents (<18 years) in a paediatric referral centre in Barcelona. Patients aged≤12 and>12 years at diagnosis are compared. RESULTS: The series consisted of 124 patients (56.5% males, median age: 4.0 years). In half of the cases, the patient was of immigrant origina and TB was diagnosed after clinical-radiological suspicion, intra-thoracic disease being the most common (91.9%). Cultures yielded positive results in one third of cases (37.9%) and isolates were sensitive to oral first-line anti-TB agents in 100%. Median (interquartile range) duration of treatment was 6 (6-9) months, directly observed therapy was needed in 10 patients, and there was a satisfactory outcome after treatment in 98.4%. Among adolescents, TB was more prevalent in females (63.2%) and immigrant patients (68.4%), comorbidity at diagnosis and lung cavity forms were more common, and the source case was identified only in 21.1% of the patients. CONCLUSION: Adult-type pulmonary TB is common among adolescents, may be associated with underlying medical conditions, and is often diagnosed late, posing a significant transmission risk to the community.

Adherence to Antituberculosis Drugs in Children and Adolescents in A Low-Endemic Setting: A Retrospective Series.

Adherence to antituberculosis drug regimens is critical for the prevention and treatment of tuberculosis in pediatrics. In a large retrospective series of children and adolescents in Barcelona, Spain, completion of treatment was worse among patients treated for latent infection, compared with those treated for active tuberculosis or receiving primary chemoprophylaxis. Toxicity and cultural and language barriers were identified as predictors of nonadherence.

Impact of the Increased Recommended Dosage of Isoniazid on Pyridoxine Levels in Children and Adolescents.

Isoniazid exposure causes dose-dependent pyridoxine deficiency. Recently, the recommended dosage of isoniazid in children was increased from 5 (4-6) to 10 (10-15) mg/kg/day. We aimed to analyze longitudinally pyridoxine levels in a cohort of previously healthy children and adolescents treated with isoniazid. Mild symptom-free pyridoxine deficiency was observed in 4/75 (5.6%) and 3/40 (7.5%) at baseline and at 3-month follow-up, respectively. Classical age-related risk factors identified patients at risk of pyridoxine deficiency. Our preliminary results support current recommendations regarding pyridoxine supplementation in healthy children.

The impact of a quality improvement intervention to reduce nosocomial infections in a PICU.

OBJECTIVE: To evaluate whether a quality improvement intervention could reduce nosocomial infection rates in a PICU and improve patient outcomes. DESIGN: Prospective interventional cohort study conducted during three periods: preintervention period, intervention period, and long-term follow-up. SETTING: A 14-bed medical and surgical PICU in a university hospital for children. INTERVENTIONS: The quality improvement intervention consisted of the creation of an infection control team, a program targeting hand hygiene, and quality practices focused on preventing nosocomial infections. MEASUREMENTS AND MAIN RESULTS: We included 851 patients in the preintervention period, 822 in the intervention period, and 940 in the long-term follow-up period. Compared with the preintervention period, in the intervention period, the rates of central line-associated bloodstream infection decreased from 8.1 to 6/1,000 central venous catheter-days (p = 0.640), ventilator-associated pneumonia decreased from 28.3 to 10.6/1,000 days' ventilation (p = 0.005), and catheter-associated urinary tract infection decreased from 23.3 to 5.8/1,000 urinary catheter-days (p < 0.001). Furthermore, hospital length of stay decreased from 18.56 to 14.57 days (p = 0.035) and mortality decreased from 5.1% to 3.3% (p = 0.056). Multivariable logistic regression found that nosocomial infections was independently associated with increased mortality (odds ratio, 2.35 [95% CI, 1.02-5.55]; p = 0.046). Compared with the preintervention period, in the long-term follow-up period, central line-associated bloodstream infection decreased to 4.6/1,000 central venous catheter-days (p = 0.205); ventilator-associated pneumonia decreased to 9.1/1,000 ventilation-days (p = 0.001), and catheter-associated urinary tract infection decreased to 5.2/1,000 urinary catheter-days (p < 0.001). Hospital length of stay (14.45 days; p = 0.048) and mortality (3.2%; p = 0.058) also decreased. CONCLUSIONS: A multifaceted quality improvement intervention reduced nosocomial infection rates, hospital length of stay, and mortality in our PICU. The effects of the intervention were sustained over time.

Exposición a dispositivos extrínsecos, un indicador de infección intrahospitalaria / Exposure to devices: an indicator of nosocomial infection

Objetivo: Diseñar un protocolo de vigilancia sistemática de la infección nosocomial (IN) asociada a dispositivos extrínsecos, más frecuentemente usados en una Unidad de Cuidados Intensivos Pediátricos (UCIP). Material y métodos: Estudio prospectivo de vigilancia de la IN asociada a la exposición de dispositivos extrínsecos tipo catéter venoso central, ventilación mecánica y sonda urinaria en una UCIP, durante el período de abril a junio de 2004. Se tuvo en cuenta las infecciones tipo: bacteriemia, neumonía e infección del tracto urinario, utilizando los criterios del Centers for Disease Control and Prevention. Resultados: Se realizó el seguimiento a un total de 326 pacientes pediátricos, el 45% portadores de sonda urinaria, el 30% con catéter venoso central y el 25% expuestos a ventilación mecánica. La tasa de IN fue de 0,6 bacteriemias, 0,4 neumonías y 0,3 infecciones del tracto urinario, por 100 días de exposición al catéter venoso central, ventilación mecánica y sonda urinaria, respectivamente. Conclusiones: La vigilancia epidemiológica de la IN permite conocer las tasas de infección por factores de riesgo asociados a su desarrollo, en un período definido y, por tanto, implementar las medidas de control de la infección, con el fin de disminuir su frecuencia y reducir el coste de estancia hospitalaria secundario a éstas

Objective: To design a protocol for the systematic surveillance of nosocomial infections associated with the devices most frequently used in pediatric intensive care units (PICUs). Material and methods: We performed a prospective epidemiological surveillance study of nosocomial infections associated with devices such as central venous catheters, mechanical ventilation and urinary catheters in a PICU from April to June 2004. The criteria of the Centers for Disease Control and Prevention (CDC) were used to define bacteremia, pneumonia, and urinary tract infection. Results: A total of 326 pediatric patients were studied (45% with urinary catheters, 30% with venous catheters, and 25% under mechanical ventilation). The nosocomial infection rate was 0.6 cases of bacteremia, 0.4 cases of pneumonia and 0.3 cases of urinary tract infection per 100 device days. Conclusions: Epidemiological surveillance of nosocomial infections using a simple protocol allows risk factor-associated infection rates to be determined in a specific time period and measures for infection control to be implemented. These strategies aim to reduce the frequency of infections and consequent cost per days of hospital stay