Aggregatibacter actinomycetemcomitans infection in children: two case reports and a review of the literature.

Aggregatibacter actinomycetemcomitans (Aa), a Gram-negative coccobacillus commonly associated with endocarditis, poses a rare diagnostic challenge in pediatric cases. The presentation of two pediatric cases-myositis and chest mass-highlights novel aspects, including unusual symptom presentations in children which can be mistaken for malignancy. The limited sensitivity of standard blood tests complicates diagnosis, leading to delayed diagnosis and treatment. Representative samples must be taken, especially if blood cultures are negative. Despite advances in detection methods, diagnosing Aa infection remains difficult due to its rarity in children and variable clinical presentation. In conclusion, a comprehensive understanding of Aa infection in children is essential for early and effective diagnostic and therapeutic management.

From the original SARS-CoV-2 strain to the Omicron variant: Predictors of COVID-19 in ambulatory symptomatic children.

OBJECTIVES: To determine the predictors of a positive SARS-CoV-2 test in a pediatric ambulatory setting. PATIENTS AND METHODS: We performed a cross-sectional prospective study (November 2020-February 2022) of 93 ambulatory settings in France. We included symptomatic children < 15 years old tested for SARS-CoV-2. For each period corresponding to the spread of the original strain and its variants (period 1: original strain; period 2: Alpha, period 3: Delta; period 4: Omicron), we used a multivariate analysis to estimate adjusted odds ratios (aORs) associated with COVID-19 among age, signs, symptoms or contact, and 95 % confidence intervals (95CIs). RESULTS: Of 5,336 children, 13.9 % (95CI 13.0-14.8) had a positive test. During the first three periods, the positivity rate ranged from 5.6 % (95CI 4.6-6.7) to 12.6 % (95CI 10.8-14.6). The main factors associated with a positive test were contact with an infected adult at home or outside the home (aOR 11.5 [95CI 4.9-26.9] to 38.9 [95CI 19.3-78.7]) or an infected household child (aOR 15.0 [95CI 4.8-47.1] to 28.4 [95CI 8.7-92.6]). By contrast, during period 4, aORs for these predictors were substantially lower (2.3 [95CI 1.1-4.5] to 5.5 [95CI 3.2-7.7]), but the positivity rate was 45.7 % (95CI 42.3-49.2). CONCLUSIONS: In pediatric ambulatory settings, before the Omicron period, the main predictor of a positive test was contact with an infected person. During the Omicron period, the odds of these predictors were substantially lower while the positivity rate was higher. An accurate diagnostic strategy should only rely on testing and not on age, signs, symptoms or contact.

Training of pediatricians in infectious diseases in France: survey among pediatricians enrolled in the French infectious diseases training program: Training of pediatricians in infectious diseases in France.

The French infectious diseases (ID) program was accessible to all medical trainees enrolled in postgraduate training for other specialties until 2017, when it became an independent specialty. Therefore, the national ID training is no longer accessible to pediatricians, and a specific program for pediatric ID (PID) is under development. We conducted a survey among French pediatric trainees enrolled in the former ID training to assess their satisfaction and describe the barriers they may have faced during the training. A questionnaire was sent in October 2018 to all pediatricians enrolled in this curriculum. Among the 17 trainees who replied, almost half (8/17) described the ID training as being hardly accessible to pediatricians, and six reported difficulties in finding a mandatory one-year position in an ID department to complete their training. Future training in PID should address these issues.

Case report of nutritional rickets in an infant following a vegan diet.

We report the case of a 13-month-old infant who was referred to the pediatric emergency department because of psychomotor regression with four bone fractures due to nutritional rickets. The reason was prolonged breastfeeding from a vegetarian mother followed by a vegan diet for the infant after weaning. Rickets is one of the many nutritional deficiencies that could affect infants fed vegan or vegetarian diets. These diets are a public health concern requiring adapted information that suggests alternative formulas made from rice or soy proteins and adapted supplementation after weaning.

Vaccine-preventable meningitis in French children with incorrect vaccination status from 2011 to 2013.

The objective of this study was to determine the number of cases of pediatric meningitis or purpura fulminans associated with an incorrect vaccination status from 2011 to 2013 in France. A total of 48 children with vaccine-preventable meningitis or purpura fulminans, including three deaths, had an incorrect vaccination status: 26 cases were due to Neisseria meningitidis group C (54.2%), 19 to Streptococcus pneumoniae (39.6%), and three to Haemophilus influenzae type b (6.3%). The majority of patients (n=35, 72.9%) had received no injection of the vaccine concerned. Over a 3-year period, 48 cases of bacterial meningitis or purpura fulminans in children could have been avoided if the French immunization schedule had been followed.

[Bilateral pulmonary embolism mimicking acute chest syndrome in an adolescent with sickle cell disease]. / Embolie pulmonaire bilatérale mimant un syndrome thoracique aigu chez un adolescent drépanocytaire.

Pulmonary embolism is a life-threatening and potentially lethal disease. Its incidence in children with sickle cell disease is probably underestimated and pediatric case reports in the literature are rare. Moreover, symptoms can mimic an acute chest syndrome. We report on the case of a 17-year-old boy with SS sickle cell disease, admitted for chest pain with dyspnea and tachycardia. Pulmonary angiography revealed a partial bilateral obstructive pulmonary embolism. We did not find any deep venous thrombosis or thrombophilia. The progression was rapidly favorable with anticoagulant therapy. We recommend a pulmonary angiography for any chest pain that does not evolve favorably in a child with sickle cell disease. Large series of pediatric patients would be useful to establish diagnostic and therapeutic guidelines.

Principles of curative antibiotic treatment.

Infectious diseases are constantly evolving for many reasons. New infectious agents are regularly discovered, mainly because of the development of identification methods, including the molecular tools and mass spectrometry. Changes in the epidemiology of infectious diseases are not always understood, but several factors undoubtedly play an important role, notably the impact of vaccination implementations, the ecological consequences of antibiotic treatments and their excessive use, and the secular epidemiological trends of pathogenic agents. Antibiotic resistance has been recognized as one of the major challenges for humanity and few new antibiotics with potent activity against resistant Gram-negative rods have been developed in recent years. The rationalization of antibiotic treatments is a key for reducing or limiting antimicrobial resistance. This guide takes into account the latest recommendations, the consensus conferences, and the guidelines of the Pediatric Infectious Diseases Group of the French Society of Pediatric, the French Infectious Diseases Society, and French official agencies. For each clinical situation, the main bacterial target of the antibiotic treatment, the first-choice antibiotic and the alternative treatment, as well as the most important findings for the diagnosis and treatment of the infection are detailed.

Antimicrobial treatment of urinary tract infections in children.

Urinary tract infections are the most frequent documented bacterial infections in children. The antibiotic choices proposed in this manuscript are based on the guidelines published by the Pediatric Infectious Disease Group (GPIP) and the French-Language Infectious Disease Society (SPILF). Dipstick positive for leukocytes and/or nitrites must precede in most circumstances (excluding the newborns, neutropenic patients and those with sepsis), urine culture and antibiotic prescription. The proportion of extended-spectrum ß-lactamase (ESBL) Escherichia coli strains has increased steadily in recent years, and the situations in which oral antibiotic switch is frequently not available are increasing. Cephalosporin resistance remains below 10% in most regions of France. However, there is no doubt that the proportion of resistant strains will increase in the coming years: the only uncertainly concerns the speed of this trend. With the aim of saving penems and promoting outpatient care, this guide proposes among the acceptable initial treatments for febrile urinary tract infections in infants, amikacin. This aminoglycoside remains active against the majority of ESBL strains and can be prescribed in once-daily dose allowing also ambulatory management of patients from pediatric emergency department.

Antibiotic treatment of skin and soft tissue infections.

Bacterial skin and soft tissues infections are common in children and frequently do not require systemic antibiotics, especially if lesions are superficial. Careful washing is always indicated in superficial lesions and is often sufficient. Careful evaluation of symptoms (which may be difficult despite the accessibility of the lesions) should be performed before prescription. Therefore, the need for drainage (spontaneous or surgical) should be assessed considering that antibiotics are mostly useless if purulent lesions are drained. Presence of toxinic symptoms (i.e., generalized cutaneous rash, diarrhea, hypotension) are strongly associated with enhanced severity. The bacterial targets for antibiotics are mainly Staphylococcus aureus (SA) and Streptococcus pyogenes. Considering the low incidence of methicillin-resistant SA in France, the French Pediatric Infectious Disease Group recommends the use of amoxicillin + clavulanate as the first-line antibiotic in most children suffering from severe skin infections requiring antibiotic treatment. In patients presenting toxinic symptoms and signs, the adjunction of an antibiotic with antitoxin properties such as clindamycin should be considered.

Antibiotic therapy of bone and joint infections in children: proposals of the French Pediatric Infectious Disease Group.

Acute hematogenous bone and joint infections (osteomyelitis, septic arthritis, osteoarthritis, and spondylodiscitis) affect more frequently children younger than 5 years of age. Early diagnosis and prompt treatment are needed to limit the risk of complications. Children with suspected bone and joint infections (BJI) should be hospitalized at the beginning of treatment. Surgical drainage is indicated in patients with septic arthritis and in those with periosteal abscess. Staphylococcus aureus is involved in BJIs in children at all ages; Kingella kingae is a very common causative pathogen in children under 4 years of age. The French Pediatric Infectious Disease Group recommends in children > 3 months of age empirical antibiotic therapy with appropriate coverage against methicillin-sensitive S. aureus with high doses (150mg/kg/day) of intravenous amoxicillin-clavulanate, cefuroxime or cefazoline. In most children with uncomplicated BJI, short intravenous antibiotic therapy for 3 days can be followed by oral therapy. The minimum total duration of antibiotic therapy should be 10 days for septic arthritis and 3 weeks for osteomyelitis.

Bacterial meningitis antibiotic treatment.

The implementation of pneumococal conjugate vaccines (PCVs) 7 then 13 valent (Prevenar13®) in 2010-2011 has significantly changed the profile of pneumococcal meningitis. Since 3 years, the National Pediatric Meningitis Network of the Pediatric Infectious Disease Group (GPIP) and the National Reference Centre of Pneumococci have reported no cases of meningitis due to pneumococcus resistant to third-generation cephalosporins (3GC): cefotaxime or ceftriaxone. In the light of these new data, vancomycin should no longer be prescribed at the initial phase of pneumococcal meningitis treatment (confirmed or only suspected) and this antibiotic should only be added when 3GC minimum inhibitory concentration of the strain isolated is greater than 0.5mg/L. For meningococcal meningitis, nearly 20% of strains have decreased susceptibility to penicillin and amoxicillin, but all remain susceptible to 3GC. The National Pediatric Meningitis Network is a valuable tool because it has been sufficiently exhaustive and sustainable over 15 years. Maintaining this epidemiologic surveillance will allow us to adapt, if necessary, new regimens for subsequent changes that could be induced by vaccination and/or antibiotic uses.

Antibiotic pharmacokinetic and pharmacodynamic parameters in pediatric clinical practice.

Progress in the knowledge of antibiotic mechanisms of action allows to determine the pharmacodynamics/pharmacokinetic (PK/PD) parameters predictive of antibiotic efficacy in bacterial infections. According to the antibiotic compound, the bacterial species implicated, the location of the infection, and the severity of the disease, these parameters may vary. The PK/PD parameters described in this paper, focus only on blood compartments. These PK/PD parameters best predict efficacy in the most frequent infections (e.g., respiratory, bacteremia, skin and soft tissue infections and intra-abdominal infections). Furthermore, they contribute to the determination of doses and number of administrations per day as well as the determination of minimum inhibitory concentration (MIC) breakpoints. The time above the MIC (T> MIC) is the main criterion for ß-lactams: free drug serum levels of these drugs should be above the MIC for at least 40%-50% of the dosing interval to produce adequate clinical and microbiological efficacy. Peak/MIC ratio is the major determinant of the activity of aminoglycosides: in general, peak/MIC ratios should exceed 8-10. Area under the MIC curve (AUC/MIC) is considered for quinolones, macrolides, and vancomycin as the best predictor of efficacy.

Antimicrobial treatment of ENT infections.

ENT infections are the most common childhood infections and the leading causes of antibiotic prescriptions. These infections are mainly due to viruses and most of them (even if bacterial species are implicated) resolve spontaneously. Therefore, the first message is to not prescribe antibiotics in the following situations: common cold, non-streptococcal pharyngitis, laryngitis, non-purulent otitis media, etc. For sore throat/pharyngitis, the antibiotic treatment decision is based mainly on the use of group A streptococcus rapid diagnostic tests. For otitis media, only purulent forms occurring in children less than 2 years of age and most severe situations in older children should be treated with antibiotics. Amoxicillin is the first-line treatment for the vast majority of ENT infections requiring antibiotic treatment. Severe ENT infections (mastoiditis, epiglottitis, retro- and parapharyngeal abscesses, and ethmoiditis) are therapeutic emergencies requiring in most cases hospitalization and intravenous antibiotics.

[Treatment and progression of acute communautary osteoarticular infections in healthy children: A retrospective monocentric study of 64 patients]. / Traitement et évolution des infections ostéoarticulaires aiguës communautaires chez l'enfant sain : étude rétrospective monocentrique de 64 cas.

INTRODUCTION: The prognosis of osteoarticular infections has improved over the past 20 years but it still remains potentially severe. The treatment of these infections has been simplified and shortened. In 2008, the Pediatric Infectious Disease Group (GPIP) established new therapeutic guidelines in order to standardize treatment in France. The aim of this study is to analyze practices in a Parisian hospital and assess the efficacy of this treatment in short and medium terms. MATERIALS AND METHODS: This retrospective study focused on patients older than 3 months, without comorbidities, who were hospitalized for an acute osteoarticular infection in 2012 at Trousseau Hospital (Paris), with a follow-up of at least 4 weeks. The patients were selected from the hospital register. RESULTS: The study included 64 patients of 156, who were admitted for examination with a diagnosis of acute osteoarticular infection, bacteriologically confirmed (29/64) or presumed on the basis of bacteriological evidence (35/64). The median age of the patients was 22 months. Of the patients, 78 % were febrile; 35 patients had arthritis (54.7 %), 21 osteomyelitis (32.8 %), seven osteoarthritis (10.9 %), and one spondylitis. Preferential localizations were the knees and hips; 61 % of arthritis cases were diagnosed with ultrasound, 54 % of osteomyelitis cases with scintigraphy. The two main microorganisms found were Kingella kingae (62.1 %) and Staphylococcus aureus (24.1 %). In 98 % of cases, patients were treated by cefamandole, with or without gentamicine, for a median duration of 3 days (1-10) intravenously, with oral relay by amoxicillin-clavulanic acid, for a total duration of 6 weeks, but in association with rifampicin in 40 % of cases without explanation. The median follow-up was 13 weeks, with a treatment success rate of 86 %. CONCLUSION: The study of local practices showed us that the GPIP guidelines are not followed, with the duration of oral treatment being too long. The trend in therapy is toward short treatments of 10-20 days, with a shorter intravenous phase.

Outcomes of bacterial meningitis in children.

OBJECTIVE: Pediatricians are well aware of the immediate risks of bacterial meningitis in children. However, the long-term outcome of the disease has not been extensively studied. We aimed: (i) to evaluate the duration and quality of the long-term follow-up of children diagnosed with bacterial meningitis in a general pediatric department, (ii) to estimate the incidence of sequelae at the various stages of follow-up, and (iii) to compare our data with that of other studies. METHODS: We conducted a retrospective study and included 34 children (3 months-15 years) who had been hospitalized for bacterial meningitis in the pediatric department of a University Hospital between January 1st, 2001 and December 31st, 2013. RESULTS: Overall, 32% of patients presented with sequelae and 15% with seizures. Only one patient presented with hearing loss, but 23.5% of patients did not have any hearing test performed. Seven patients had a neuropsychological assessment performed and no severe neuropsychological sequela was observed in this group. The average follow-up duration increased during the study period (from 23 to 49months). The long-term follow-up modalities observed in other studies were highly variable. Assessing the incidence and severity of sequelae was therefore difficult. CONCLUSION: A standardized follow-up should be implemented by way of a national surveillance network of children presenting with bacterial meningitis.