Invasive Group A streptococcal infections: are we facing a new outbreak? A case series with the experience of a single tertiary center.

BACKGROUND: In pediatric age, Group A Streptococcus (GAS) is responsible for a wide spectrum of clinical manifestations, from mild localized infections to life-threatening invasive diseases. In December 2022, the World Health Organization reported an increased incidence of scarlet fever and invasive GAS infections (iGAS) cases in Europe and the United States. In line with these observations, surveillance has been strengthened in our Region, allowing the identification of certified or highly suspected forms of iGAS. CASE PRESENTATION: We report here 4 emblematic cases of iGAS admitted to our Intensive Care Unit (ICU) in the short time span from mid-February to mid-March 2023. Particularly, we describe a case of pleuropneumonia (4 year old boy) and a case of respiratory failure (2 year old boy), who necessitated Non-Invasive Ventilation support, a case of Streptococcal Toxic Shock Syndrome (6 year old girl), presenting with multi-organ failure, who needed Invasive Ventilation, and a case of meningitis (5 year old girl). All these patients needed intensive care support. CONCLUSIONS: Accurate differential diagnosis and early treatment both could help to reduce the transmission of GAS and consequently the risk of severe iGAS. These cases confirmed the need for close monitoring and appropriate notification, in order to verify their actual increased incidence.

Epidemiological and Clinical Profile of Pediatric Burns in the COVID-19 Era: The Experience of a Reference Center.

Pediatric burns represent a significant public health problem. We analyzed the characteristics of pediatric burns in a reference center, in order to identify better strategies for prevention and care. Burn patients admitted to the pediatric departments of our hospital from January 2020 to June 2022 were retrospectively evaluated. Age, gender, the etiology of injuries, the total burn surface area (TBSA), the degree of burns, the length of hospital stay (LOS), concomitant SARS-CoV-2 infection, and burn surface microbial colonization were analyzed. Forty-seven patients were included in the analysis (M:F = 1:0.67). Most of the cases involved patients between 0 and 4 years of age (83%). Hot liquid burns accounted for 79% of cases, flame burns for 9%, thermal burns for 6%, scald burns for 4% and chemical burns for 2%. Mean TBSA was 14 ± 11%. A second-degree lesion was detected in 79% of patients and third-degree in 21%. Mean LOS was 17 days. No additional infection risks or major sequelae were reported in patients with SARS-CoV-2 infection. Fifteen different species of bacteria plus C. parapsilosis were isolated, while no anaerobic microorganisms were detected. In the light of our experience, we recommend a carefully planned and proactive management strategy, always multidisciplinary, to ensure the best care for the burned child.

Multicentre study found no increased risk of clinically important brain injuries when children presented more than 24 h after a minor head trauma.

AIM: Validated clinical decision rules on neuroimaging are not available for children who are evaluated more than 24 h after a minor head trauma. We compared clinically important traumatic brain injuries in children who presented with a minor head trauma within or after 24 h. METHODS: This was a retrospective analysis of patients aged 0-17 years, who were evaluated for minor head traumas by five paediatric emergency departments in Northern Italy between January 2019 and June 2020. Children with clinically important traumatic brain injuries were divided into those who had presented within and after 24 h. RESULTS: The study comprised 5981 children (59.9% boys), with a median age of 2 years, including 243 (4.1%) who had presented more than 24 h after their minor head trauma. Neuroimaging was performed on 448 (7.5%) patients and the time of presentation had no impact on the rates of clinically important traumatic brain injuries. Multiple logistic regression did not show any association between clinically important traumatic brain injuries and late presentation. CONCLUSION: Delayed presentation to a paediatric emergency department after a minor head trauma did not alter the risk of clinically important traumatic brain injuries and the same neuroimaging rules could apply.

Caregivers' Intention to Vaccinate Their Children Under 12 Years of Age Against COVID-19: A Cross-Sectional Multi-Center Study in Milan, Italy.

The impact of Coronavirus disease 2019 (COVID-19) on the pediatric population is increasingly recognized. A widespread vaccination in childhood would provide benefits for children and might help ending the pandemic by enhancing community protection. Following recent approval by the European Medicines Agency (EMA) of Comirnaty (Pfizer-BioNTech) for children aged 5-11 years, we aimed to investigate caregivers' intention to vaccinate their children <12 years of age against COVID-19. A structured questionnaire was administered to caregivers of children aged <12 years visiting the Emergency Department or the outpatient clinics in three major hospitals of Milan, Italy, from 20 September to 17 October 2021. A total of 612 caregivers were invited to participate and 604 accepted (response rate >98%). Three questionnaires were excluded due to compiling errors and 601 were included in the analysis. A total of 311 (51.7%) caregivers stated they would have their child vaccinated, 138 (23%) would refuse to vaccinate their child and 152 (25.3%) were unsure. The intention to vaccinate the child was higher in caregivers vaccinated against COVID-19, in those with a bachelor's degree or higher level of education, and in those with friends/acquaintances who became ill or died due to COVID-19. This study shows that increasing efforts are necessary to provide evidence-based tailored information to caregivers and to promote vaccination in this pediatric age group.

Bloody Diarrhea and Shiga Toxin-Producing Escherichia coli Hemolytic Uremic Syndrome in Children: Data from the ItalKid-HUS Network.

OBJECTIVE: To analyze the results of an enhanced laboratory-surveillance protocol for bloody diarrhea aimed at identifying children with Shiga toxin-producing Escherichia coli (STEC) infection early in the course of the disease toward the early identification and management of patients with hemolytic uremic syndrome (HUS). STUDY DESIGN: The study (2010-2019) involved a referral population of 2.3 million children. Stool samples of patients with bloody diarrhea were screened for Shiga toxin (Stx) genes. Positive patients were rehydrated and monitored for hemoglobinuria until diarrhea resolved or STEC-HUS was diagnosed. RESULTS: A total of 4767 children were screened; 214 (4.5%) were positive for either Stx1 (29.0%) or Stx2 (45.3%) or both Stx1+2 (25.7%); 34 patients (15.9%) developed STEC-HUS (0.71% of bloody diarrheas). Hemoglobinuria was present in all patients with HUS. Patients with Stx2 alone showed a greater risk of STEC-HUS (23.7% vs 12.7%) and none of the patients with Stx1 alone developed HUS. During the same period of time, 95 other patients were diagnosed STEC-HUS but were not captured by the screening program (26 had nonbloody diarrhea, 11 came from areas not covered by the screening program, and 58 had not been referred to the screening program, although they did meet the inclusion criteria). At HUS presentation, serum creatinine of patients identified by screening was significantly lower compared with that of the remaining patients (median 0.9 vs 1.51 mg/dL). CONCLUSIONS: Nearly 1% of children with bloody diarrhea developed STEC-HUS, and its diagnosis was anticipated by the screening program for Stx. The screening of bloody diarrhea for Stx is recommended, and monitoring patients carrying Stx2 with urine dipstick for hemoglobinuria is suggested to identify the renal complication as early as possible.

Supporting the Regional Network for Children with Burn Injuries in a Pediatric Referral Hospital for COVID-19.

Considerable reorganization of the regional network for pediatric burn treatment during the pandemic was required to cope with severe burn injuries in small children. In support of the emergency network for burns during the COVID-19 pandemic, we referred to regional indications for centralization in our hospital for all children aged less than 5 years who presented with severe burns, >15% of total body surface area (TBSA), or who necessitated admittance to the pediatric intensive care unit (PICU). A new service with a dedicated management protocol was set up to treat pediatric burns in our SARS-CoV-2 pediatric hospital during the lockdown period. A multidisciplinary burn treatment team was set up to offer compassionate and comprehensive burn care. Patient's clinical data, burn features, treatment and follow up were recorded. A higher number of admissions was recorded from February to December 2020 compared with the same period in 2019 (52 vs. 32 admissions). Eighteen patients were admitted to the COVID-19 Service (10 M/8 F; 3.10 ± 2.6 yrs); ten children (55.5%) were hospitalized in the ward and eight in the ICU (44.5%). Fifty percent of the cases presented with lesions extending over >15% TBSA; in one case, TBSA was 35%. All patients suffered 2nd-degree burns; while five patients also had 3rd degree lesions covering more than 15% TBSA. All of the injuries occurred at home. No major secondary infections were recorded. Successful treatment was achieved in 94.4% of cases. The average length of stay was 15.2 ± 12.6 days. A proactive, carefully planned service, involving a multidisciplinary team, was created to ensure appropriate care in a pediatric hospital during the COVID-19 period, despite the effective pandemic associated challenges. Better health promotion in pediatric burn cases should also include dedicated TBSA assessment and a database of children's burn characteristics.

Epidemiology of haemolytic uremic syndrome in children. Data from the North Italian HUS network.

UNLABELLED: Despite the severity of HUS and the fact that it represents a leading cause of acute kidney injury in children, the general epidemiology of HUS is all but well documented. The present study provides updated, population-based, purely epidemiological information on HUS in childhood from a large and densely populated area of northern Italy (9.6 million inhabitants, 1.6 million children). We systematically reviewed the files concerning patients with STEC-HUS and atypical HUS (aHUS) over a 10-year observation period (January 2003-December 2012). We included all incident cases with a documented first episode of HUS before the age of 18 years. We identified 101 cases of HUS during the 10 years. The overall mean annual incidence was 6.3 cases/million children aged <18 years (range 1.9-11.9), and 15.7/million of age-related population (MARP) among subjects aged <5 years; aHUS accounted for 11.9 % of the cases (mean incidence 0.75/MARP). The overall case fatality rate was 4.0 % (3.4 % STEC-HUS, 8.3 % aHUS). CONCLUSION: Given the public health impact of HUS, this study provides recent, population-based epidemiological data useful for healthcare planning and particularly for estimating the financial burden that healthcare providers might have to face in treating HUS, whose incidence rate seems to increase in Northern Italy. WHAT IS KNOWN: • HUS is a rare disease, but it represents the leading cause of acute kidney injury in children worldwide. • STEC-HUS (also called typical, D + HUS) is more common compared to atypical HUS, but recent, population-based epidemiological data (incidence) are scanty. What is New: • Comprehensive, population-based epidemiological data concerning both typical and atypical HUS based on a long observational period.