Update of the consensus document on the aetiology, diagnosis and treatment of acute otitis media and sinusitis.

Update of the consensus on acute otitis media (AOM) (2012) and sinusitis (2013) following the introduction of pneumococcal vaccines in the immunization schedule, and related changes, such as epidemiological variation, colonization by of nonvaccine serotypes and emerging antimicrobial resistances. A majority of studies show that the introduction of the pneumococcal 13-valent conjugate vaccine has been followed by a reduction in the nasopharyngeal carriage of pneumococcus, with an increase in the proportion of drug-resistant nonvaccine serotypes. The diagnosis of AOM is still clinical, although more stringent criteria are proposed, which are based on the visualization of abnormalities in the tympanic membrane and the findings of pneumatic otoscopy performed by trained clinicians. The routine diagnosis of sinusitis is also clinical, and the use of imaging is restricted to the assessment of complications. Analgesia with acetaminophen or ibuprofen is the cornerstone of AOM management; watchful waiting or delayed antibiotic prescription may be suitable strategies in select patients. The first-line antibiotic drug in children with AOM and sinusitis and moderate to severe disease is still high-dose amoxicillin, or amoxicillin-clavulanic acid in select cases. Short-course regimens lasting 5-7 days are recommended for patients with uncomplicated disease, no risk factors and a mild presentation. In allergic patients, the selection of the antibiotic agent must be individualized based on severity and whether or not the allergy is IgE-mediated. In recurrent AOM, the choice between watchful waiting, antibiotic prophylaxis or surgery must be individualized based on the clinical characteristics of the patient.

Actualización del documento de consenso sobre etiología, diagnóstico y tratamiento de la otitis media aguda y sinusitis / Update of the consensus document on the aetiology, diagnosis and treatment of acute otitis media and sinusitis

Actualización de los documentos de consenso de OMA (2012) y sinusitis (2013) tras la introducción de las vacunas antineumocócicas en el calendario vacunal, tras los cambios derivados de las variaciones epidemiológicas, colonización por serotipos no vacunales y la aparición de resistencias. Según la mayoría de los estudios, la introducción de la vacuna antineumocócica conjugada tridecavalente (VNC-13) se ha traducido en un descenso de la colonización nasofaríngea por neumococo, con un aumento porcentual de serotipos resistentes no cubiertos. El diagnóstico de la OMA continúa siendo clínico, aunque se proponen criterios más rigurosos, apoyados en la visualización de alteraciones en la membrana timpánica y la otoscopia neumática realizada por personal entrenado. El diagnóstico rutinario de la sinusitis es clínico y la realización de pruebas de imagen está limitada al diagnóstico de complicaciones asociadas. La analgesia con paracetamol o ibuprofeno es la base del tratamiento en la OMA; la conducta expectante o la prescripción antibiótica diferida podrían ser estrategias adecuadas en pacientes seleccionados. El tratamiento antibiótico de elección en niños con OMA y sinusitis aguda con síntomas moderados-graves continúa siendo la amoxicilina a dosis altas o la amoxicilina-clavulánico en casos seleccionados. En cuadros no complicados, sin factores de riesgo y con buena evolución se proponen pautas cortas de 5-7 días. En pacientes alérgicos se debe individualizar especialmente la indicación de tratamiento antibiótico, que dependerá del estado clínico y si existe o no alergia IgE-mediada. En la OMA recurrente, la elección entre un manejo expectante, profilaxis antibiótica o cirugía se debe individualizar según las características del paciente. (AU)

Update of the consensus on acute otitis media (AOM) (2012) and sinusitis (2013) following the introduction of pneumococcal vaccines in the immunization schedule, and related changes, such as epidemiological variation, colonization by of nonvaccine serotypes and emerging antimicrobial resistances. A majority of studies show that the introduction of the pneumococcal 13-valent conjugate vaccine has been followed by a reduction in the nasopharyngeal carriage of pneumococcus, with an increase in the proportion of drug-resistant nonvaccine serotypes. The diagnosis of AOM is still clinical, although more stringent criteria are proposed, which are based on the visualization of abnormalities in the tympanic membrane and the findings of pneumatic otoscopy performed by trained clinicians. The routine diagnosis of sinusitis is also clinical, and the use of imaging is restricted to the assessment of complications. Analgesia with acetaminophen or ibuprofen is the cornerstone of AOM management; watchful waiting or delayed antibiotic prescription may be suitable strategies in select patients. The first-line antibiotic drug in children with AOM and sinusitis and moderate to severe disease is still high-dose amoxicillin, or amoxicillin-clavulanic acid in select cases. Short-course regimens lasting 5–7 days are recommended for patients with uncomplicated disease, no risk factors and a mild presentation. In allergic patients, the selection of the antibiotic agent must be individualized based on severity and whether or not the allergy is IgE-mediated. In recurrent AOM, the choice between watchful waiting, antibiotic prophylaxis or surgery must be individualized based on the clinical characteristics of the patient. (AU)

Antimicrobial Stewardship Programs (ASPS) in pediatric primary care.

Antibiotic resistance is a major threat to global health. Optimizing the use of antibiotics is a key measure to prevent and control this problem. Antimicrobial Stewardship Programs (ASPs) are designed to improve clinical outcomes, minimize adverse effects and protect patients, and to ensure the administration of cost-effective treatments. Inappropriate use of antibiotics also occurs in pediatric clinical practice. For this reason, ASPs should include specific objectives and strategies aimed at pediatricians and families. Implementing these programs requires the involvement of institutions and policy makers, healthcare providers as well as individuals, adapting them to the characteristics of each healthcare setting. Pediatric primary care (PPC) faces specific issues such as high demand and immediacy, scarce specialized professional resources, difficulties to access regular training and to obtain feedback. This requires the design of specific policies and strategies to achieve the objectives, including structural and organizational measures, improvement of the information flow and accessibility to frequent trainings. These programs should reach all health professionals, promoting regular trainings, prescription support tools and supplying diagnostic tests, with adequate coordination between health care levels. Periodic evaluations and surveillance tools are useful to assess the impact of the actions taken and to provide feedback to health providers in order to adapt and improve their clinical practice to meet ASPs objectives.

Programas de optimización del uso de antibióticos (PROA) en pediatría de atención primaria / Antimicrobial Stewardship Programs (ASPS) in pediatric primary care

La resistencia a antibióticos supone una amenaza para la salud pública a nivel mundial. Su estrecha relación con el consumo de antibióticos hace necesaria la adopción de medidas para optimizar su uso. Los programas de optimización del uso de antibióticos (PROA) se diseñan para mejorar los resultados clínicos de los pacientes con infecciones, minimizar los efectos adversos asociados a su uso y garantizar la administración de tratamientos costo-eficientes. En la práctica clínica pediátrica el uso inadecuado de antibióticos es una realidad. Es por ello que los PROA deben incluir objetivos y estrategias específicos dirigidos a familias y pediatras. La implementación de estos programas requiere la implicación de instituciones, profesionales y población, adaptándolos a las características de cada ámbito asistencial. La atención primaria (AP) pediátrica presenta unas peculiaridades organizativas y asistenciales (hiperdemanda e inmediatez, escasos recursos profesionales especializados, dificultades en el acceso a la formación continuada y a la retroalimentación informativa) que exigen el diseño de medidas y estrategias propias para conseguir los objetivos fijados, que incluyan medidas estructurales, organizativas, de flujo de información y de formación continuada. Es necesario que estos programas alcancen a todos los profesionales, abordando la formación continuada, las herramientas de apoyo a la prescripción y el acceso a pruebas diagnósticas, con la adecuada coordinación interniveles. Se debe evaluar periódicamente el impacto de las distintas acciones en los objetivos planteados. La información generada debe revertir a los profesionales para que puedan adaptar su práctica clínica a la consecución óptima de los objetivos. (AU)

Antibiotic resistance is a major threat to global health. Optimizing the use of antibiotics is a key measure to prevent and control this problem. Antimicrobial Stewardship Programs (ASPs) are designed to improve clinical outcomes, minimize adverse effects and protect patients, and to ensure the administration of cost-effective treatments. Inappropriate use of antibiotics also occurs in pediatric clinical practice. For this reason, ASPs should include specific objectives and strategies aimed at pediatricians and families. Implementing these programs requires the involvement of institutions and policy makers, healthcare providers as well as individuals, adapting them to the characteristics of each healthcare setting. Pediatric primary care (PPC) faces specific issues such as high demand and immediacy, scarce specialized professional resources, difficulties to access regular training and to obtain feedback. This requires the design of specific policies and strategies to achieve the objectives, including structural and organizational measures, improvement of the information flow and accessibility to frequent trainings. These programs should reach all health professionals, promoting regular trainings, prescription support tools and supplying diagnostic tests, with adequate coordination between health care levels. Periodic evaluations and surveillance tools are useful to assess the impact of the actions taken and to provide feedback to health providers in order to adapt and improve their clinical practice to meet ASPs objectives. (AU)

Estudio multicéntrico nacional sobre la organización de las consultas de Pediatría de Atención Primaria en España durante la primera ola de la pandemia de COVID-19 / Nationwide multicentre study on the organization of primary care paediatrics services in the first wave of the COVID-19

Introducción: la pandemia de COVID-19 ha originado cambios organizativos en los centros de Atención Primaria (AP). El objetivo de este estudio es conocer los cambios producidos en las consultas de Pediatría de AP durante la primera ola de la pandemia por COVID-19. Material y métodos: estudio observacional, descriptivo, retrospectivo, multicéntrico y de ámbito nacional, a través de una encuesta dirigida a los pediatras de Atención Primaria (PAP) distribuida en junio de 2020. Se recogieron datos desde el 16 de marzo al 10 de mayo de 2020, dividido en cuatro periodos de dos semanas cada uno. Se preguntó sobre la forma de trabajar en los centros durante ese periodo: existencia de sistema de triaje, modalidad de atención, presencial o telefónica, y volumen de consultas atendidas. Resultados: se consideraron válidas 105 encuestas de las 110 contestadas por PAP. Participaron pediatras de 17 comunidades autónomas (el 72,4% de medio urbano). Cubrían una población de 107 715 pacientes. Realizaron consulta telemática el 90,5% (38,1% antes de la pandemia). En todos los centros se realizó triaje. La media de pacientes atendidos por profesional en cada uno de los periodos considerados fue de 144, 114, 123, 136 (277, 214, 207 y 233 en los mismos periodos del año 2019). En el 88,6% de cupos se realizaron visitas presenciales del programa de salud infantil (PSI). De toda la población atendida, los PAP notificaron ingresos por cualquier motivo de 79 pacientes y en la unidad de cuidados intensivos (UCI) de siete. No se les notificó ningún fallecimiento. Conclusiones: durante el periodo inicial de pandemia COVID-19 se registró en las consultas de Pediatría de AP un aumento muy importante de la consulta telemática y, paralelamente, una disminución significativa de la consulta presencial. Se instauraron sistemas de triaje. Se mantuvo una actividad muy alta en el PSI. Hubo un número muy bajo de ingresos y casos graves (AU)

Introduction: the COVID-19 pandemic has driven changes in the organization of care delivery in primary care (PC) centres. The objective of our study was to describe the changes in PC paediatric care that took place in the first wave of the COVID-19 pandemic. Material and methods: we conducted a nationwide, multicentre, retrospective, observational and descriptive study through a survey of PC paediatricians with distribution of the questionnaire in June 2020. We collected data from March 16 to May 10, 2020, divided in four 2-week periods. We asked about care delivery in these centres during this period: use of triage systems, modalities of care delivery (in person or by telephone) and volume of visits. Results: we received 105 responses by PC paediatricians, of which 110 were considered valid. We obtained responses from paediatricians in 17 autonomous communities (72.4% in urban settings). Respondents served a cumulative population of 107 715 patients. A total of 90.5% provided remote care (38.1% did before the pandemic). Triage was conducted in all centres. The mean number of patients managed per paediatrician in each of the time intervals under study was 144, 114, 123 and 136 (compared to 277, 214, 207 and 233 in the same periods in 2019). In 88.6% of the caseloads, in-person appointments were conducted as part of the child health programme (CHP). The total number of hospital admissions for any reason in the cumulative catchment population was of 79 patients, and the number of admissions to the intensive care unit was 7. The respondents did not report any deaths. Conclusions: in the first wave of the COVID-19 pandemic, there was a substantial increase in remote primary care paediatric visits parallel to a significant decrease in in-person visits. Triage systems were implemented. There was still substantial activity in the CHP. The number of hospital admissions and cases of serious disease was very low (AU)

Fiebre sin foco / Unfocused fever

La fiebre sin foco (FSF) es uno de los motivos de consulta más frecuentes en Pediatría, y generalmente se debe a procesos infecciosos banales que no van a requerir realización de pruebas complementarias ni tratamiento antibiótico. Es por ello que conocer la etiología, diferente según la edad del paciente y el estado de inmunización y medio donde nos encontremos, así como realizar una correcta anamnesis y exploración física, con apoyo de los algoritmos disponibles, es imperativo para identificar aquellos pacientes que estén en riesgo de padecer una infección bacteriana grave (IBG). En ellos, habrá que hacer una petición justificada de pruebas complementarias y tratar de acuerdo con la etiología más frecuente. En los pacientes con bajo riesgo de IBG, que serán la mayoría, es preciso tranquilizar a los cuidadores, explicando los signos y síntomas de alerta de progresión o gravedad, combatir la fiebrefobia, prescribiendo antitérmicos para tratar el malestar asociado, y reevaluar cuando sea preciso (AU)

Manejo del paciente pediátrico ante sospecha de infección por el nuevo coronavirus SARS-CoV-2 en atención primaria (COVID-19). AEPap-SEIP/AEP-SEPEAP / No disponible

No disponible

Recomendaciones sobre el diagnóstico y tratamiento de la infección urinaria / Recommendations on the diagnosis and treatment of urinary tract infection

La infección del tracto urinario se define como el crecimiento de microorganismos en orina recogida de forma estéril, en un paciente con síntomas clínicos compatibles. En ausencia de sintomatología el aislamiento de bacterias en urocultivo se denomina bacteriuria asintomática y no precisa tratamiento. En neonatos y lactantes el signo guía para sospechar una infección del tracto urinario es la fiebre. En niños continentes los síntomas urinarios clásicos cobran mayor importancia. El diagnóstico requiere siempre la recogida de urocultivo previo al inicio de tratamiento antibiótico. En niños continentes la muestra de orina para urocultivo se debe recoger por micción espontánea. En niños no continentes mediante sondaje vesical, pudiendo optar por punción suprapúbica en neonatos y lactantes pequeños. No se debe enviar para urocultivo una muestra recogida mediante bolsa adhesiva. No se han demostrado diferencias significativas en la evolución clínica y desarrollo de secuelas entre la administración antibiótica oral exclusiva frente a la intravenosa de corta duración seguida de administración oral. La selección de la antibioterapia empírica inicial se basará en el patrón local de susceptibilidad. En la cistitis este consenso recomienda el uso empírico de cefalosporinas de segunda generación en menores de 6 años y fosfomicina trometamol en mayores. La antibioterapia empírica recomendada en pielonefritis que no precisan ingreso son las cefalosporinas de tercera generación. En caso de precisar ingreso se recomiendan los aminoglucósidos. En menores de 3 meses se debe añadir ampicilina. Una vez conocido el resultado del cultivo se debe dirigir el tratamiento de continuación, tanto intravenoso como oral

Urinary tract infection (UTI) is defined as the growth of microorganisms in a sterile urine culture in a patient with compatible clinical symptoms. The presence of bacteria without any symptoms is known as asymptomatic bacteriuria, and does not require any treatment. In neonates and infants, fever is the guiding sign to suspecting a UTI. Classic urinary tract symptoms become more important in older children. Urine cultures collected before starting antibiotics is always required for diagnosis. Clean-catch (midstream) specimens should be collected for urine culture. In the case of non-toilet-trained children, specimens must be obtained by urinary catheterisation, or suprapubic puncture in neonates and infants. Specimens collected by urine bag should not be used for urine culture. There are no significant differences in the clinical evolution and prognosis between oral versus short intravenous followed by oral antibiotic. Empirical antibiotic therapy should be guided by local susceptibility patterns. Second-generation cephalosporin (children under 6 years) and fosfomycin trometamol (over 6 years), are the empiric therapy recommended in this consensus. In the case of pyelonephritis, recommended antibiotic treatment are third-generation cephalosporins (outpatient care) or, if admission is required, aminoglycosides. Ampicillin should be added in infants less than 3 months old. Antibiotic de-escalation should be always practiced once the result of the urine culture is known

[Recommendations on the diagnosis and treatment of urinary tract infection]. / Recomendaciones sobre el diagnóstico y tratamiento de la infección urinaria.

Urinary tract infection (UTI) is defined as the growth of microorganisms in a sterile urine culture in a patient with compatible clinical symptoms. The presence of bacteria without any symptoms is known as asymptomatic bacteriuria, and does not require any treatment. In neonates and infants, fever is the guiding sign to suspecting a UTI. Classic urinary tract symptoms become more important in older children. Urine cultures collected before starting antibiotics is always required for diagnosis. Clean-catch (midstream) specimens should be collected for urine culture. In the case of non-toilet-trained children, specimens must be obtained by urinary catheterisation, or suprapubic puncture in neonates and infants. Specimens collected by urine bag should not be used for urine culture. There are no significant differences in the clinical evolution and prognosis between oral versus short intravenous followed by oral antibiotic. Empirical antibiotic therapy should be guided by local susceptibility patterns. Second-generation cephalosporin (children under 6 years) and fosfomycin trometamol (over 6 years), are the empiric therapy recommended in this consensus. In the case of pyelonephritis, recommended antibiotic treatment are third-generation cephalosporins (outpatient care) or, if admission is required, aminoglycosides. Ampicillin should be added in infants less than 3 months old. Antibiotic de-escalation should be always practiced once the result of the urine culture is known.

Prevalencia de trastornos del neurodesarrollo, comportamiento y aprendizaje en Atención Primaria / Prevalence of neurodevelopmental, behavioural and learning disorders in Pediatric Primary Care

OBJETIVOS: Conocer la prevalencia de patología psiquiátrica en atención primaria en la Galicia atlántica. MÉTODOS: Se realizó un estudio observacional, descriptivo, transversal de prevalencia, en 9 consultas de A Coruña y Pontevedra, con una población de 8.293 niños, entre septiembre y noviembre del 2015. Se incluyó a 1.286 pacientes entre 0 y 14 años que acudieron a las consultas en unos días aleatoriamente seleccionados. Se registraron los siguientes datos de la historia clínica: edad, sexo, diagnóstico psiquiátrico establecido por criterios DSM-IV-TR en sus 5 ejes. Se determinó qué profesionales intervinieron en el diagnóstico y tratamiento del proceso y qué tipo de tratamiento recibían. Se obtuvo la autorización del Comité de Ética de Investigación de Galicia número 2015/427. RESULTADOS: Ciento cuarenta y ocho de los 1.286 pacientes presentaban patología psiquiátrica (11,5%, IC del 95%, 9,73-13,29), 68% varones. Entre los 0 y 5 años la prevalencia fue del 4,5%; entre los 6 y 10 del 18,5% y entre los 11 y 14, del 22%. El tiempo de duración de los síntomas tenía una mediana de 25 meses. Las patologías más frecuentes en los 1.286 pacientes fueron TDAH (5,36%), trastornos del lenguaje (3,42%), trastornos del aprendizaje (3,26%) trastornos ansioso-depresivos (2,4%) y trastornos de la conducta (1,87%). De los 148 casos, el 47% presentaba comorbilidad con otro trastorno mental; la mayoría precisó atención por múltiples profesionales del ámbito social, sanitario y educativo; un 33% recibía tratamiento psicofarmacológico. CONCLUSIONES: La prevalencia de patología psiquiátrica en pediatría de atención primaria es frecuente, crónica y compleja, aumenta con la edad y precisa muchos recursos sanitarios, educativos y sociales

OBJECTIVES: To determine the prevalence of psychiatric disorders in primary care pediatrics in Atlantic Galicia. METHODS: An observational, descriptive, cross-sectional prevalence study was carried out in 9 outpatient clinics in A Coruña and Pontevedra with a population of 8293 children between September and November 2015. A total of 1286 randomly selected patients from 0 to 14 years of age were included. From the medical history was registered: age, sex, psychiatric diagnosis established by DSM-IV-TR criteria in its five axes, professionals who participated in the diagnosis and treatment of the process and what type of treatment was received. Authorization was obtained from the Research Ethics Committee of Galicia number 2015/427. RESULTS: 148 of 1286 patients presented psychiatric pathology (11,5% IC 95% 9.73-13,29), 68% male. Between 0 and 5 years, the prevalence was 4.5%; between 6 y and 10 y, 18.5% and between 11y and 14 y 22%. Symptoms lasted a median of 25 months. The most frequent pathologies in 1286 patients were ADHD (5.36%), language disorders (3.42%), learning disorders (3.26%), anxiety-depressive disorders (2.4%) and behavior disorders (1.87%). Of the 148 cases, 47% had comorbidity with another mental disorder. Most of them required attention by multiple social, health and educational professionals; 33% received psychopharmacological treatment. CONCLUSIONS: The prevalence of psychiatric disorders in pediatric primary care is frequent, chronic and complex, increases with age and requires many health, educational and social resources

Amoxicilina, ácido clavulánico y quinolonas: ¿hay algo nuevo? / Amoxicillin, clavulanic acid and quinolones: is there something new?

Ninguno de estos antimicrobianos son novedades terapéuticas, y ambos son ampliamente utilizados en Atención Primaria. Sin embargo el interés por cada uno de ellos es radicalmente distinto desde el punto de vista pediátrico. Por un lado, las quinolonas, usadas en exceso en la patología infecciosa en adultos y restringida en población infantil. Por otro, la combinación de amoxicilina con ácido clavulánico, con diferentes formulaciones, alguna de ellas prácticamente olvidada y denostada por los pediatras, es uno de los antibióticos de mayor uso en Pediatría. Viejos conocidos, de los que es posible se desconozcan ciertas características que merece la pena actualizar. La selección del agente adecuado, junto con la dosis, la pauta y la duración serán esenciales tanto para un adecuado tratamiento como para evitar resistencias bacterianas, así como el conocimiento de sus restricciones y posibles efectos adversos. Por lo tanto, profundizar en el conocimiento de estos fármacos potenciará uno de los elementos de la lucha frente al aumento de resistencias de los microorganismos. El objetivo final será fomentar el uso racional de estos fármacos antimicrobianos, siguiendo las indicaciones de guías y consensos actuales

Neither of these antimicrobials are innovations; both are widely spread therapeutic tools at primary health care. However, the interest for each of them is dramatically different from the pediatric point of view. On the one hand, the quinolones, overused in adults ́ infectious patologies and restricted for children. On the other hand, the combination of amoxicillin with clanulanic acid, using different formulations, some of which has been almost forgotten and disdained by peditricians, is one of the most useful antibiotics in pediatrics. Old acquaintances, whose characteristics are worth updating. The selection of the right agent, along with the dose, the pattern and the duration will be essential both for an adequate treatment and to avoid bacterial resistences, and also to know their restrictions and possible adverse effects. Therefore, to deepen in the knowledge of these drugs will boost one of the elements of the fight against the increase of microbial resistances. The final goal will be to encourage the use of this antimicrobials, following the indications of guidelines and actual consensus

[Prevalence of neurodevelopmental, behavioural and learning disorders in Pediatric Primary Care]. / Prevalencia de trastornos del neurodesarrollo, comportamiento y aprendizaje en Atención Primaria.

OBJECTIVES: To determine the prevalence of psychiatric disorders in primary care pediatrics in Atlantic Galicia. METHODS: An observational, descriptive, cross-sectional prevalence study was carried out in 9 outpatient clinics in A Coruña and Pontevedra with a population of 8293 children between September and November 2015. A total of 1286 randomly selected patients from 0 to 14 years of age were included. From the medical history was registered: age, sex, psychiatric diagnosis established by DSM-IV-TR criteria in its five axes, professionals who participated in the diagnosis and treatment of the process and what type of treatment was received. Authorization was obtained from the Research Ethics Committee of Galicia number 2015/427. RESULTS: 148 of 1286 patients presented psychiatric pathology (11,5% IC 95% 9.73-13,29), 68% male. Between 0 and 5years, the prevalence was 4.5%; between 6y and 10y, 18.5% and between 11y and 14y 22%. Symptoms lasted a median of 25 months. The most frequent pathologies in 1286 patients were ADHD (5.36%), language disorders (3.42%), learning disorders (3.26%), anxiety-depressive disorders (2.4%) and behavior disorders (1.87%). Of the 148 cases, 47% had comorbidity with another mental disorder. Most of them required attention by multiple social, health and educational professionals; 33% received psychopharmacological treatment. CONCLUSIONS: The prevalence of psychiatric disorders in pediatric primary care is frequent, chronic and complex, increases with age and requires many health, educational and social resources.