Salmonella Bacteremia in Spanish Pediatric Emergency Departments: Uncommon But Not Mild.

BACKGROUND: Salmonella spp. is an uncommon microorganism in bloodstream infections among pediatric patients in our setting, although in developing countries it is the most common causative organism in blood cultures. METHODS: We describe the children presenting to pediatric emergency departments and diagnosed with Salmonella bacteremia (SB) and identify clinical and laboratory predictors of poor outcome (ie, complications, sequelae and death) by bivariate analysis. We performed an observational study and subanalysis of a multicenter prospective registry, including patients <18 years of age with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered young age, chronic diseases, immunosuppressive treatment and intestinal flora disruption as risk factors for SB. RESULTS: Of the 55 patients with SB (3.2% of registered bacteremia), 32 (58.2%) had no risk factors for SB, 42 (76.3%) had a normal pediatric assessment triangle and 45 (81.8%) an associated gastrointestinal infection (acute gastroenteritis or enteric fever). Nine (16.4%) had a poor outcome, including 1 death (1.8%). A poor outcome was more common in patients with an abnormal pediatric assessment triangle [odds ratio (OR): 51.6; 95% confidence interval (CI): 9.2-289.5], an altered physical examination (OR: 15.2; 95% CI: 4.4-58.8) and elevated C-reactive protein (OR: 1.01; 95% CI: 1.005-1.03). CONCLUSIONS: Most SBs were related to a gastrointestinal infection. One in 6 children had a poor outcome; abnormal pediatric assessment triangle on arrival (25% of patients) was the main risk factor identified.

Critical Stenosis Because of Vocal Cord Synechiae in a Child.

Stridor is a clinical sign of an underlying disease and a common reason for pediatric emergency department (PED) consultation. Patients presenting with stridor must be evaluated to determine the origin of this abnormality. We present the case of a 7-year-old female patient who presented to our Pediatric Emergency Department with a history of recurrent episodes of stridor with increasing frequency over the previous 4 years, for this reason she was previously admitted to the pediatric intensive care unit. Findings from the otorhinolaryngologic assessment with flexible fiber-optic endoscopy led to a diagnosis of congenital synechia of the vocal cords. The cervical CT scan evidenced critical stenosis of the airway. An initial cordectomy and placement of a silicone device for fixation were performed. Subsequently, the patient required 6 additional interventions for progressive dilation of the glottic space at the level of the vocal cords and injections of mitomycin C injections (an antineoplastic that inhibits collagen proliferation). This case highlights the importance of additional studies (especially examination of the upper airway) when atypical or recurrent findings are revealed by the clinical history, physical examination, or disease course in patients with croup to prioritize cases severe enough to require pediatric intensive care unit admission.

Staphylococcus aureus Bacteremia in the Pediatric Emergency Department and Predictors of Poor Outcome.

BACKGROUND: Staphylococcus aureus has become the leading cause of bacteremia among previously healthy children older than 5 years. METHODS: We aimed to describe the infants presenting to pediatric emergency departments and diagnosed with S. aureus bacteremia (SAB) and identify predictors (clinical and laboratory variables) of poor outcome (complications, sequelae or death). We performed an observational study and subanalysis of a multicenter prospective registry, including every patient under the age of 18 years with a positive blood culture obtained at any of the 22 participating Spanish pediatric emergency departments between 2011 and 2016. We considered chronic diseases, immunosuppressive treatment and the presence of mechanical devices as risk factors for SAB. RESULTS: Of the 229 patients with SAB, 176 (76.9%) were previously healthy, 192 (83.8%) had a normal pediatric assessment triangle and 158 (69.0%) had an associated focal infection (mainly osteoarticular infection, skin and soft tissue infection and pneumonia). Fifty-three patients (23.1%) had 1 or more risk factors for SAB. Thirty-one (13.5%) presented a poor outcome, including 4 deaths (1.7%). A poor outcome was more common in patients with SAB risk factors [odds ratio (OR): 7.0; 95% CI: 3.2-15.4], abnormal PAT (OR: 5.9; 95% CI: 2.6-13.3), elevated procalcitonin (OR: 1.2; 95% CI: 1.05-1.3) and C-reactive protein, the latter being the only independent predictor of poor outcome (OR: 1.01; 95% CI: 1.01-1.02). CONCLUSIONS: Overall, children with SAB are previously healthy, appear well, and have an associated focal infection. One of 7 had a poor outcome, with C-reactive protein being the only predictor identified.

Improving emergency department care of infants with acute bronchiolitis by reducing the use of unrecommended drugs: a quality-of-care initiative in a Spanish autonomous community. / Iniciativa de mejora para reducir el uso de fármacos no recomendados en el manejo de lactantes con bronquiolitis aguda en los servicios de urgencias de una comunidad autónoma.

OBJECTIVES: To evaluate the impact of a quality-of-care improvement program implemented in emergency departments (EDs) in a Spanish autonomous community with the aim of reducing the use of unrecommended drugs when treating infants for acute bronchiolitis. MATERIAL AND METHODS: Before-after quasi-experimental intervention study. We retrospectively included infants aged 12 months or less who were treated for acute bronchiolitis in 24 Spanish national health system hospital EDs in December during 2 epidemic periods: in 2018, before implementing the program, and in 2019, after implementation. Data collected included epidemiologic information, clinical and care details, and clinical course. The program consisted of providing informative material and training sessions before the epidemic period started. RESULTS: A total of 7717 episodes (4007 in 2018 and 2710 in 2019) were identified. Epidemiologic and clinical characteristics did not differ between the 2 periods. ED use of the following treatments decreased between the 2 periods: salbutamol, from 29.4% (95% CI, 28.8%-30.8%) in 2018 to 10.6% (95% CI, 9.6%-11.6%) in 2019; epinephrine from 6.0% (95% CI, 5.3%-6.8%) to 0.9% (95% CI, 0.7%-1.3%); and hypertonic saline solution fell from 8.2% (95% CI, 7.3%-9.1%) to 2.1% (95% CI, 1.7%-2.6%) (P.001, all comparisons). Prescriptions for salbutamol on discharge fell from 38.7% (95% CI, 36.9%-40.4%) to 10.6% (95% CI, 9.6%-11.6%) (P.001). Admissions and readmissions did not change, and the median time (interquartile range) spent in the ED fell from 81 (44-138) minutes to 66 (37-127) minutes (P.001). CONCLUSION: The quality-of-care improvement initiative was able to decrease the number of unrecommended therapeutic interventions for acute bronchiolitis. However, we identified great variations between EDs, suggesting that training and assessment of impact should continue.

OBJETIVO: Evaluar el impacto de una iniciativa de mejora realizada en los servicios de urgencias (SU) de una comunidad autónoma para reducir el uso de fármacos no recomendados en lactantes con bronquiolitis aguda (BA). METODO: Estudio cuasi-experimental analítico del tipo "antes y después de una intervención". Se incluyeron de forma retrospectiva todas las BA en niños # 12 meses atendidas en los SU de 24 hospitales públicos durante el mes de diciembre de dos periodos epidémicos: 2018 (preintervención) y 2019 (postintervención). Se recogieron variables epidemiológicas, clínicas, asistenciales y evolutivas. La intervención consistió en difundir material informativo y realizar actividades formativas previas al periodo epidémico. RESULTADOS: Se incluyeron 7.717 episodios (2018: 4.007 y 2019: 3.710). No existieron diferencias en las características epidemiológicas y clínicas. El empleo de salbutamol en los SU descendió del 29,4% [intervalo de confianza del 95% (IC 95%): 28,8-30,8] en 2018 al 10,6% (IC 95%: 9,6-11,6) en 2019 (p 0,001), el de adrenalina del 6,0% (IC 95%: 5,3-6,8) al 0,9% (IC 95%: 0,7-1,3) y el de suero salino hipertónico del 8,2% (IC 95%: 7,3-9,1) al 2,1% (IC 95%: 1,7-2,6) (p 0,001). La prescripción al alta de salbutamol se redujo del 38,7% (IC 95%: 36,9-40,4) al 10,6% (IC 95%: 9,6-11,6) (p 0,001). La tasa de ingreso y la tasa de readmisión no cambiaron y la mediana de tiempo de estancia en los SU se redujo 81 minutos [rango intercuartil (RIC) 44-138] a 66 (RIQ: 37-127) (p 0,001). CONCLUSIONES: La iniciativa de mejora ha conseguido disminuir la tasa de intervenciones terapéuticas no indicadas en BA. Sin embargo, existe una gran variabilidad entre los diferentes SU por lo que la estrategia y la medición de su impacto deben mantenerse en el tiempo.

Rate of methicillin-resistant Staphylococcus aureus in pediatric emergency departments in Spain.

INTRODUCTION: Staphylococcus aureus is a common germ in bacterial infections in children. The rate of methicillin-resistant S. aureus (MRSA) is increasing lately. OBJECTIVES: The main aim is to know the rate of positive cultures to MRSA in Spanish pediatric emergency departments. The secondary aims are to analyse the risk factors for MRSA isolation (patient origin, history of hospitalization or surgery in the previous 90 days, antibiotherapy in the previous 60 days, presence of comorbidity, invasive devices, prior MRSA isolation) and to analyse the morbidity of these infections. METHODOLOGY: Retrospective multicenter study (07/01/2017-06/30/2018) with review of patient histories with isolation of S. aureus in samples of any origin obtained in 8 pediatric emergency departments of the Infectious Diseases Working Group of the Spanish Society of pediatric Emergencies. RESULTS: During this period, S. aureus was detected in 403 patients (average age 75.8 ± 59.2 months; 54.8% male): 28.8% hospital-related infections (HRI) and 71.2% community-related infections (CRI). Overall, MRSA rate was 16.6% (95% CI: 13-20.2%); 18.1% in HRI and 16.2% in CRI (p > 0.05). The highest rates of MRSA were obtained in skin abscesses (29.3%, CI 95%: 21.8-36.8%), patients not born in Spain (52%; CI 95%: 32-72%) or patients with a previous MRSA infection (90%; CI 95% 71.4-100%). 167 (41%) patients were admitted, 12 (3%) had complications and 4 (1%) suffered sequels. There were no deaths. CONCLUSIONS: The overall MRSA rate was one in 6 staphylococcal infections. Higher MRSA rates were detected in samples of suppurating skin injuries and in foreign children or in children with a history of previous MRSA infection. In suppurative skin lesions, early drainage is essential and the change to an antibiotic with MRSA coverage should be considered if the evolution is inadequate.

Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives.

INTRODUCTION: In the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines. MATERIAL AND METHODS: A quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out. RESULTS: 1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6-55.8%) in 2012 to 7.8% (95% CI: 5.7%-10.5%) in 2018 (P < .001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%-16.3%) to 0.2% (95% CI: 0-1.1%) (P < .001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72 h. CONCLUSIONS: The systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.

Late-onset Group B Streptococcus Bacteremia Evaluated in the Pediatric Emergency Department and Risk Factors for Severe Infection.

BACKGROUND: To describe the infants presenting to pediatric emergency departments (PEDs) and diagnosed with group B Streptococcus (GBS) late-onset disease (LOD) bacteremia and identify risk factors for severe infection and pediatric intensive care unit (PICU) admission. METHODS: Observational study and subanalysis of a multicenter prospective registry. Setting: pediatric emergency department. Inclusion criteria: infants between 7 and 89 days of age with positive blood culture for GBS seen between 2011 and 2016 at any of 22 Spanish PEDs. Main outcome: risk factors (clinical and laboratory variables) for severe infection (sepsis/septic shock or meningitis) and PICU admission. Second, the prevalence of poor outcomes (acute complications, sequelae or death). RESULTS: Among 118 patients with LOD, 74 (62.7%) presented a severe infection: 66 sepsis/septic shock (11 with associated meningitis) and 8 meningitis. Thirty-five patients (29.7%) were admitted to a PICU. An altered Pediatric Assessment Triangle (PAT) upon arrival and leukopenia were the only independent risk factors for severe infection [odds ratio (OR): 43.6; 95% confidence interval (CI): 8.1-235.7, P < 0.01] and PICU admission (OR: 11.6; 95% CI: 1.5-91.4; P < 0.019), respectively. Six patients (5.1%) developed a poor outcome, including 2 deaths (1.7%); all had an altered PAT, elevated procalcitonin (range 4.7-100 ng/ml), and were diagnosed with sepsis/septic shock and admitted to a PICU. Four developed leukopenia. CONCLUSIONS: Infants with GBS LOD frequently develop sepsis/septic shock and bacterial meningitis, associated with non-negligible morbidity and mortality. Clinical appearance was the only risk factor for severe infection, whereas leukopenia was related to PICU admission.

[Rate of methicillin-resistant Staphylococcus aureus in pediatric emergency departments in Spain]. / Tasa de Staphylococcus aureus resistentes a meticilina en urgencias pediátricas en España.

INTRODUCTION: Staphylococcusaureus (S. aureus) is a common germ present in bacterial infections in children. Lately, the rate of methicillin-resistant S. aureus (MRSA) is increasing. OBJECTIVES: The main aim of this study is to know the rate of positive cultures to MRSA in Spanish pediatric emergency departments. The secondary aims are to analyze the risk factors for MRSA isolation (patient origin, history of hospitalization or surgery in the previous 90 days, antibiotherapy in the previous 60 days, presence of comorbidity, invasive devices, prior MRSA isolation) and to analyze the morbidity of these infections. METHODOLOGY: Retrospective multicenter study (07/01/2017-06/30/2018) with review of patient histories with isolation of S. aureus in samples of any origin obtained in 8 pediatric emergency departments of the Infectious Diseases Working Group of the Spanish Society of Pediatric Emergencies. RESULTS: During this period, S. aureus was detected in 403 patients (average age 75.8±59.2 months; 54.8% male): 28.8% hospital-related infections and 71.2% community-related infections. Overall, MRSA rate was 16.6% (95% CI: 13-20.2%); 18.1% in hospital-related infections and 16.2% in community-related infections (P>.05). The highest rates of MRSA were obtained in skin abscesses (29.3%, 95% CI: 21.8-36.8%), patients not born in Spain (52%; 95% CI: 32-72%) or patients with a previous MRSA infection (90%; 95% CI: 71.4-100%). 167 (41%) patients were admitted, 12 (3%) had complications and 4 (1%) suffered sequels. There were no deaths. CONCLUSIONS: The overall MRSA rate was one in six staphylococcal infections. Higher MRSA rates were detected in samples of suppurating skin injuries and in foreign children or in children with a history of previous MRSA infection. In suppurative skin lesions, early drainage is essential and the change to an antibiotic with MRSA coverage should be considered if the evolution is inadequate.

[Decrease in the use of bronchodilators in the management of bronchiolitis after applying improvement initiatives]. / Descenso del uso de broncodilatadores en el manejo de la bronquiolitis tras aplicar iniciativas de mejora.

INTRODUCTION: In the treatment of patients with acute bronchiolitis there is great variability in clinical practice. Treatments whose efficacy has not been demonstrated are frequently used despite the recommendations contained in the Clinical Practice Guidelines. MATERIAL AND METHODS: A quality improvement strategy is implemented in the care of patients with acute bronchiolitis in the Emergency Department, which is maintained for five years and is periodically updated to be increasingly restrictive regarding the use of bronchodilators. To evaluate the impact of the intervention, a retrospective study of the rates of prescription of bronchodilators in children diagnosed with acute bronchiolitis in the month of December of four epidemic periods (2012, 2014, 2016 and 2018) was carried out. RESULTS: 1767 children are included. There were no differences regarding age, respiratory rate, oxygen saturation or the estimated severity in each of the study seasons. The use of salbutamol in the Emergency Department decreased from 51.2% (95% CI: 46.6%-55.8%) in 2012 to 7.8% (95% CI: 5.7%-10.5%) in 2018 (P<.001) and epinephrine prescription rates fell from 12.9% (95% CI: 10.1%-16.3%) to 0.2% (95% CI: 0-1.1%) (P<.001). At the same time, there was a decrease in the median time of attendance in the Emergency Department and in the admission rate without changing the readmission rate in 72h. CONCLUSIONS: The systematic and continuous deployment over time of actions aimed at reducing the use of salbutamol and epinephrine in the treatment of bronchiolitis, prior to the epidemic period, seems an effective strategy to reduce the use of bronchodilators in the Emergency Department.

Erythema multiforme-like lesions in children and COVID-19.

During examination of cases of chilblains in children and adolescents, we identified four patients who also showed skin lesions similar to erythema multiforme (EM). They had no other known triggers for EM. One of them had a positive PCR for SARS-CoV-2, while the other three were negative. Skin biopsies from two patients showed features not typical of EM, such as deep perivascular and perieccrine infiltrate and absence of necrosis of keratinocytes. Immunohistochemistry for SARS-CoV/SARS-CoV-2 spike protein showed granular positivity in endothelial cells and epithelial cells of eccrine glands in both biopsies. All patients had an excellent outcome, and had minimal or no systemic symptoms. The coincidence of EM, a condition commonly related to viruses, and chilblains in the setting of COVID-19, and the positivity for SARS-CoV/SARS-CoV-2 spike protein by immunohistochemistry strongly suggest a link between EM-like lesions and SARS-CoV-2.

Chilblains in children in the setting of COVID-19 pandemic.

BACKGROUND: Different skin manifestations of COVID-19 are being reported. Acral lesions on the hands and feet, closely resembling chilblains, have been recognized during the peak incidence of the COVID-19 pandemic. MATERIAL AND METHODS: A retrospective review of 22 children and adolescents with chilblain-like lesions seen over a short period of time in the Emergency Department of a children's hospital during the peak incidence of COVID-19 in Madrid, Spain. RESULTS: All patients had lesions clinically consistent with chilblains of the toes or feet, with three also having lesions of the fingers. Pruritus and mild pain were the only skin symptoms elicited, and only 10 had mild respiratory and/or GI symptoms. None had fever. Coagulation tests, hemogram, serum chemistry, and lupus anticoagulant were normal in all patients tested. One out of 16 tested cases had elevated D-dimer results, but without systemic symptoms or other laboratory anomalies. SARS-CoV-2 PCR tested in 19 cases was positive in just one case. Skin biopsies obtained in six patients were consistent with chilblains. On follow-up, all cases showed spontaneous marked improvement or complete healing. CONCLUSION: Acute chilblains were observed during COVID-19 pandemic in children and teenagers. It is a mildly symptomatic condition with an excellent prognosis, usually requiring no therapy. Etiopathogenesis remains unknown.

[Impact of a new acute bronchiolitis protocol on clinical practice]. / Impacto en la práctica clínica de un nuevo protocolo de bronquiolitis aguda.

INTRODUCTION: The prevalence and the variability of clinical practice in acute bronchiolitis make it a perfect candidate to monitor the proper use of resources. The aim of this study is to analyse the differences in the use of non-recommended resources in the management of bronchiolitis in the Emergency Department, before and after the establishment of a new protocol. METHODS: A retrospective study was conducted on a sample of patients diagnosed with acute bronchiolitis in the Emergency Department of a tertiary hospital, before (December 2014) and after (December 2016) the implementation of a new protocol. A comparison was made on the use of diagnostic tests and treatments in both groups. RESULTS: The analysis included a total of 113 patients with acute bronchiolitis examined in December 2014, and 128 patients in December 2016. The clinical characteristics in both groups were similar. In the post-protocol period, there was a significant decrease in the use of salbutamol, both in the Emergency Department (33.6% vs 19.5%, P<.01) and at discharge (46.7% vs 15.2%, P<.001); adrenaline (12.4% vs 2.4%, P=.002), and nebulised hypertonic saline solution (5.3% vs 0.8%, P=.04). Rapid respiratory syncytial virus (RSV) testing was also decreased (40.7% vs 26.6%, P=.01). This decrease was not associated with an increase in the number of admissions or re-assessments in the Emergency Department. CONCLUSIONS: The establishment of a new protocol for acute bronchiolitis decreased the use of non-recommended resources, mainly the use of bronchodilators and rapid RSV testing.

Evaluation and Impact of the "Advanced Pediatric Life Support" Course in the Care of Pediatric Emergencies in Spain.

INTRODUCTION: The Advanced Pediatric Life Support (APLS) course was introduced in the training of professionals who care for pediatric emergencies in Spain in 2005. OBJECTIVE: To analyze the impact of the APLS course in the current clinical practice in Spanish PEDs. METHODS: The directors of APLS courses were asked about information regarding the courses given to date, especially on the results of the satisfaction survey completed by students at the end of the course. Furthermore, in December 2014, a survey was conducted through Google Drive, specifically asking APLS students about the usefulness of the APLS course in their current clinical practice. RESULTS: In the last 10 years since the APLS course was introduced in Spain, there have been 40 courses in 6 different venues. They involved a total of 1520 students, of whom 958 (63.0%) felt that the course was very useful for daily clinical practice. The survey was sent to 1,200 students and answered by 402 (33.5%). The respondent group most represented was pediatricians, 223 (55.5%), of whom 61 (27.3%) were pediatric emergency physicians, followed by pediatric residents, 122 (30.3%). One hundred three (25.6%) respondents had more than 10 years of professional practice and 291 (72.4%) had completed the course in the preceding four years. Three hundred forty-one of the respondents (84.9%: 95% confidence interval [CI], 81.9-87.9) said that they always use the pediatric assessment triangle (PAT) and 131 (32.6%: 95% CI, 28-37.1) reported that their organization has introduced this tool into their protocols. Two hundred twenty-three (55.5%: 95% CI, 50.6-60.3) believed that management of critically ill patients has improved, 328 (81.6%: 95% CI, 77.8-85.3) said that the PAT and the systematic approach, ABCDE, help to establish a diagnosis, and 315 (78.4%: 95% CI, 74.3-82.4) reported that the overall number of treatments has increased but that these treatments are beneficial for patients. Hospital professionals (191; 47.5%) include the PAT in their protocols more frequently than pre-hospital professionals (68.5% vs 55.4%; p <0.01) and consider PAT useful in the management of patients (60.2% vs 51.1%; p <0.05). Neither the time elapsed since the completion of the course, nor category and years of professional experience had any influence on the views expressed about the impact of the APLS course in clinical practice. CONCLUSIONS: Most health professionals who have received the APLS course, especially those working in the hospital setting, think that the application of the systematic methods learned, the PAT and ABCDE, has a major impact on clinical practice.

Acute glomerulonephritis associated with pneumonia: a review of three cases.

We evaluated the clinical presentation and prognosis of three children with acute glomerulonephritis (AGN) associated with pneumonia. The patient database of Niño Jesús Children's Hospital was analyzed retrospectively (1996-2007) for patients diagnosed at discharge with both pneumonia and AGN. Those with recent pharyngeal or cutaneous infection were excluded. Three patients (1.67, 4.25, and 5 years old, respectively) were selected. All of them had lobar pneumonia, developing both macrohematuria and proteinuria within 24 h after admission. Decreased glomerular filtration rate was found in one patient. Two children developed arterial hypertension and one a slight pleural effusion. Two children had low C3 levels, and one had both low C3 and C4 levels. A Streptococcus pneumoniae serotype 17F was isolated from the blood culture of one patient. On follow-up, all patients had normal blood pressure and renal function with microhematuria persisting long term. Our patients with pneumonia-associated AGN had a good prognosis for both pulmonary and renal involvement.