Nutritional status, metabolic state and nutrient intake in children with bronchiolitis.

Nutrition has a coadjuvant role in the management of children with acute diseases. We aimed to examine nutritional status, macronutrient requirements and actual macronutrient delivery in bronchiolitis. The nutritional status was classified according to WHO criteria and resting energy expenditure (MREE) was measured using an indirect calorimeter. Bland-Altman analysis was used to examine the agreement between MREE and estimated energy expenditure (EEE) with standard equations. Based on the ratio MREE/EEE in relation to Schofield equation on admission, we defined the subjects' metabolic status. A total of 35 patients were enrolled and 46% were malnourished on admission, and 25.8% were hypermetabolic, 37.1% hypometabolic and 37.1% normometabolic. We performed a 24-h recall in 10 children and 80% were overfed (AEI: MREE >120%). Mean bias (limits of agreement) with MREE was 8.9 (-73.9 to 91.8%) for Schofield; 61.0 (-41 to 163%) for Harris-Benedict; and 9.9 (-74.4 to 94.2%) for FAO-WHO equation. Metabolism of infants with bronchiolitis is not accurately estimated by equations.

Acute otitis media in pediatrics: are there rational issues for empiric therapy?

BACKGROUND: Acute otitis media in children is a significant clinical problem that requires a rational approach to treatment. The condition is extremely common and has important economic implications. At present there is considerable controversy over the most appropriate strategy and over the use and choice of antibiotics. OBJECTIVES: To analyze the various factors that influence therapeutic decisions and consider how these may assist in the formulation of a rational approach to therapy. DISCUSSION: Otitis media has a multifactorial etiology but it is extremely difficult to differentiate between bacterial and viral causes on clinical grounds. Culture of the middle ear fluid is rarely practicable; however, nasal swabs are relatively noninvasive and can provide useful microbiologic information, especially in excluding a bacterial cause. Published information provides little guidance on the most appropriate therapy; a rational approach to treatment is based on many considerations including the local epidemiology. The minimum criteria for the empiric choice of an antibiotic for acute otitis media are that it should be rapidly bactericidal and reach adequate concentrations in the middle ear fluid. In areas where beta-lactamase-producing strains are prevalent, a beta-lactamase-stable antibiotic should be chosen; good absorption from the gastrointestinal tract and high and consistent penetration into the middle ear are important characteristics. Compliance-enhancing factors such as fewer doses per day and good palatability are also important.

Short course therapy with cefitbuten versus azithromycin in pediatric streptococcal pharyngitis.

OBJECTIVE: To compare the safety and efficacy of a short course (5 days) of ceftibuten vs. azithromycin for 3 days for treatment of group A beta-hemolytic streptococcal (GABHS) pharyngitis in children. METHODS: A multicenter, open label, prospective, randomized trial in which patients > or =3 to < or =16 years of age with proven GABHS pharyngitis were randomized to receive either once daily ceftibuten for 5 days or azithromycin for 3 days. Patients were evaluated for clinical outcomes and/or for adverse events at days 6 to 8, 13 to 15 and 33 to 35 posttherapy. Microbiologic assessments (pharyngeal cultures) were conducted at baseline and at each follow-up visit. RESULTS: A total of 132 patients in the ceftibuten arm and 116 in the azithromycin arm were enrolled in the safety analysis, whereas 126 and 101, respectively, were enrolled for ceftibuten and azithromycin efficacy evaluation. Clinical success (cure or marked amelioration) at days 6 to 8 was recorded in 98 and 94% in the 2 groups, respectively. In the bacteriologic efficacy analysis at 6 to 8 days, the GABHS strain was eradicated in 76% of the patients treated with ceftibuten and in 76% of those receiving azithromycin. At 33 to 35 days, 84% of the patients in the ceftibuten arm and 71% in the azithromycin arm were GABHS-negative, and bacteriologic relapse was observed in 4 and 7% of the ceftibuten and azithromycin cases, respectively. Both treatments were well-tolerated by all patients. CONCLUSIONS: Ceftibuten and azithromycin allow simple treatment schedules (i.e. once daily administration, short duration of treatment). The somewhat higher eradication rate recorded after ceftibuten administration is consistent with the overall superior bactericidal activity of beta-lactams compared with macrolides vs. GABHS in vitro.

Clinical and pharmacological evaluation of a modified cefotaxime bid regimen versus traditional tid in pediatric lower respiratory tract infections.

It is generally accepted that the treatment of community-acquired pneumonia, either in adults or in pediatric patients, is mainly empirical. Thus, the treatment selection must fulfill both the epidemiological requirements, according to the most frequently described pathogens, and the pharmacological criteria to ensure adequate and prolonged drug concentrations at the infection site, to reach clinical efficacy. Cefotaxime has proven to be effective in this indication when traditionally administered three times daily and, more recently, twice daily, as a result of a re-evaluation of its pharmacokinetic/pharmacodynamic features. To gain further evidence using this updated dosing schedule, 258 pediatric patients with lower respiratory tract infections were treated with cefotaxime 100 mg/kg/day, administered as a twice daily or three times daily regimen. In the cefotaxime 50 mg/kg twice-daily group (n = 130), a complete resolution of clinical signs and symptoms were observed in 88.5% of patients. Similarly, in the cefotaxime 33.3 mg/kg group (n = 128), 93.6% of patients had a complete resolution of clinical signs and symptoms. Both drug schedules were well tolerated. Pharmacokinetic parameters determined for the two cefotaxime dosing schedules showed comparability. The serum half-life of desacetylcefotaxime was marginally longer than for cefotaxime in both dosage groups (1.64 and 1.36 h for desacetylcefotaxime versus 1.2 and 0.85 h for cefotaxime after 50 mg/kg or 33.3 mg/kg doses, respectively). Results from this study support the use of twice-daily cefotaxime administration for the treatment of lower respiratory tract infections in pediatric patients.

Management of upper respiratory tract infections in primary care in Italy: a national survey.

This prospective study, carried out in Italy during the winter of 1998 by the means of questionnaires, was designed to investigate the diagnostic and therapeutic approach of the Italian general practitioners (GPs) to the management of acute upper respiratory tract infections (URTIs) in adult outpatients. A total of 354 GPs were questioned about ten adult patients each who had visited the surgery with an URTI requiring an antibiotic prescription. Our data showed there was a tendency to prescribe antibiotics only on the basis of clinical diagnosis, microbiological investigations being required very rarely. Orally administered antibiotics were preferred and compliance with the number of daily doses strongly influenced the antibiotic prescription. In patients affected by more severe infections, injectable antibiotics were frequently prescribed.

Efficacy and tolerability of brodimoprim in pediatric infections.

Brodimoprim is a long acting broad spectrum antibacterial agent. It is a new selective inhibitor of bacterial dihydrofolate reductase, structurally related to trimethoprim. The aim of the present study was to investigate the efficacy and tolerability of brodimoprim (10 mg/kg on the first day, 5 mg/kg/die onward) in the treatment of upper respiratory tract infections in children (age range: 2-14 years). This open group comparative study was performed either in 68 children affected by bacterial pharyngotonsillitis (37 treated with brodimoprim, 31 with erythromycin 560 mg/kg/8 hours) or in 50 patients affected by otitis media (25 treated with brodimoprim, 25 with amoxicillin/clavulanic acid 50 mg/kg/12 hours) or in 52 patients affected by acute sinusitis (25 treated with brodimoprim, 27 with amoxicillin/clavulanic acid 50 mg/kg/12 hours). All patients were clinically evaluated before admission, during the trial and 48 hours after the last dose of antibiotic. At the same time blood and secretion samples were collected for hematology/biochemistry and microbiological assays. A total of 170 subjects were treated and 141 patients demonstrated a clinical recovery/improvement following the treatment period, with approximately the same recovery rate (83%) among the groups. The bacteriological response was evaluated in 169 subjects. Eradication of pathogens was documented in 27 subjects treated with brodimoprim and 28 with erythromycin in the pharyngotonsillitis group, in 22 subjects treated with brodimoprim and 16 with amoxicillin/clavulanic acid in the otitis group and in 17 subjects treated with brodimoprim and 20 with amoxicillin/clavulanic acid in the sinusitis group. The overall eradication in brodimoprim treated patients was 77% in comparison with 76% of eradication obtained in the control groups.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute rheumatic fever: a report]. / Segnalazioni di malattia reumatica.

Acute rheumatic fever (ARF) is still an important disease of the pediatric and adult age. The increased number of cases described in the literature in the last 10 years brought us to evaluate the ARF cases diagnosed in a Pediatric Teaching Hospital in the period 1988-1997. Most of the children with ARF presented with joint involvement even if patients with cardiac disease or chorea minor were numerous. About 50% of our patients with ARF did not refer a history of a febrile tonsillopharyngitis in the 15-60 days before the presentation of ARF. The remaining patients have had a preceding pharyngitis not adequately treated. In none of the subjects a throat swab positive for group A beta hemolytic streptococci was available. These results confirm the importance of the correct diagnosis and treatment of streptococcal pharyngitis but suggest that ARF can develop without any outstanding clinical evidence of streptococcal infection.

[Moraxella catarrhalis: an emerging respiratory pathogen]. / Moraxella (Branhamella) catarrhalis: un patogeno respiratorio emergente.

In the past years Moraxella (Branhamella) catarrhalis has finally gained respect as a pathogen thanks to the many reports of its causal role. The intent of this review is to provide a critical evaluation of the intent of this review is to provide a critical evaluation of the microbiological features (taxonomy, diagnosis, virulence, epidemiology and drug resistance), clinical diseases and therapy of this microorganism

[Amoxicillin-clavulanic acid combination in bacterial infections of the upper respiratory tract in childhood. Controlled clinical study]. / L'associazione amoxicillina-acido clavulanico nelle infezioni batteriche delle vie respiratorie superiori in età pediatrica. Studio clinico controllato.

A comparative clinical trial of amoxycillin - clavulanic acid combination versus erythromycin was carried out in a case series of 20 pediatric patients, suffering from upper respiratory tract infections with a proven bacterial etiology and different localization (tonsils, nasal and paranasal sinuses and ear). The results have confirmed the highly innovative efficacy of amoxycillin - clavulanic acid combination: the clinical judgement was in fact favourable, with eradication of the pathogenic agent in 90% of cases. The tolerability of the combination was globally good from both the general and local point of view.

[Streptococcal tonsillopharyngitis: clinical vs. microbiological diagnosis]. / Faringotonsillitestreptococcica: confrontotra diagnosi clinicae microbiologica.

This study aimed to evaluate the role of clinical diagnosis vs. rapid antigen detection tests (RADT) in identifying streptococcal vs. non-streptococcal cases of acute pharyngitis (AP) with respect to a scoring schedule. The Breese scoring system, modified by eliminating the count of peripheral WBC, was used in the study. At enrolment, cases of AP observed by office-based pediatricians were judged on a clinical basis as possibly of streptococcal or of non-streptococcal origin and a clinical score recorded. At the end of the visit and following completion of the clinical score to document the presence/absence of a group A beta haemolytic streptococcus (GABHS), a confirmatory RADT was performed. In RADT negative cases a standard throat swab and culture were performed. In all, 629 children presenting with AP were enrolled in the study. A correct clinical diagnosis was predicted on the basis of the clinical observation in 74.2% of cases (with a sensitivity of 81.1% and specificity of 70.5%). In cases judged as "streptococcal", a mean score of 27.6 was recorded both in those patients with a positive or negative RADT/throat swab for GABHS. By contrast, among cases considered of non-streptococcal aetiology, negative RADT/culture had a mean score of 24.3 compared to a mean score of 25 in those with a positive RADT/culture. Intragroup score differences were not significant, while intergroup differences were highly significant. Optimization of AP treatment requires careful identification of streptococcal cases, avoiding unnecessary antibiotic treatment which would contribute to enhancing antibiotic resistance and increase medical treatment costs. We document that clinical observation alone, although performed by skilled pediatricians, will misdiagnose a sizeable percentage of cases. As indicated by this study, scores may suffer from a subjective interpretative bias in grading the severity of signs and symptoms.

[Topical treatment of localized edemas of mechanical or inflammatory origin with a novel antiedema ointment. A prospective study]. / Studio prospettico di un nuovo unguento antiedemigeno nel trattamento locale di edemi localizzati di origine meccanica o infi ammatoria.

OBJECTIVE: Following traumas, muscular or articular injuries it is common to observe lesions where edema is the main finding, with local pain leading to a muscular and/or articular limitation hindering the usual activity. MATERIALS AND METHODS: In this study, a new anti-edema ointment with elevated saline concentration designed for the osmotic treatment of swelling has been evaluated. 21 subjects (mean age 34.2 yrs; range 6-73 yrs) have been enrolled and evaluated for the resolution of edema and restoration of the normal functional activity following the local application (3 times/daily) of the ointment until resolution for a maximum of 9 days (mean duration of treatment 5 days; range 2-9 days). RESULTS: After 2-3 days of application edema disappeared or was ameliorated in 13/21 cases, and in other 7/21 at 5-9 days of follow-up (p0.001 chi square for number of beneficial occurrences). Normal activity has been documented in 10/11 subjects in whom it was altered at enrollment. Local tolerability of the ointment has been optimal or good in the majority of patients, being represented only by local itching or erythema. The local application of the anti-edema ointment has allowed also a marked reduction in the use of acetaminophen or other anti-inflammatory treatments, that were infrequent and present only in 4/21 subjects. CONCLUSIONS: This study demonstrates that the local application of an anti-edema osmotic ointment allows to obtain a prompt resolution of the swelling coupled with a marginal use of anti-inflammatory therapies for the control of the local algic and inflammatory component of the disease.

Penetration of roxithromycin into bronchial secretions.

The penetration of an antibacterial agent into the bronchial secretions is a crucial factor in determining its clinical efficacy in the treatment of bacterial respiratory infections. Roxithromycin is a novel macrolide compound active against the most frequent respiratory pathogens. Following administration of 150 mg p.o., we observed a prompt penetration of the compound into bronchial secretions of critically ill patients. Elevated concentrations above the MICs of the commonest susceptible pathogens are reached and maintained until the next administration.

Pharmacokinetics and bacteriological effect of ceftazidime in experimental Streptococcus pneumoniae, Haemophilus influenzae, and Escherichia coli meningitis.

The pharmacokinetics and bacteriological effect of ceftazidime were evaluated in rabbits experimentally infected with Streptococcus pneumoniae, Haemophilus influenzae type b, and Escherichia coli K1. The mean penetration of ceftazidime into cerebrospinal fluid after single-dose or constant-infusion administration ranged from 7.8 to 14.9%. The median cerebrospinal fluid bactericidal titers were 1:64 against S. pneumoniae and H. influenzae and 1:128 against E. coli. The bacterial colony counts in cerebrospinal fluid were reduced by 58% to 100% (-2.3 to -3.9 log10 CFU/ml) in 3 h and by 100% (-3.2 to -5.1 log10 CFU/ml) in 9 h of constant infusion, whereas in untreated infected animals, bacterial counts increased from +1.4 to +2.1 log10 CFU/ml in 9 h. These data on ceftazidime compare favorably with those on penicillin, chloramphenicol, netilmicin, and moxalactam in this experimental meningitis model.

Penetration of ceftazidime into bronchial secretions in critically ill patients.

Five adult patients admitted to ICU, with respiratory failure, required endotracheal intubation and respiratory support. They were treated with ceftazidime because of lower respiratory tract infections. All patients were given ceftazidime at 1, 2 and 3 g dosages in a randomized sequence and timed serum and bronchial secretion samples collected. Mean peak serum concentrations of 60.3, 148.7 and 224.8 mg/L were found in the three treatment groups and mean trough levels of 1.02, 1.85 and 1.63 mg/L respectively. Ceftazidime appeared rapidly in bronchial secretions reaching mean maximal concentrations of 2.2, 4.81 and 5.69 mg/L in the first sampling period (0-2 h). Serum and bronchial secretions AUCs have been calculated showing that both almost doubled their values between 1 and 2 g dosing, while between 2 and 3 g doses only a moderate and non-significant increase were found. On the basis of these results, the existence of a saturable transport mechanism for ceftazidime from serum to bronchial secretions can be postulated.

Oxatomide in the treatment of atopic dermatitis in breast-fed and very young infants.

BACKGROUND: This study was designed to assess the efficacy and safety of oxatomide oral suspension, in breast-fed and young babies with atopic dermatitis. METHODS: Thirty-one children (11 females, 20 males) aged between 4 and 35 months (mean+/- SD 15.4+/-7.6 months) were treated with oxatomide (2.5 mg/mL) at a dose of 1 mg/kg/day) split into two doses, every 12 hrs; treatment lasted 30 days. Efficacy was evaluated on the basis of the following signs and symptoms: itching (severity, extension and duration), blisters (number, extension), erythema (severity, extension), papules (number, extension), lesions from scratching (yes/no), dry skin (yes/no). RESULTS: Skin signs improved significantly with oxatomide. Itching was reduced 58.2% from baseline, and erythema 57.6% (both p<0.001). Vesicles, papules, lesions due to scratching and dry skin also improved significantly. Oxatomide had to be stopped only in one child in whom the dermatitis became worse. CONCLUSIONS: These results show the efficacy and safety of oxatomide in breast-fed or very young babies with atopic dermatitis. The oral suspension was particularly easy to use in children less than two years old, on account of the simple dosage schedule.

Ceftriaxone kinetics after a single intravenous dose in leukemic children with fever and granulocytopenia.

Ceftriaxone (CFX) is a new third-generation cephalosporin with interesting characteristics as regards both its antibacterial spectrum and kinetics which make it potentially useful in the empiric treatment of infections in neutropenic cancer patients. However, since its kinetic characteristics in children with leukemia are not known and its pharmacokinetics are reported to be altered in such patients, we studied ceftriaxone's activity in ten leukemic children with fever and neutropenia. Our findings seem to be confirm the potential efficacy of the drug also in this particular type of patient.

Comparison of the concentrations of ceftazidime in the serum of newborn infants after intravenous and intramuscular administration.

The concentrations of ceftazidime in serum were studied in 16 preterm and term neonates to whom a single dose of 50 mg/kg had been administered intramuscularly or intravenously. After intramuscular injection, concentrations of ceftazidime in serum were comparable to those obtained with the intravenous dose, although they were more variable. Peak serum levels ranging from 50 to 102 micrograms/ml were reached 30 to 60 min after intramuscular injection. The concentrations declined monoexponentially after the peak, with a mean half-life of 3.8 +/- 1.1 h. Concentrations of ceftazidime in serum declined biexponentially after intravenous injection, with a terminal half-life of 4.7 +/- 1.5 h.