Great Plasticity in a Great Pathogen: Capsular Types, Virulence Factors and Biofilm Formation in ESBL-Producing Klebsiella pneumoniae from Pediatric Infections in Uruguay.

Klebsiella pneumoniae is widely recognized as an opportunistic hospital and community pathogen. It is one of the priority microorganisms included in the ESKAPE group, and its antibiotic resistance related to extended-spectrum ß-lactamases (ESBL) is a global public health concern. The multi-drug resistance (MDR) phenotype, in combination with pathogenicity factors, could enhance the ability of this pathogen to cause clinical infections. The aim of this study was to characterize pathogenicity factors and biofilm formation in ESBL-producing K. pneumoniae from pediatric clinical infections. Capsular types, virulence factors, and sequence types were characterized by PCR. Biofilm formation was determined by a semiquantitative microtiter technique. MDR phenotype and statistical analysis were performed. The K24 capsular type (27%), virulence factors related to iron uptake fyuA (35%) and kfuBC (27%), and sequence types ST14 (18%) and ST45 (18%) were the most frequently detected. Most of the strains were biofilm producers: weak (22%), moderate (22%), or strong (12%). In 62% of the strains, an MDR phenotype was detected. Strains with K24 capsular type showed an association with ST45 and the presence of fyuA; strains with kfuBC showed an association with moderate or strong biofilm production and belonging to ST14. Weak or no biofilm producers were associated with the absence of kfuBC. The MDR phenotype was associated with the main ESBL gene, blaCTX-M-15. The high plasticity of K. pneumoniae to acquire an MDR phenotype, in combination with the factors exposed in this report, could make it even more difficult to achieve a good clinical outcome with the available therapeutics.

Vancomycin pharmacokinetic-pharmacodynamic parameters to optimize dosage administration in critically ill children.

OBJECTIVE: Critically ill children may present changes in pharmacokinetic parameters and may not reach effective concentrations of vancomycin with current dosages. The objective of this study is to calculate vancomycin pharmacokinetic parameters in critically ill children and to estimate area under the curve at 24 hrs/minimal inhibitory concentration reached for Staphylococcus aureus. DESIGN, SETTING, AND PATIENTS: Children treated with vancomycin, hospitalized in the Intensive Care Unit of the Pediatric Hospital-Centro Hospitalario Pereira Rossell, were included. Samples to determine vancomycin serum concentration were obtained on first and third days of treatment, 1 hr after the end of the third daily dose administration (maximum drug concentration) and 15 mins before the fourth (minimum drug concentration). Half-life elimination, volume of distribution, clearance, and area under the curve at 24 hrs were estimated. Vancomycin concentration values of 20-40 µg/mL (maximum drug concentration) and 5-10 µg/mL (minimum drug concentration) were considered therapeutic. MEASUREMENTS AND MAIN RESULTS: Twenty-two children were included. On day 1, seven of 18 children for maximum drug concentration and 16 of 22 for minimum drug concentration reached concentrations in therapeutic range; on day 3, seven of 16 children for maximum drug concentration and 11 of 17 for minimum drug concentration did. Mean values of maximum drug concentration and minimum drug concentration were higher in children with negative water balance. Mean value of half-life elimination increased from day 1 to day 3. Considering a value of minimal inhibitory concentration for S. aureus of 1 µg/mL, nine of 18 children reached a relationship area under the curve at 24 hrs/minimal inhibitory concentration >400 on day 1 and seven of 15 on day 3. Considering a minimal inhibitory concentration of 2 µg/mL, one child reached it on day 1 and one on day 3. CONCLUSIONS: Critically ill children show changes in pharmacokinetic parameters. Serum concentration monitorization is necessary for dosage individualization. Most children do not reach an area under the curve at 24 hrs/minimal inhibitory concentration >400 with current dosage.

[Antibiotic consumption and antimicrobial susceptibility evolution in the Centro Hospitalario Pereira Rossell in methicillin resistant Staphylococcus aureus era]. / Evolución del consumo de antibióticos y de la susceptibilidad antimicrobiana en el Centro Hospitalario Pereira Rossell en la era de Staphylococcus aureus resistente a meticilina.

INTRODUCTION: In the past few years, an increase in methicillin resistant-not multiresistant Staphylococcus aureus was observed in Uruguay among children with community acquired infections. Recommendations for empiric antibiotic treatment required adjustments and new national guidelines were recommended in July 2004. Adherence to these guidelines was indirectly performed by monitoring antibiotic consumption and antimicrobial susceptibility patterns in Uruguay. OBJECTIVE: To describe and compare antibiotic consumption and antimicrobial susceptibility of Staphylococcus aureus in a Pediatric Hospital of the Centro Hospitalario Pereira Rossell (PH-CHPR) between 2001 and 2006. METHODS: Antibiotic consumption in hospitalized children was calculated using the Defined Daily Dose per 100 bed-days (DDD/100). Reference values were obtained from the World Health Organization Collaborating Center for Drug Statistics Methodology of. Consumption. Data were obtained using the WinPharma programme of the Pharmacy Department of CHPR. The fraction of annual occupancy of hospital beds was obtained from the Statistic Division of CHPR. Antibiotic consumption was evaluated between 2001 and 2006 and expressed as DDD/100 and percent change. Antimicrobial susceptibility was evaluated using CHPR's Microbiology Laboratory data during the same time period. RESULTS: After 2003 a significant increase in consumption of clindamycin, ceftriaxone, trimethoprim-sulphamethoxazole, cefuroxime, vancomycin and gentamycin was observed, except for cephradine. Consumption of clindamycin, ceftriaxone and trimethoprim-sulphamethoxazole showed the highest increase (6.15%; 1.44% and 1.17% respectively). Detection of Staphylococcus aureus increased significantly mostly from skin and soft tissue infections. Oxacillin susceptibility of S. aureus strains obtained from different sites had a significant and persistent decrease after 2003 (from 81 % during year 2001 to 40% in year 2006 (p < 0.05). Susceptibility to others antibiotics did not decrease. Between 2004 and 2006 the "D effect" decreased from 28% to 21 %. Antimicrobial susceptibility patterns did not differ by site of infection. CONCLUSIONS: Methicillin resistant-not multiresistant Staphylococcus aureus has established itself as a regular community pathogen in Uruguayan children. Changes in antimicrobial consumption patterns reflect the impact of this pathogen in clinical practice and the overall adherence to new recommendations. This change was not associated with an increase in antibiotic resistance. Clindamycin is an alternative treatment although Clindamycin inducible resistance is a worry. Continuous monitoring of antibiotic consumption and local susceptibility patterns are required to promote rational use of antibiotics.

Características clínicas y demográficas de los niños hospitalizados con infección por SARS-CoV-2

Introducción: en marzo de 2020 se registraron los primeros casos de infección por SARS-CoV-2 en Uruguay y se decretó la emergencia sanitaria. Objetivo: describir las características clínicas demográficas de los menores de 15 años hospitalizados con infección por SARS-CoV-2 en el período 13 de marzo de 2020 al 30 de septiembre de 2021 en el Hospital Pediátrico del Centro Hospitalario Pereira Rossell, centro de referencia público de Uruguay. Metodología: estudio descriptivo, retrospectivo, en el que se describen edad, manifestaciones clínicas, comorbilidades, severidad, tratamiento y evolución. Resultados: se hospitalizaron 207 niños con una frecuencia de 1,6%. La mediana (rango intercuartil) de edad fue 1,5 años (3 meses - 8 años); <1 año 44%; 54% de sexo masculino. Presentaron comorbilidades, 59 niños. Fueron sintomáticos, 71%. De los sintomáticos, presentaron síntomas leves 48%. Las manifestaciones clínicas fueron respiratorias en 96 (65%) y no respiratorias en 51 (fiebre sin foco 15, digestivas 19, exantema viral 3, SIM-Ped S 10 y atípicas 3). Treinta niños ingresaron a unidad de cuidados intensivos (UCI) y tres requirieron ventilación invasiva. Estos pacientes presentaron comorbilidades, tuvieron más días de fiebre y necesitaron oxigenoterapia que los que no requirieron UCI. Un paciente de 2 años con comorbilidades falleció. Conclusión: la frecuencia de hospitalizaciones fue de 1,6%. La mayoría de los niños sintomáticos presentaron formas leves. En los sintomáticos las manifestaciones fueron respiratorias. Los hallazgos en esta serie aportan al conocimiento del comportamiento de la infección por SARS-CoV-2 en niños.

Introduction: in March 2020, the first cases of SARS CoV-2 infection were registered in Uruguay and a health emergency was decreed. Objective: To describe the clinical and demographic characteristics of children under 15 years of age hospitalized with SARS-CoV-2 infection from March 13, 2020, to September 30, 2021, at Pereira Rossell Pediatric Hospital, a public reference center in Uruguay. Method: descriptive, retrospective study describing age, clinical manifestations, comorbidities, severity and treatment. Results: a total of 207 children were hospitalized, with a frequency of 1.6%. The median (interquartile range) age was 1.5 years (3 months - 8 years); <1 year accounted for 44%, and 54% were male. Comorbidities were present in 59 children. 71% of them were symptomatic, and among the symptomatic cases, 48% presented mild symptoms. Clinical manifestations were respiratory in 96 (65%) cases and non-respiratory in 51 (fever without a focus 15, gastrointestinal 19, viral exanthem 3, pediatric inflammatory multisystem syndrome 10, and atypical 3). Thirty patients were admitted to the Intensive Care Unit (ICU), and 3 required invasive ventilation. These patients had comorbidities, more days of fever, and required oxygen therapy compared to those who did not need ICU. One 2-year-old patient with comorbidities died. Conclusion: the hospitalization frequency was 1.6%. Most symptomatic children had mild forms of the disease. Among the symptomatic cases, respiratory manifestations were predominant. The findings from this series contribute to the understanding of the behavior of SARS-CoV-2 infection in children.

Introdução: Os primeiros casos de infecção por SARS CoV-2 no Uruguai foram registrados em março de 2020 quando foi decretada a emergência sanitária. Objetivo: descrever as características clínicas e demográficas das crianças menores de 15 anos internadas com infecção por SARS CoV-2 no período 13 de março de 2020 - 30 de setembro de 2021 no Hospital Pediátrico do Centro Hospitalar Pereira Rossell, centro público de referência no Uruguai. Metodologia: estudo descritivo, retrospectivo, incluindo idade, manifestações clínicas, comorbidades, gravidade, tratamento e evolução. Resultados: 207 crianças foram internadas com infecção por SARS CoV-2 correspondendo a frequência de 1,6% do total de crianças hospitalizadas no período estudado. A mediana (intervalo interquartil) de idade foi de 1,5 anos (3 meses - 8 anos) dos quais 44% eram <1 ano 44% e 54% do sexo masculino. 59 crianças apresentaram comorbidades. 71% eram sintomáticas sendo que 48% delas apresentaram sintomas leves. As manifestações clínicas foram respiratórias em 96 (65%) e não respiratórias em 51 (febre sem foco 15, digestiva 19, exantema viral 3, SIM-Ped S 10 e atípico 3). 30 crianças foram internadas na Unidade de Terapia Intensiva e 3 precisaram de ventilação invasiva; esses pacientes apresentavam comorbidades, necessitaram de oxigenoterapia e tiveram mais dias de febre do que aqueles que não necessitaram de UTI. Uma paciente de 2 anos com comorbidades faleceu. Conclusão: a frequência de internações foi de 1,6%. A maioria das crianças sintomáticas apresentou formas leves. Nas sintomáticas as manifestações foram respiratórias. Os achados desta série contribuem para o conhecimento do comportamento da infecção por SARS CoV-2 em crianças.

[Gentamicin pharmacokinetics in term newborn: ¿Is it necessary to systematically monitor plasmatic levels?]. / Parámetros farmacocinéticos de gentamicina en recién nacidos de término: ¿Es necesario monitorizar en forma sistemática sus concentraciones plasmáticas?

BACKGROUND: Gentamicin is indicated as empiric treatment for neonatal sepsis. Plasmatic levels dosification of gentamicin is a common practice. The relationship between peak plasma concentration (Cmáx) with minimum inhibitory concentration (MIC) (Cmáx/MIC) is the parameter that best predicts treatment efficacy. AIM: To determine pharmacokinetics of gentamicin in term newborn infants. METHODS: Term newborn infants receiving gentamicin, without critical illness in which plasmatic levels of gentamicin was performed were included. Elimination clearance (Cl) elimination half-life (t½) and volume of distribution (Vd) were calculated. In each case the value of Cmax/MIC parameter was calculated, considering a MIC value of 1 µg/mL for Escherichia coli. RESULTS: Thirteen newborns were included. The mean PK values were Cl: 0.26 mL/hour, Vd: 0.54 L/kg and t½: 6.8 h. Cmax/MIC was > 8 in 6 newborns. CONCLUSIONS: Pharmacokinetic parameters of gentamicin are predictable in term newborn infants. With gentamicin doses normally used Cmax/MIC values reached 8 in 6 newborns. It is necessary to review the usefulness of plasma drug monitoring and gentamicin dosage in this group of newborns.

International Nosocomial Infection Control Consortium report, data summary of 50 countries for 2010-2015: Device-associated module.

BACKGROUND: We report the results of International Nosocomial Infection Control Consortium (INICC) surveillance study from January 2010-December 2015 in 703 intensive care units (ICUs) in Latin America, Europe, Eastern Mediterranean, Southeast Asia, and Western Pacific. METHODS: During the 6-year study period, using Centers for Disease Control and Prevention National Healthcare Safety Network (CDC-NHSN) definitions for device-associated health care-associated infection (DA-HAI), we collected prospective data from 861,284 patients hospitalized in INICC hospital ICUs for an aggregate of 3,506,562 days. RESULTS: Although device use in INICC ICUs was similar to that reported from CDC-NHSN ICUs, DA-HAI rates were higher in the INICC ICUs: in the INICC medical-surgical ICUs, the pooled rate of central line-associated bloodstream infection, 4.1 per 1,000 central line-days, was nearly 5-fold higher than the 0.8 per 1,000 central line-days reported from comparable US ICUs, the overall rate of ventilator-associated pneumonia was also higher, 13.1 versus 0.9 per 1,000 ventilator-days, as was the rate of catheter-associated urinary tract infection, 5.07 versus 1.7 per 1,000 catheter-days. From blood cultures samples, frequencies of resistance of Pseudomonas isolates to amikacin (29.87% vs 10%) and to imipenem (44.3% vs 26.1%), and of Klebsiella pneumoniae isolates to ceftazidime (73.2% vs 28.8%) and to imipenem (43.27% vs 12.8%) were also higher in the INICC ICUs compared with CDC-NHSN ICUs. CONCLUSIONS: Although DA-HAIs in INICC ICU patients continue to be higher than the rates reported in CDC-NSHN ICUs representing the developed world, we have observed a significant trend toward the reduction of DA-HAI rates in INICC ICUs as shown in each international report. It is INICC's main goal to continue facilitating education, training, and basic and cost-effective tools and resources, such as standardized forms and an online platform, to tackle this problem effectively and systematically.

Incidencia de bacteriemia asociada al uso de accesos venosos centrales en cuidados intensivos de niños / Central venous catheter-related bloodstream infections in a pediatric intensive care unit / Incidência de bacteriemia associada ao uso de acesso venoso central em cuidados intensivos pediátricos

Resumen: Introducción: la bacteriemia relacionada con el uso de catéter es la infección intrahospitalaria más frecuente en las unidades de cuidados intensivos pediátricos y es la principal causa de bacteriemia intrahospitalaria. Objetivo: determinar la incidencia de bacteriemia asociada al uso de catéter venoso central y al uso de catéter venoso central por inserción periférica en la Unidad de Cuidados Intensivos del Niño del Centro Hospitalario Pereira Rossell. Material y método: se realizó un estudio descriptivo observacional prospectivo que comenzó el 1 de junio de 2016 y que se extendió hasta la fecha en que se alcanzó el valor de 1.000 días de cateterización. Se incluyeron todos los niños hospitalizados en la Unidad de Cuidados Intensivos del Niño en los que se colocó un catéter venoso central y/o un catéter venoso central por inserción periférica. La fuente de recolección de datos fueron las historias clínicas. Resultados: se incluyeron 117 niños con catéter venoso central y con catéter venoso central por inserción periférica, un total de 134 vías y 1.028 días de cateterización. Se identificó un caso de bacteriemia relacionada con el uso de catéter a partir de un catéter venoso central por inserción periférica. Se registró una densidad de incidencia de bacteriemia relacionada al uso de catéter de 0,97 casos cada 1.000 días de cateterización. Conclusiones: el valor de incidencia de bacteriemia relacionada al uso de catéter hallado en la Unidad de Cuidados Intensivos del Niño es menor a los valores reportados en los años 2010 y 2013.

Summary: Introduction: catheter-related bloodstream infection (CRBSI) is the most frequent hospital infection in pediatric intensive care units and it is the most common cause of hospital bacteremia. Objective: calculate the incidence of catheter-related bloodstream infection in the Pediatric Intensive Care Unit of the Pereira Rossell Children Hospital. Methods: we carried out a retrospective and descriptive study as of June 1st, 2016 and until 1000 days of catheterization. We included all children hospitalized in the pediatric intensive care unit who had a central catheter inserted. Clinical data was obtained from their Health Medical Records. Results: 117 children participated in the study. They received a total of 134 central catheters during 1028 catheterization days. Only one case of catheter-related bloodstream infection was reported from a peripheral inserted central venous catheter. The catheter-related incidence density was of 0.97 cases per 1000 catheterization days. Conclusions: the catheter-related incidence of bloodstream infection in pediatric ICUs is lower than the levels reported in 2010 and in 2013.

Resumo: Objetivo: determinar a incidência de bacteremia associada ao uso de cateter venoso central e o uso de cateter venoso central através da inserção periférica na Unidade de Terapia Intensiva do Centro Hospitalar Pereira Rossell. Materiais e métodos: realizamos um estudo observacional prospectivo descritivo, iniciado no 1º de junho de 2016 e que se estendeu até a data em que foi atingido o valor de 1000 dias de cateterismo. Todas as crianças que tinham um cateter venoso central e/ou nas quais foi inserido perifericamente um cateter venoso central e que estavam internadas na Unidade de Terapia Intensiva Pediátrica foram incluídas. A fonte de coleta de dados foi obtida dos prontuários pessoais de saúde. Resultados: incluímos 117 crianças com cateter venoso central e com cateter venoso central inserido perifericamente, totalizando 134 cateteres e 1028 dias de cateterismo. Identificamos um caso de bacteremia relacionado ao uso de um cateter venoso central feito através de inserção periférica. A densidade de incidência de bacteremia relacionada ao uso de cateter foi de 0,97 casos a cada 1000 dias de cateterismo. Conclusões: o valor da incidência de bacteremia relacionada ao uso de cateter encontrado na Unidade Pediatrica de Terapia Intensiva foi inferior aos valores reportados nos anos de 2010 e 2013.

Neumonia asociada a ventilación mecánica. Incidencia y dificultades diagnósticas en una unidad de cuidados intensivos pediátricos / Incidence and difficulties in the diagnosis of ventilator associated pneumonia at a pediatric intensive care unit / Incidência e dificuldades no diagnóstico da pneumonia associada à ventilação mecânica em unidade de terapia intensiva pediátrica

Resumen: Introducción: la neumonia asociada a la ventilación mecánica (NAVM) es frecuente, en las unidades de cuidados intensivos. Genera aumento de los días de ventilación mecánica (VM), la estadía y los costos asistenciales. Objetivo: determinar la incidencia de NAVM en la Unidad de Cuidados Intensivos de Niños (UCIN) del Centro Hospitalario Pereira Rossell (CHPR) durante el año 2015. Material y método: se realizó un estudio descriptivo entre el 1 de enero al 31 de diciembre del año 2015. Se incluyeron todos los pacientes que requirieron ventilación mecánica (VM) por más de 24 h. Se aplicaron los criterios diagnósticos de Center for Diseases Control (CDC) y se cotejaron con el Clinical Pulmonary Score (CIPS). La fuente de recolección de datos fueron las historias clínicas. Resultados: se incluyeron 147 niños, 686 días de VM. En 15 se sospechó NAVM, un caso cumplió los criterios del CDC. La incidencia fue 1,45 casos por cada 1.000 días de VM. Los gérmenes aislados fueron Acinetobacter baumanii complex y Enterobacter cloacae. Conclusión: la incidencia de NAVM fue elevada en comparación con el reporte de NNIS 2013, pero baja compararla con datos regionales. Se observó escasa adherencia a los criterios del CDC. Es necesario fomentar una mayor adherencia a los criterios diagnósticos para evitar sobrediagnóstico de NAVM y racionalizar el uso de antibióticos.

Summary: Introduction: ventilator associated pneumonia (VAP) is a common hospital infection in ICUs and it can increase of morbidity, mortality, length of hospital stay and health care costs. Objective: determine the incidence of VAP in the Pediatric Intensive Care Unit of the Pereira Rossell Children Hospital (CHPR) in 2015. Material and methods. from January 1st to December 31st, 2015, we carried out a descriptive study that included children who required mechanical ventilation (MV) for 24 hours or longer. We recorded the number of days of MV, applied the Center for Diseases Control (CDC) diagnostic criteria and compared it against the Clinical Pulmonary Socore (CIPS). Clinical data were extracted from the patients' medical records. Results: 147 children met the inclusion criteria during 686 days of mechanical ventilation. We suspected VAP in 15 cases, and one of these 15 cases met the CDC criteria for VAP. The incidence of VAP was 1.45 cases/1000 days of MV. The isolated bacteria were Acinteobacter baumanii complex and Enterobacter cloacae. Conclusion: the incidence of VAP was high when compared to the 2013 NNIS Report, but low when compared to regional data. The data showed a low adherence to the CDC VAP diagnostic criteria. It is necessary to encourage compliance to CDC criteria in order to avoid VAP over diagnosis and to rationalize the use of antibiotics.

Resumo: Introdução: a pneumonia associada à ventilação mecânica (PAV) é uma infecção hospitalar comum em UTIs e pode aumentar a morbidade, a mortalidade, o tempo de internação hospitalar e os custos com assistência médica. Objetivo: determinar a incidência de PAV na Unidade de Terapia Intensiva Pediátrica do Hospital Infantil Pereira Rossell (CHPR) em 2015. Material e métodos: de 1º de janeiro a 31 de dezembro de 2015, foi realizado um estudo descritivo que incluiu crianças que necessitaram de ventilação mecânica (VM) por 24 horas ou mais. Registramos o número de dias de VM, aplicamos os critérios diagnósticos do Center for Diseases Control (CDC) e comparamos com o Clinical Pulmonary Score (CIPS). Dados clínicos foram extraídos dos prontuários médicos dos pacientes. Conclusão: a incidência de PAVM foi alta em comparação com o Relatório NNIS 2013, mas baixa quando comparada aos dados regionais. Os dados mostraram baixa aderência aos critérios diagnósticos da CDV. É necessário incentivar o cumprimento dos critérios do CDC, a fim de evitar o diagnóstico precoce da PAV e racionalizar o uso excessivo de antibióticos.

Efectos adversos neuropsiquiátricos de montelukast / Neuropsychiatric adverse effects of montelukast / Reações psiquiátricas adversas do montelucaste

Resumen: En la última década se ha registrado un aumento en la prescripción de antileucotrienos, en particular montelukast. A partir del año 2007 comenzaron los primeros reportes efectos adversos de esfera neuropsiquiátrica en la edad pediátrica. Los efectos reportados incluían trastornos del sueño y del humor hasta una posible asociación con ideación suicida y suicidio consumado. En el presente trabajo se realiza una revisión de la seguridad de montelukast tema con objetivo de establecer o descartar una eventual asociación entes los fenómenos mencionados y la administración de antileucotrienos.

Summary: In the last decade there has been an increase in the prescription of antileukotrienes, specifically montelukast. The first pediatric reports discussing adverse neuropsychiatric effects go back to 2007. The reported effects included a range from sleep and mood disorders, to even a possible association with suicidal ideation and consummated suicide. In the present paper we carry out a review of the safety of using montelukast in order to confirm or rule out an eventual association between such adverse effects and the administration of antileukotrienes.

Resumo: Na última década, houve um aumento na prescrição de antileucotrienos, em particular do montelucaste. A partir de 2007, começaram a surgir os primeiros reportes relativos aos efeitos neuropsiquiátricos adversos na idade pediátrica. Os efeitos relatados incluíram desde distúrbios do sono e do humor até uma possível associação com ideação suicida e suicídio consumado. No presente paper realizamos uma revisão da segurança no uso do montelucaste com o objetivo de confirmar ou descartar uma eventual associação entre os seus efeitos adversos e a administração de antileucotrienos.

Evaluación del uso de sedación y analgesia en niños con asistencia ventilatoria mecánica / Assessing the use of sedation and analgesia on children under mechanical ventilation / Avaliação do uso de sedação e analgesia em crianças com assistência ventilatória mecânica

Resumen: Objetivo: cuantificar el uso de sedoanalgesia en niños críticamente enfermos con asistencia ventilatoria mecánica (AVM) en la Unidad de Cuidados Intensivos (UCIN) del Centro Hospitalario Pereira Rossell (CHPR). Metodología: estudio observacional descriptivo y prospectivo realizado entre los meses de mayo a setiembre de 2017. Se incluyeron pacientes ingresados a UCIN que requirieron AVM y sedoanalgesia o mioparalización. Se registraron las siguientes variables: sexo, edad, peso, diagnóstico al ingreso. En relación con la sedación y analgesia se registraron dosis indicadas y recibidas de cada fármaco y las dosis acumulativas. Se las comparó con un estudio realizado en 2012 en UCIN. Resultados: se incluyeron 37 pacientes. El promedio de días de AVM fue de 3,7. La causa más frecuente de AVM fue patología respiratoria (n=34). Se observó discordancia entre dosis indicada y dosis recibida tanto de opiáceos, benzodiacepinas y paralizantes musculares, pero en menor medida que lo registrado en el año 2012. Las dosis acumulativas de midazolam, fentanyl y atracurio disminuyeron respecto al año 2012. Conclusión: se observó una disminución de las dosis promedio utilizadas de cada fármaco, de la duración de la AVM y una menor incidencia de síndrome de abstinencia. Las causas de esta observación pueden ser multifactoriales.

Summary: Objective: to quantify benzodiazepines and opioids dosages used in critically ill children under invasive mechanical ventilation (IMV) hospitalized in a Paediatric Intensive Care Unit (PICU). Methodology: an observational study was carried out from May to September 2017. It included children who under IMV hospitalized in a PICU and who were treated with benzodiazepines, opioids and/or neuromuscular blockers. These children key clinical features were recorded. Cumulative doses of benzodiazepines, opioids and neuromuscular blockers were recorded. Results were compared with the data obtained in a previous experience in the same PICU in 2012. Results: 37 children were included. IMV average duration of was 3.7 days. Cumulative doses and treatment duration of midazolam, fentanyl and atracurium decreased from 2012 to 2017. There were differences between the doses prescribed and the doses actually received in both periods. Conclusion: cumulative doses of benzodiazepines, opioids and neuromuscular blockers decreased in the 2012-2017 period.

Resumo: Objetivo: quantificar o uso da sedação e analgesia em crianças criticamente doentes com Assistência de Ventilação Mecânica (MAV) na Unidade de Terapia Intensiva (UTIN) do Centro Hospitalar Pediátrico Pereira Rossell (CHPR). Metodologia: estudo observacional descritivo e prospectivo realizado de maio a setembro de 2017. Incluíram-se pacientes internados em UTIN que necessitaram de MAV e sedação e analgesia e / ou bloqueadores neuromusculares. Registraram-se as seguintes variáveis: sexo, idade, peso, diagnóstico no momento da admissão. Foram registradas as doses indicadas e recebidas de cada droga de sedação e analgesia, assim como as doses cumulativas. Os resultados foram comparados com um estudo realizado em 2012 na UTIN. Resultados: incluíram-se 37 pacientes. O tempo médio de AVM foi de 3,7 dias. A causa mais frequente de MAV foi doença respiratória (n = 34). Observou-se dissonância entre a dose indicada e a dose recebida dos opiáceos, benzodiazepínicos e agentes paralisantes musculares, mas em grau menor do que o registrado em 2012. As doses cumulativas de midazolam, fentanil e atracúrio diminuíram em relação a 2012. Conclusão: observamos uma diminuição nas doses médias de cada droga utilizada, na duração da MAV e uma menor incidência de síndrome de abstinência. Esta observação pode ter causas multifatoriais.

Exposición a cocaína en niños menores de 5 años: serie de casos / Cases of exposure to cocaine in children under 5 years of age / Casos de exposição à cocaína em crianças menores de 5 anos

Resumen: Los hijos de madres consumidoras de cocaína están expuestos en la etapa prenatal y durante la lactancia. Asimismo, están en riesgo de ingesta no intencional o contacto mucoso de restos de la sustancia a su alcance y de inhalación pasiva del humo de cocaínas fumables en ambientes cerrados. Objetivo: describir el perfil epidemiológico de la exposición a cocaína en los niños menores a 5 años en nuestro país analizando circunstancias de exposición, manifestaciones clínicas y complicaciones agudas. Material y método: estudio observacional, descriptivo, retrospectivo de las consultas reportadas a un centro de toxicología en el período 2010-2016 de niños de hasta 5 años de edad con screening positivo para cocaína en orina. Resultados: se incluyeron 18 casos, se analizaron 17 por insuficiencia de datos. Todos fueron menores de 2 años. Predominaron manifestaciones neurológicas (12/17): convulsiones (7/12). Otras manifestaciones incluyeron: taquicardia (2/17), hipertensión (3/17), elevación de creatinfosfokinasa total (4/17) y rabdomiólisis (2/17). Catorce pacientes se encontraban en lactancia pero solo siete madres presentaron screening positivo. El screening de cocaína fue el criterio de selección por su baja tasa de falsos positivos. Esta serie coincide con la literatura en edad de riesgo para exposición a cocaína, planteándose la lactancia como principal vía de ingreso. Sin embargo, los resultados muestran que otras vías de ingreso son posibles. Las convulsiones fueron la forma de presentación más frecuente. Conclusiones: los casos reportados evidencian la necesidad de mantener un alto índice de sospecha ante síntomas neurológicos o cardiovasculares, evidencian el valor de los tests de screening y expanden las circunstancias de riesgo.

Summary: Children born of cocaine-using mothers are exposed to the substance during the prenatal and breastfeeding periods. They are also at risk of cocaine unintentional ingestion or mucosal contact when the substance remains within their reach or at risk of passive inhalation of smoke from cocaine smoked in confined environments. Objective: describe the cocaine exposure epidemiological profile in children under 5 years of age in our country, analyze circumstances of exposure, clinical manifestations and acute complications. Material and methods: observational, descriptive and retrospective study of the consultations reported to a Toxicological Center during 2010-2016 of children up to 5 years of age with positive urine cocaine screening. Results: we included 18 cases, but only 17 were analyzed, due to insufficient data. All children were under 2 years of age. Neurological manifestations were predominant (12/17): seizures (7/12). Other manifestations included tachycardia (2/17), hypertension (3/17), total creatinine phosphokinase increase (4/17) and rhabdomyolysis (2/17). Fourteen patients have been breastfed, but only seven mothers showed positive screening. Cocaine positive screening was the selection criteria because of its low false positive rate. This series matches the literature regarding the main age risk regarding cocaine exposure; breastfeeding was considered the main source of exposure. However, the results show that other sources are possible. Seizures were the most frequent form of presentation. Conclusions: reported cases show that we should be cautious regarding neurological or cardiovascular symptoms, support the implementation of screening tests and expand risk circumstances.

Resumo: Os filhos de mães que usam cocaína estão expostos durante a fase pré-natal e durante a lactação. Da mesma forma, correm o risco de ingestão não intencional ou contato mucoso de restos da substância ao seu alcance e de inalação passiva de fumaça de cocaína fumável em ambientes fechados. Objetivo: descrever o perfil epidemiológico da exposição à cocaína em crianças menores de cinco anos de idade em Uruguai, analisar as circunstâncias de exposição, as manifestações clínicas e as complicações agudas. Material e métodos: estudo observacional, descritivo retrospectivo das consultas reportadas a um Centro de Toxicologia no período 2010-2016, realizado a crianças de até 5 anos de idade com triagem positiva para cocaína na urina. Resultados: nós incluímos 18 casos e analisamos 17 devido a dados insuficientes. Todos tinham menos de 2 anos de idade. As principais manifestações neurológicas (12/17) foram: convulsões (7/12). Outras manifestações incluíram: taquicardia (2/17), hipertensão (3/17), elevação total da creatinofosfoquinase (4/17) e rabdomiólise (2/17). 14 pacientes eram lactantes, mas apenas 7 mães tiveram triagem positiva. O rastreamento de cocaína foi o critério de seleção devido à baixa taxa de falsos positivos. Esta série coincide com a literatura sobre a idade de risco para a exposição à cocaína, considerando a amamentação como a principal via de entrada da substância no organismo. No entanto, os resultados mostram que existem outras vias de entrada da substancia no organismo. A forma de apresentação mais frequente foram as convulsões. Conclusões: os casos relatados mostram que devemos ser cautelosos quanto aos sintomas neurológicos ou cardiovasculares, apoiar a implementação de testes de triagem e expandir as circunstâncias de risco.

Montelukast en menores de 5 años con sibilancias recurrentes: ¿cuáles son sus beneficios? / Montelukast in children under 5 years old with recurrent wheezing: what are its benefits?

Resumen Introducción: las sibilancias son frecuentes en la infancia. El uso de montelukast ha aumentado en los últimos años para el tratamiento de las sibilancias recurrentes. El objetivo de la presente revisión fue analizar la eficacia de montelukast en el tratamiento de las sibilancias recurrentes en menores de 5 años. Metodología: se realizó una búsqueda en PubMed con las siguientes palabras Mesh: "montelukast", "wheezing", "respiratory sound" y "preschool". Se incluyeron estudios entre 2000-2016. La búsqueda fue limitada a ensayos clínicos controlados (ECC) y revisiones sistemáticas realizadas en menores de 5 años. Resultados: se encontraron 5 ECC que cumplieron con los criterios de inclusión. Las variables primarias de los estudios fueron variadas: número de exacerbaciones, ausencia se síntomas diurnos y nocturnos, uso de (2 agonistas, uso de glucocorticoides sistémicos, necesidad de uso de servicio de emergencia y de hospitalización. Los resultados fueron dispares entre los estudios. Las diferencias necesidad de consulta en emergencia (0,19 vs 0,28 eventos/año) y en la necesidad de hospitalización (0,07 vs 0,13 eventos/año). En otro de los ECC montelukast disminuyó la necesidad del uso de (2 y glucocorticoides sistémicos. Conclusiones: del análisis realizado se desprende que montelukast no ha demostrado beneficios sobre variables de impacto clínico tales como la necesidad de hospitalización. Es necesario interpretar con precaución las recomendaciones provenientes de las guías clínicas.

Summary Introduction: recurrent wheezing is frequent in children. The use of Montelukast has increased in the last years to treat recurrent wheezing. The study aims to analyze Montelukast's efficacy in children younger than 5 years old with recurrent wheezing. Method: a PubMed search was conducted using the following Mesh words: "Montelukast", "wheezing", "respiratory sound" and "preschool", for the period between 2000 and 2016. Clinical trials and systematic reviews in children younger than 5 years old, were considered for the study. Results: five clinical trials met the inclusion criteria. The main outcomes of these trials were extremely variable (number of exacerbations, free symptoms, period of use of (2 agonists, use of corticosteroids, rate of hospitalization, and visit to the emergency department). Results were different between the analyzed trials. Montelukast was not better than placebo to reduce the number of visits to the emergency department (0.19 vs 0.28 events/year) and the hospitalization rate (0.07 vs 0.13 events/year). In another trial, Montelukast reduced the use of (2 agonists and corticosteroids. Conclusions: the study showed no effects of montelukast on reducing the incidence of recurrent wheezing in children younger than 5 years old.

Incidencia y etiología de la candidiasis invasiva en la Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell / Incidence and etiology of invasive candidiasis in the Pediatric Intensive Care Unit of of the Pereira Rossell Hospital Center

Introducción: en los últimos años ha aumentado la incidencia de candidiasis invasiva (CI) a nivel mundial. En nuestro país no se disponen de estudios epidemiológicos sobre CI. El objetivo fue determinar incidencia de CI en la Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell. Metodología: estudio descriptivo retrospectivo. Se incluyeron los niños con CI hospitalizados entre 1/1/2009-1/6/2014. A partir de los cultivos micológicos se identificaron las historias clínicas de los pacientes que desarrollaron CI. Se definió CI al aislamiento de Candida en algún sitio estéril. Se calcularon la densidad de incidencia y de prevalencia. Se registró motivo de ingreso y presencia de factores de riesgo para CI. Resultados: se identificaron 6 casos de CI, incidencia de 1,86 c/1000 ingresos. Los aislamientos se realizaron en hemocultivos (n=3) y líquido peritoneal (n=3). Las especies de Candida aisladas fueron C. albicans (n=3), C. parapsilosis (n=2) y C. tropicalis (n=1). Los factores de riesgo para CI presentes fueron dispositivos invasivos (n=6), antibióticos de amplio espectro (n=6), alimentación parenteral (n=5), cirugía abdominal(n=4). Todos los aislamientos fueron sensibles a los azoles. En 1 de las 6 CI se inició tratamiento empírico previo al aislamiento. Fallecieron 4 de los 6 pacientes. Discusión: la incidencia fue similar a otra experiencia realizada en cuidados intensivos pediátricos. Los pacientes que desarrollaron CI presentaron asociación de factores de riesgo. Los aislamientos fueron sensibles a fluconazol. Caracterizar a estos niños permitirá iniciar en forma oportuna el tratamiento antifúngico. Se destaca la importancia de desarrollar la vigilancia continua sobre las especies de Candida y su patrón de sensibilidad a los antifúngicos.

Introduction: invasive infections by Candida strains have increased around the world in the last years. There are no epidemiological studies on invasive candidiasis (IC) in Uruguay. The study aimed to find out the incidence of IC in the Pediatric Intensive Care Unit (PICU) at the Pereira Rossell Hospital Center (CHPR). Method: a retrospective and descriptive study was conducted. Children hospitalized in PICU of the CHPR between 1/1/2009 and 1/6/2014 were included in the study. The medical records of patients who developed IC were identified based on mycological cultures. Invasive candidiasis was defined as the isolation of the fungus in a sterile site. Incidence and prevalence density were calculated. Cause for hospitalization and risk factors for IC were recorded. Results: six cases of IC were identified and the incidence was of 1.86/1000 hospitalized children in PICU. Isolation of Candida was done in blood cultures (n=3) and peritoneal fluid (n=3). The species of Candida isolated were C. albicans (n=3), C.parapsilosis (n=2) and C. tropicalis (n=1). Risk factors for IC were identified in the 6 cases. Use of invasive prosthesis and a wide spectrum antibiotics were identified in the 6 cases, as well as parenteral nutrition (n=5) and abdominal surgery (n=4). All isolations of Candida were sensitive to fluconazole. Antifungal empiric treatment was started in one case prior to the isolation of Candida. Four out of six children died. Discussion: the incidence of IC found was similar to that in another study in a PICU. Children who developed IC presented several risk factors for IC. The 6 isolations of Candida were sensitive to fluconazole. Analyzing the clinical features of these children will allow the identification of patients with high risk of IC and to timely initiate antifungal treatment. It is necessary to maintain a continuous surveillance on Candida species and their sensitivity pattern to antifungal medication.

Transfusión de glóbulos rojos en niños con enfermedad respiratoria aguda. Necesidad de protocolización / Red blood cell transfusion in children with acute respiratory disease

Introducción: la anemia tiene elevada prevalencia en niños críticamente enfermos. Se estima que entre un 15-50% de los niños ingresados en terapia intensiva recibirán una transfusión con glóbulos rojos (GR) durante su estadía. El objetivo fue realizar un diagnóstico de situación sobre el uso de GR en niños ingresados a UCIN con enfermedad respiratoria aguda. Metodología: se realizó un estudio descriptivo en el que se analizaron las últimas 200 transfusiones realizadas en niños ingresados UCIN. De estas se seleccionaron las que fueron realizadas en niños con fallo respiratorio. Se registró valor de hemoglobina pre y postranfusional. Los resultados se cotejaron con un gold estándar seleccionado. Resultados: se identificaron 73 pacientes en total, en 4 casos se cumplió la recomendación considerada como gold standard. La edad media fue de 7,1 meses. La bronquiolitis fue la principal causa de fallo respiratorio. La mediana de hemoglobina (Hb) pretransfusión fue 8,2 g/dL. La latencia promedio hasta la realización de la transfusión fue de 1,4 días y la mediana de Hb postransfusión fue de 11,5 g/dL. No se encontró diferencia significativa en el valor de Hb pretransfusión agrupado según la necesidad de soporte respiratorio requerido. Conclusiones: se encontró una baja adherencia a las recomendaciones internacionales para el uso de GR en niños con insuficiencia respiratoria. Se plantea la protocolización del uso de GR en niños con fallo respiratorio.

Introduction: anemia is frequent in critically ill children. Between 15-50% of children hospitalized at the Pediatric Intensive Care Unit (PICU) will receive red blood cell transfusion during their intensive care unit (PICU) stay. The purpose of the present study was to diagnose current red blood cell transfusion practices in children with acute respiratory disease hospitalized in PICU. Methodology: a retrospective study was conducted analyzing the last 200 requests for red blood transfusions in children hospitalized in the PICU. The transfusions performed in children with acute respiratory failure secondary to acute respiratory disease were selected out of the initial 200 cases. Pre and post-transfusion hemoglobin values were recorded. Results were compared to the gold standard. Results: 73 of the 200 red blood cell transfusions met the inclusion criteria. The mean age of children included was 7.1 months. Bronchiolitis was the main cause of respiratory failure. Median pre-transfusion hemoglobin value was 8.2 g/dl and the post-transfusion value was 11.5 g/dl. Mean time since admission until transfusion was performed was 1.4 days. In 4/73 cases, recommendation selected as gold standard was followed. No significant differences were found in the pre- Hb value, grouped according to the need for required respiratory support. Conclusions: there was a low adherence to red blood cells transfusions recommendations for children with respiratory failure.

Incidencia del síndrome de abstinencia en niños críticamente enfermos / Incidence of withdrawal syndrome in critically ill children

Objetivo: determinar la incidencia del síndrome de abstinencia (SA), describir presentación clínica e identificar la presencia de factores de riesgo. Metodología: se realizó un estudio prospectivo, observacional, de evaluaciones reiteradas usando la Sophia Observation Withdrawal Symptoms Scale (SOWS), en la Unidad de Cuidado Intensivo de Niños (UCIN) de 20 camas, del Centro Hospitalario Pereira Rossell (CHPR). Se incluyeron los niños ingresados en UCIN entre el 1 de noviembre de 2013 y el 30 de setiembre de 2014 tratados con benzodiacepinas y/o opiáceos por cinco días o más. Se registró: duración de la estadía, fármacos utilizados para sedación y analgesia, días de uso, máximo de dosis, dosis total acumulada. El diagnóstico de SA se realizó a través del uso de la SOWS. Los pacientes fueron divididos en dos grupos, con y sin SA. Se analizaron y compararon las características de ambos grupos. Resultados: se incluyeron 39 niños. La incidencia de SA fue 18% (7/39). Los ítems del SOWS más frecuentes fueron ansiedad y sueño menor a 1 hora. Los niños que desarrollaron SA presentaron dosis acumulativas más elevadas tanto de midazolam (54,1 mg/kg vs 44,2 mg/kg) como de fentanilo (464,2 mg/kg vs 380,1 mg/kg). Conclusiones: el SA fue frecuente en este grupo de niños. Las dosis acumulativas fueron mayores en el grupo con SA. La SOWS es una herramienta útil y de fácil aplicación para el diagnóstico de SA.

Objective: The study aims to determine the incidence of withdrawal syndrome, its clinical features and the presence of risk factors. Methodology: An observational and prospective study. Assessment was repeated and the Sophia Observation Withdrawal Symptoms Scale (SOWS) was used. The study was conducted at the Pediatric Intensive Care Unit (PICU) of Centro Hospitalario Pereira Rossell (CHPR). Hospitalized children in PICU between 1/11/2013- 30/9/2014 and treated with benzodiazepines and opioids during 5 days or more were included in the study. Days of stay at the PICU, agents used for sedation (dose, duration) and cumulative doses were recorded. Withdrawal syndrome diagnosis was done using the SOWS. Results: 39 children were included in the study. The incidence of withdrawal syndrome was 18% (7/39). Children who developed withdrawal syndrome presented higher cumulative doses of midazolam (54.1 mg/kg vs. 44.2 mg/kg) and fentanyl (464.2µg/kg vs. 380.1 µg/kg) than those without withdrawal syndrome. Conclusions: the withdrawal syndrome was frequent in this population. Cumulative doses of midazolam and fentanyl were higher in those with withdrawal symptoms. The SOWS is a useful resource for diagnosis.

Características del uso de psicofármacos en niños hospitalizados / Use of psychtropic drugs in hospitalized children

Resumen: Introducción a nivel nacional la prevalencia estimada de problemas emocionales y conductuales en niños es 20%. Los psicofármacos constituyen uno de los recursos terapéuticos dentro de su abordaje multimodal. Su uso a nivel mundial está en aumento. Objetivo describir la frecuencia y caracterizar el uso de psicofármacos en menores de 15 años hospitalizados en el Centro Hospitalario Pereira Rossell. Material y métodos se realizó una encuesta a padres y/o tutores de niños (2 años hospitalizados entre febrero y abril de 2014, previo consentimiento informado verbal y autorización del protocolo por la Dirección del Centro. Las variables fueron: frecuencia de consumo, tipo de psicofármaco, politerapia, duración, conocimiento sobre motivo de la indicación, tipo de profesional que indicó y monitorizó el tratamiento, frecuencia de tratamientos no farmacológicos. Resultados se encuestaron 608 cuidadores; consumían 74 psicofármacos 46 niños (7,6%, IC95% 5,1-9,7%); edad media 10 años. Risperidona fue el más frecuente (33/46). Se identificó uso (2 psicofármacos en 21/46 niños. La asociación más frecuente fue antipsicóticos con estabilizantes del humor. Al momento de la entrevista el consumo era (1 año en 58%. En 89% de los casos el seguimiento era realizado por un psiquiatra. Recibía tratamiento no farmacológico 50%. Conclusión en esta población predominó el uso de risperidona y la combinación de antipsicóticos con estabilizantes del humor. Se destaca la baja proporción de pacientes en tratamiento multimodal y la necesidad de jerarquizar el rol del pediatra en la monitorización y coordinación de estos tratamientos.

Summary: Introduction the estimated prevalence of emotional and behavioral problems in children is 20% at the national level. Psychotropic drugs are one of the therapeutic resources within their multimodal approach. Currently, there is a global increase in the use of these drugs. Objective to describe the frequency and to characterize the use of psychotropic drugs in children under 15 years old, who are hospitalized at the Pereira Rossell Hospital Center (CHPR). Methods a survey to parents and/or guardians of children older than 2 years old who were hospitalized between February and April 2014 was conducted, subsequent to their verbal informed consent and the hospital's authorization of the protocol. The variables were the following: frequency of use, type of psychotropic drug, polytherapy, duration, source of knowledge about indication, type of professional treatment indicated and monitored, frequency of non-pharmacological treatments. Results 608 caregivers were surveyed; 46 children consumed 74 psychotropic drugs (7.6%, 95% CI 5.1 to 9.7%); average age 10 years old. Risperidone was the most frequently used drug (33/46). 21/46 children used 2 or more psychotropic drugs. The most frequent association was antipsychotics with mood stabilizers. At the time of the interview consumption was over one year for 58% of children in the study. In 89% of cases a psychiatrist was responsible for monitoring. 50% of children received no drug treatment. Conclusion the use of risperidone and the combination of antipsychotics with mood stabilizers prevails in this population. The study found a low proportion of patients was under multimodal treatment. It is necessary to prioritize the role of pediatricians in monitoring and coordinating these treatments.

Parámetros farmacocinéticos de gentamicina en recién nacidos de término: ¿Es necesario monitorizar en forma sistemática sus concentraciones plasmáticas? / Gentamicin pharmacokinetics in term newborn: ¿Is it necessary to systematically monitor plasmatic levels?

Background: Gentamicin is indicated as empiric treatment for neonatal sepsis. Plasmatic levels dosification of gentamicin is a common practice. The relationship between peak plasma concentration (Cmáx) with minimum inhibitory concentration (MIC) (Cmáx/MIC) is the parameter that best predicts treatment efficacy. Aim: To determine pharmacokinetics of gentamicin in term newborn infants. Methods: Term newborn infants receiving gentamicin, without critical illness in which plasmatic levels of gentamicin was performed were included. Elimination clearance (Cl) elimination half-life (t½) and volume of distribution (Vd) were calculated. In each case the value of Cmax/MIC parameter was calculated, considering a MIC value of 1 μg/mL for Escherichia coli. Results: Thirteen newborns were included. The mean PK values were Cl: 0.26 mL/hour, Vd: 0.54 L/kg and t½: 6.8 h. Cmax/MIC was > 8 in 6 newborns. Conclusions: Pharmacokinetic parameters of gentamicin are predictable in term newborn infants. With gentamicin doses normally used Cmax/MIC values reached 8 in 6 newborns. It is necessary to review the usefulness of plasma drug monitoring and gentamicin dosage in this group of newborns.

Introducción: Gentamicina es utilizada como tratamiento empírico en la sepsis neonatal. El monitoreo de su concentración plasmática es una práctica frecuente. La relación entre la concentración plasmática máxima (Cmax) y la concentración inhibitoria mínima (Cmax/ CIM) es el parámetro que mejor predice la eficacia. Objetivo: Determinar los parámetros farmacocinéticos (FC) de gentamicina en recién nacidos (RN) de termino. Material y Métodos: Se incluyeron RN de término, sin enfermedad crítica, en tratamiento con gentamicina (4 mg/kg/24 h) en los que se realizó monitoreo de su concentración plasmática. Se determinaron: clearence de eliminación (Cl), vida media de eliminación (t½) y volumen de distribución (Vd). Se estimó la Cmax/CIM, considerando una CIM de 1 μg/mL para Escherichia coli. Resultados: Participaron 13 RN. La media de Cmax fue 8,19 μg/mL y de Cmin 0,73 μg/mL. La media de los parámetros farmacocinéticos fue: Cl 0,26 mL/h, Vd 0,54 L/kg, t½ 6,8 h. La razón Cmáx/CIM fue ≥ 8 en 6 de los 13 RN. Conclusiones: Los parámetros FC de gentamicina en RN de término, sin enfermedad crítica, son predecibles. La posología habitual no permitió obtener valores de Cmax/CIM > 8 en todos los casos. Es necesario revisar la necesidad de monitorizar su concentración plasmática en forma sistemática y la posología de gentamicina en este grupo de pacientes.

Intoxicación aguda por cocaína en un lactante no asociada a lactancia materna. A propósito de un caso clínico / Acute cocaine intoxication in an infant that is not associated to maternal breastfeeding. A clinical case

La intoxicación aguda por cocaína es infrecuente en lactantes y niños. Las formas más frecuentes de presentación clínica son las convulsiones tónico-clónicas en apirexia, alteraciones motoras y la excitación psicomotriz. Se presenta el caso de un lactante de 1 mes que ingresó a la Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell por una intoxicación aguda por cocaína. El cuadro clínico consistió en manifestaciones secundarias a un estado hiperadrenérgico generalizado, con lesión miocárdica, excitación psicomotriz, distonías cervicales, convulsiones y acidosis metabólica persistente. Presentó el test de detección de benzoilecgonina en orina positivo al momento del ingreso a la emergencia. No se pudo establecer con exactitud cuál fue la vía de ingreso de la cocaína. Es necesario un alto índice de sospecha para llegar al diagnóstico de intoxicación por cocaína en lactantes.

Prevención de bacteriemia asociada a catéteres intravenosos en UCIN mediante la implementación de un protocolo de trabajo / Prevention of catheter-related bacteremia in the Pediatrics Critical Care Unit by means of a protocol

Introducción: la bacteriemia asociada al uso de catéter venoso central (BCVC) es una causa frecuente de infección intrahospitalaria en las unidades de cuidados intensivos pediátricos. Objetivo: evaluar el impacto sobre la incidencia de BCVC de la implementación de un paquete de medidas destinadas a su prevención en la Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell. Metodología: se realizó un estudio descriptivo intervencionista desde el 1 de mayo de 2013 al 31 de octubre del mismo año. Se aplicó un paquete de medidas en la colocación de catéteres venosos centrales (CVC). Las mismas consistieron en higiene de manos, uso de barreras asépticas máximas, asepsia de la piel con clorhexidina, evitar el uso del acceso femoral, retiro temprano de los CVC y cuidados posteriores del CVC. Se determinó la densidad de incidencia de BCVC. Resultados: se incluyeron 45 niños con CVC colocados en UCIN, con un total de 51 CVC y 419 días de cateterización. Se identificó un caso de BCVC. La densidad de incidencia de BCVC fue 2,38 casos/1.000 días de CVC. El cumplimiento del paquete de medidas para la prevención de la BCVC fue elevado. Conclusiones: la incidencia de BCVC ha descendido a partir del año 2010. El protocolo de trabajo propuesto fue implementado como pauta de UCIN.

Prevención de bacteriemia asociada a catéteres intravenosos en UCIN mediante la implementación de un protocolo de trabajo / Prevention of catheter-related bacteremia in the Pediatrics Critical Care Unit by means of a protocol

Introducción: la bacteriemia asociada al uso de catéter venoso central (BCVC) es una causa frecuente de infección intrahospitalaria en las unidades de cuidados intensivos pediátricos. Objetivo: evaluar el impacto sobre la incidencia de BCVC de la implementación de un paquete de medidas destinadas a su prevención en la Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell. Metodología: se realizó un estudio descriptivo intervencionista desde el 1 de mayo de 2013 al 31 de octubre del mismo año. Se aplicó un paquete de medidas en la colocación de catéteres venosos centrales (CVC). Las mismas consistieron en higiene de manos, uso de barreras asépticas máximas, asepsia de la piel con clorhexidina, evitar el uso del acceso femoral, retiro temprano de los CVC y cuidados posteriores del CVC. Se determinó la densidad de incidencia de BCVC. Resultados: se incluyeron 45 niños con CVC colocados en UCIN, con un total de 51 CVC y 419 días de cateterización. Se identificó un caso de BCVC. La densidad de incidencia de BCVC fue 2,38 casos/1.000 días de CVC. El cumplimiento del paquete de medidas para la prevención de la BCVC fue elevado. Conclusiones: la incidencia de BCVC ha descendido a partir del año 2010. El protocolo de trabajo propuesto fue implementado como pauta de UCIN.

Introduction: intravascular-device bacteremia is a frequent cause of intrahospitalary infections in the Pediatrics Critical Care Units. Objective: to establish the impact of a bunddle of strategies on the incidence of catheter-related bacteremia in the Pediatrics Critical Care Unit of Centro Hospitalario Pereira Rossell. Method: an observational descriptive study was conducted from May 1, 2013 to October 31, 2013. Patients hospitalized in the Pediatrics Critical Care Unit with a central catheter were included. Six interventions were applied as a bundle at the moment of insertion of catheter. Data were collected from the patients’ clinical history and from the checklist filled at the moment of insertion of catheter. Density of the incidence of of bacteremia related to central catheter was calculated. Results: 45 children were included in the study, adding up to 51 central venous access and 419 days of catheterization. One case of catheter-related bacteremia was identified, there being 2.38 cases/ 1000 days of catheterization. The isolation was coagulase negative Staphylococcus. The bundle of interventions was highly accepted. Conclusions: the incidence of catheter-related bacteremia has diminished since 2010. The bundle of interventions has been established as a guide in the Pediatrics Critical Care Unit of Centro Hospitalario Pereira Rossell.