[Impact of influenza rapid diagnostic tests (IRDT) on the diagnosis of influenza and on the management of influenza in children in ambulatory pediatric setting]. / Impact des tests de diagnostic rapide de la grippe dans la prise en charge des enfants en période d'épidémie en pédiatrie de ville.

OBJECTIVE: Several studies have highlighted the assets of the influenza rapid diagnostic tests (IRDT) for the emergency department management of febrile children. The objective of this study was to determine in ambulatory pediatric setting impact of IRDT on the management of febrile children during an epidemic, especially on other diagnostic testing performed, antibiotic and antiviral treatments. METHODS: During an influenza epidemic, 37 paediatricians in three different areas of France included all children presenting fever with respiratory illnesses; they performed IRDT (test QuickVue for Influenza A and B, Quidel). Data collected were antiflu vaccination, previous asthma, symptoms, clinical signs, other diagnostic testing performed, and a follow-up two weeks later. RESULTS: Between December, 2006 and April, 2007, 695 children entered the program. The average age of those children was 4.1 years old (SD 3.4), median 3.2 (0.07-17.5). In 41.6% of the cases, the tests proved positive. Among 13 symptoms of influenza, only five were significantly more present in the group IRDT+: shiver (68.1% versus 57.4%), asthenia (87% versus 79.9%), cough (87.5% versus 70.1%), rhinorrhea (93.4% versus 83.3%), and sleepiness (54.2% versus 43.4%). The number of laboratory tests and radiographs ordered were less frequent in group IRDT+ than in group IRDT-: respectively 0.7% versus 11.6%, and 0.7% versus 8.6% (p<0.0001). IRDT+ group received antibiotics in 7.6% of cases (22 patients, 20 for OMA) and antiviral in 64.7%. IRDT- group received respectively 18.5% antibiotics, and no antiviral (p<0.0001). CONCLUSION: This study confirms the difficulty of clinical influenza diagnosis, and suggests the assets of IRDT to diagnose influenza and to improve the management of influenza in ambulatory paediatric setting.

[BCG vaccine coverage in private medical practice: First data in children below two years old, seven months after the end of compulsory vaccination in France]. / Couverture vaccinale BCG en médecine libérale : premières données chez le nourrisson, sept mois après la levée de l'obligation vaccinale en France.

OBJECTIVES: In July 2007, compulsory BCG vaccination for all children was replaced by a strong recommendation to vaccinate children at high risk of tuberculosis (children who live in Ile-de-France [IDF] or Guyana regions, who were born or whose parents were born in tuberculosis endemic countries, with a family history of tuberculosis or living in conditions defined as at risk by the doctor). In the absence of tools to detect an early decrease in vaccine coverage (VC) in this specific group, we conducted a survey with the main objective of measuring BCG VC in high risk children for which BCG is now recommended and who were born after the change in BCG vaccine policy. METHODS: Cross-sectional survey performed amongst physicians registered at "Infovac-France", a network of general practitioners and paediatricians particularly aware of recent changes in the field of vaccinations. Each doctor was asked to recruit, during his medical consultation, between six and 12 children aged 2-7 months (born after the end of compulsory BCG vaccination in July 2007) and 8-23 months (born after the withdrawal from the market of the multipuncture form of BCG [Monovax] in January 2006 and before the end of compulsory BCG vaccination in July 2007). Doctors were asked to fill in a structured online questionnaire. Data were standardized and analysed with Stata 9.2. RESULTS: A total of 2536 children, recruited by 279 general practitioners and paediatricians (6.5% of all contacted doctors), were included. VC in the target group of high risk children for who BCG is still recommended and who were seen by doctors working in a private medical practice was: overall 68%; 58% in children born after the end of compulsory BCG vaccination (68% in IDF, 48% outside IDF); 77% in those born after the withdrawal of Monovax from the market and before the end of compulsory BCG vaccination; 90% in children living in IDF born after the end of compulsory vaccination and considered as particularly at risk of tuberculosis (presence of vaccination criteria other than residing in IDF) and 60% in the same category of children whose sole criteria for vaccination was residing in IDF. Of doctors who worked in a private medical practice: 75% used to perform the BCG vaccination themselves and 58% had recommended or suggested vaccination to children at risk who were not yet vaccinated. Seventy-six percent of parents of children at risk of tuberculosis not yet vaccinated accepted BCG vaccination when recommended by their doctor. CONCLUSION: Our survey showed, on the one hand, insufficient VC in children seen in a private medical practice and born after the end of compulsory vaccination for whom BCG is still recommended. This should encourage the Ministry of Health to reinforce its communication concerning this new policy. On the other hand, the survey showed encouraging results concerning both the coverage of children at particularly high risk in IDF and the adherence of doctors and families to the new vaccine policy. These results should be interpreted with caution, taking into account the methodological limitations of this survey.

[Epidemiology of pediatric bacterial meningitis in France]. / Actualisation de l'épidémiologie des méningites bactériennes de l'enfant en France.

This review of pediatric bacterial meningitis was presented in the 17th French Consensus Conference of antimicrobial chemotherapy. It should contribute to the elaboration of guidelines for the treatment of this disease. The incidence of bacterial meningitis rates is 44/100,000 in children under 1 year of age and 6.9/100,000 for children between 1 and 4 years of age (in 2002). Neisseria meningitidis was the most frequently identified bacterium (53.7%) followed by Streptococcus pneumoniae (32.5%), group B streptococci (5.8%), and H. influenzae (3.2%). Group B streptococci predominated in children 28 days to 2 months of age (49.4%) and S. pneumoniae in children 2 to 12 months of age (45.2%). In children older than 1 year of age, N. meningitidis was the most frequently identified bacterium (69.7%). All N. meningitidis strains were susceptible to cefotaxim and ceftriaxone, one-third had decreased susceptibility to penicillin. Ten percent of S. pneumoniae strains were resistant to penicillin G in 2001, but this decreased to 3% in 2005. No strain was resistant to cefotaxim, while 6% had decreased susceptibility to cefotaxim in 2005 and highest MIC was 2 microg/ml. Using new conjugate vaccines and selective pressure on bacterial strains exhibited by antibiotics use have probably changed the epidemiology of pediatric bacterial meningitis in France.

[Evaluation of impact of CRP rapid test in management of febrile children in ambulatory pediatric practice]. / Evaluation de l'impact du test rapide de la CRP en microméthode par des pédiatres de ville prenant en charge des enfants de plus de trois mois avec fièvre isolée.

OBJECTIVE: Fever without source (FWS) is a common cause of children visits to pediatric practices. Clinical evaluation does not always rule out efficiently an invasive bacterial infection. Among blood markers, several publications have suggested the value of C-reactive protein (CRP). This study was performed to assess, in private practices, the impact of rapid CRP test compared to usual technique at the laboratory for the management of children with FWO. MATERIAL AND METHODS: The study was undertaken in 2006-2007, in 14 pediatric practices. Pediatricians had to enroll all children, older than three months, consulting for FWS, for whom CRP was prescribed. The pediatric practices were distributed in two groups: in the first one, pediatricians had rapid CRP tests (NycoCard) CRP test, Progen Biotechnique) and in the second one, they sent children to laboratory for the dosage of CRP as usually. RESULTS: Between October 2006 and June 2007, 227 children were enrolled by 17 pediatricians: 159 in the group with rapid CRP test (group 1), 68 in the group without (group 2). The cost of routine biological tests (micro or macro CRP, blood cell count and urine cultures) was on average lower for group 1 compared to the group 2: respectively 7.7 versus 39.3 euro (P<0.0001), a reduction from approximately 80% of cost. In group 1, more dipstick urine tests (22.6 versus 4.4, P=0.0009), less urine cultures (19.5% versus 67.6% P<0.0001) and blood prescriptions were prescribed (3.8% versus 100%, P<0.0001), pulmonary X-rays were not different (23.9% versus 19.1%, P=0.4). It was not observed difference in antibiotic prescription between the two groups (15.7% group 1 versus 19.1% group 2, p=0.5). The average time to obtain the results examinations in laboratory was approximately 11h (median 4.5h, extremes 45 min to two days), for five min in group 1. In group 1, children management was different according to the CRP levels. During the follow-up, no difference was observed between the two groups except less hospitalizations in group 1 (2.9% versus 15.3%, P=0.0015). CONCLUSION: This study suggests the interest of rapid CRP test for febrile children in ambulatory pediatric practice by reducing number and cost of laboratory examinations and timesaving for patients and practitioners.

[Pneumococcal meningitis in children in France: 832 cases from 2001 to 2007]. / Méningites à pneumocoque de l'enfant en France : 832 cas de 2001 à 2007.

BACKGROUND: Pneumococcal meningitis represents one major cause of morbidity and mortality in children in France. The GPIP/ACTIV (Groupe de Pathologie Infectieuse Pédiatrique and Association Clinique et Thérapeutique Infantile du Val de Marne) set up an active surveillance network to analyze the clinical and biological features of pneumococcal meningitis and the impact of 7-valent pneumococcal conjugate vaccine (PCV7). METHODS: From 2001 to 2007, 252 French pediatric wards working with 168 microbiology laboratories enrolled all children (0-18 years old) with bacterial meningitis. Risk factors, signs and symptoms, vaccination status, cerebrospinal fluid analysis, treatments and case fatality rate were recorded. RESULTS: Within the 7 years study period, 832 pneumococcal meningitis were reported among 2951 bacterial meningitis. In 2001 as in 2007, excluding the neonatal period, pneumococal meningitis represented nearly 1/3 of bacterial meningitis without significant decline in the number of reported cases (less than 30% for children under 2 years old). The peak of incidence was at 5 months of age and 61.7% of cases occured in children 2 to 24 months old. PCV7 vaccinated patients represented 154 cases from 2003 to 2007. In the vaccinated population, serotypes were identified in 136 cases. Few vaccine serotypes (VT) were identified (n=18). The most important was serotype 19F (n=8) followed by 6B (n=4) and 14 (n=3). Three vaccine failures (case occurring after complete vaccination) were observed (serotypes 6B, 4 and 19F). Remaining cases (n=118) were mainly due to non vaccine serotypes (NVT): serotypes 19A, 15B/C and 7F. In 2007, the serotype 19A, more often intermediary strains to cytoxin, represented about 20% of cases. Among non vaccinated children, VT decreased between 2001 and 2007 (59/92 in 2001 vs 15/39 in 2007). Case fatality rate was stable around 11.4%. CONCLUSION: In France, probably because of the insufficient vaccination coverage and the slow implementation of the PCV7, the expected decline in the number of cases of pneumococcal meningitis has not been observed. The impact of PCV7 appeared clearly since only few cases of VT pneumococcal meningitis were reported in vaccinated children.

[Clinical outcome and bacterial characteristics of 99 Escherichia coli meningitis in young infants]. / Méningite à Escherichia coli de l'enfant : analyse descriptive clinique et microbiologique de 99 cas.

OBJECTIVE: To conduct a descriptive analysis of clinical, biological and prognostic aspects of Escherichia coli meningitis in young infants. METHODS: Clinical and biological data on young infants diagnosed with neonatal E. coli meningitis (NECM) between 1988 and 2004 were collected retrospectively and analyzed with respect to the isolates'phenotypic and genotypic characteristics. The molecular analyses focused on the phylogenetic group, the sequence-O-type, and genetic virulence traits. The virulence of lethal strains was tested in a newborn rat meningitis model. RESULTS: The median age of the 99 children analyzed was 10 days (0 to 90 days), and 83 of the patients were newborns. Thirty-three children were premature. Hyper- or hypothermia was the most frequent clinical sign at admission. Intercurrent urinary tract infection was present in 28% of cases, all over 6 days of age. 81% of blood cultures were positive. The CSF cytology was abnormal in 97% of cases. Twelve hours after admission, 34% of infants were transferred to intensive care. One-third of transfontanellar ultrasound scans done on admission were abnormal. CSH sterilization was slow in 15 % of cases, despite appropriate antibiotic therapy. The use of ciprofloxacin was associated with more rapid CSF sterilization (94 % vs 77 %, p=0.03). Six children relapsed. The average follow-up was eight months, and 21 % of children had sequelae. The case lethality rate was 14%. Fatal outcome was associated with signs of septic shock (57% vs 3%, p<10(-4)) and neurological failure (76% vs 19%, p<10(-4)) within the first 24 hours, and with abnormalities on the first ultrasound scan (63% vs 27%, p=0.03). The risk of death was higher among children infected by strains belonging to unusual sequence-O-types (50% vs 18%, p=0.01), which harbored fewer virulence factors (4.8 vs 5.9, p<10(-4)). Only aerobactin was less frequent in lethal strains (71 % vs 94%, p=0.02). Strains belonging to unusual sequence-O-types and that were lethal in the animal model induced a significantly lower level of bacteremia than strains belonging to frequent sequence-O-types (p<0.001). CONCLUSION: E. coli meningitis remains highly lethal in infants. Clinical and molecular analyses showed a link between lethality and infrequent sequence-O-types. The avirulence of these strains in animal models suggests that fatal outcome could be due to host susceptibility more than to strain virulence.

Paediatric varicella hospitalisations in France: a nationwide survey.

Paediatric patients hospitalised with varicella (n = 1575) were reported to a French national network between March 2003 and July 2005. Superinfection was identified in 50.3% of cases, principally of skin and soft-tissue (36.5%). The risk of superinfection increased with fever relapse, use of non-steroidal anti-inflammatory drugs, prolonged fever, an age of 1-5 years, and contamination at the childminder's home. Neurological complications were observed in 7.8% of cases, while pulmonary complications were less frequent (3.1%). Forty-nine patients had sequelae and eight patients died. Surveillance should continue in France with a view to the future implementation of a universal vaccination programme.

[Vaccination in parents of young infants survey]. / Enquête sur le statut vaccinal des parents de jeunes nourrissons.

Since 2004, in France, pertussis booster is recommended in parents of young infants and adults likely to become parents. This recommendation adds to others such as rubella vaccination in unvaccinated or seronegative women and decennial dT-IPV booster. The objective of this study is to evaluate the impact of these recommendations in parents of young infants. Pediatricians had to include parents of infants at the first well-baby visit after birth. Vaccination data were secondary recorded from parent's health record or called upon their memory. Between June and October 2006, 41 pediatricians included parents of 400 infants (median age: 36 days). dT-IPV booster was recorded or recalled in 37.4% within the 10 previous years and 17.7% within the 3 previous years. Among this last group, only 11.8% had received a combination including pertussis. Rubella serology was declared as positive by 94% of the mothers, but the physicians obtained the information of a previous rubella vaccination in only 71.7% of the mothers. Among the 9 seronegative mothers during pregnancy, only 3 were vaccinated in postpartum. Adults' immunization guidelines are not well known and poorly applied in France. The unavailability of monovalent pertussis vaccine reduces the eligible population. Two years after the launch of the pertussis cocoon strategy, the coverage of eligible young parents remains low and many opportunities are too frequently missed on the opportunity of decenial dTPolio booster. Rubella catch up strategy should be improved. Adults' vaccination strategies and guidelines need to be better broadcasted to health care professionals and also families.

[French survey about intradermal BCG SSI adverse events in children under 6 years of age]. / Enquête sur les effets secondaires locaux du vaccin intradermique BCG-SSI chez l'enfant de moins de six ans en France.

During April 2006, 579 physicians took part in a survey about intradermal BCG SSI adverse events (AE) in children less than 6 years old, managed by InfoVac France. Since January 2006, 68% physicians (paediatricians: 73% and general practitioners [GP]: 60%) have vaccinated at least one child. The site of injection is mainly the extern side of the shoulder (72%), according to the recommendations. Systematic vaccination is continued by 54% GP and 26% paediatricians. Others indications are: admission in day care center (33%), admission in day care center associated with risk factors (24%), or only risks factors (8%). Half physicians observed AE and 6% of them reported them at pharmacovigilance centers or pharmaceutical company. AE were mainly inflammations or indurations over 1 cm (for 75% of physicians who observed AE), oozing (73%). Abscesses are notified by 54%, ulcers by 39%, lymphadenopathies over 1 cm by 20%, suppurative lymphadenopathies by 3% and keloid scares by 17% of them, several AE may coexist for some children. Our aim is to start a prospective follow-up of BCG-SSI vaccination and its AE; 58% physicians who answered this investigation agreed to participate.

[Impact of the rapid diagnosis downtown in the assumption of responsibility of the children in period of influenza]. / Impact des tests de diagnostic rapide en ville dans la prise en charge des enfants en période de grippe.

Several studies in children showed at the paediatric emergency hospital the interest of influenza rapid diagnostic tests (IRDT) in this disease for which the clinical diagnosis is difficult in children. The purpose of this prospective study carried out in ambulatory paediatric setting was to evaluate impact of the IRDT in the assumption of responsibility of children suspected of Influenza infection. Thirty paediatricians (14 without IRDT, 16 with IRDT) included 602 children between 2004 and 2005. The influenza was confirmed by IRDT in 54% of the cases. Among the 13 symptoms or signs recorded, only 4 - chills (61.6 vs 48.4%), cough (89.8 vs 71.1%), rhinorrhea (97.9 vs 86.2%), and anorexia (50.3 vs 34.8%) - were significantly more frequent (P

Relationship between clinical signs and symptoms and nasopharyngeal flora in acute otitis media.

Possible links between the clinical signs and symptoms of acute otitis media and the composition of the nasopharyngeal flora were investigated by reviewing the files of 1807 children enrolled in four randomised, multicentre trials. A standard protocol was used, nasopharyngeal samples were cultured, and signs and symptoms were recorded. Carriage of Haemophilus influenzae was associated positively with conjunctivitis (OR 4.83, 95% CI 3.76-6.20) and negatively with fever (OR 0.69, 95% CI 0.56-0.86). Carriage of pneumococci was associated positively with fever (OR 1.32, 95% CI 1.08-1.63) and negatively with conjunctivitis (OR 0.50, 95% CI 0.40-0.63).

[Impact of CRP rapid test in management of febrile children in paediatric emergency units of Ile-de-France]. / Impact de la protéine C-réactive (CRP) en microméthode sur la prise en charge des enfants fébriles aux urgences pédiatriques en Ile-de-France.

OBJECTIVE: Fever is a common cause of children visits to emergency units. Clinical evaluation does not always eliminate a bacterial infection. Among blood markers, several publications showed the interest of CRP. This study was undertaken to evaluate correlation between two techniques of CRP, one by usual technique at the laboratory and the other by a rapid test, and to evaluate the impact of this rapid test for febrile children at the emergency room, when a hospitalization was not immediately decided. MATERIAL AND METHODS: The study was undertaken in 2004-2005 in eight emergency paediatric units in Ile-de-France concerning febrile children during two periods. In period A, children had at the same time a CRP dosage through two methods, whereas in period B, only a rapid CRP test was first managed. The test used was NycoCard CRP Single test (Progen Biotechnique). RESULTS: Between September 2004 and June 2005, 572 children were included, 268 in period A and 304 in period B. Comparison of CRP results by the two methods showed for 247 children (93%) a fairly good linear correlation (r: 0.929). Blood cell count was the most often prescribed test (99.4 vs 10.5%). Conversely to chest radiography, blood culture, fibrinogen and urinary test were significantly most frequent in period A. The average cost of the additional examinations was 2.6 times more important during the first period. Duration of children management in the units was approximately two times shorter when rapid CRP test was used (199.7+/-92.8 vs 103.5+/-98.6 min). CONCLUSION: This study shows the interest of rapid CRP test for febrile children in the emergency units, and has to be confirmed in ambulatory paediatric practice.

[Management of intussusception in France in 2004: investigation of the Paediatric Infectious Diseases Group, the French Group of Paediatric Emergency and Reanimation, and the French Society of Paediatric Surgery]. / Modalités de prise en charge des invaginations intestinales aiguës en France en 2004: enquête commune du Groupe de pathologie infectieuse pédiatrique (GPIP), du Groupe francophone d'urgences et de réanimation pédiatrique (GFRUP) et de la Société française de chirurgie pédiatrique (SFCP).

OBJECTIVES: To describe the different pathways of management of intussusception (IS) in infants and children in metropolitan France and to identify paediatric emergency centres that might constitute a surveillance network for IS. MATERIAL AND METHODS: A questionnaire was sent to 273 paediatric emergency centres distributed across France in 2005. Modalities of diagnosis and treatment of IS had to be precised. RESULTS: One hundred and sixty-seven centres (61.2%) responded. The response was given by 131 paediatricians (78.4%) and 36 surgeons (21.6%) working in 38 universitary hospitals (22.7%) and 129 general hospitals (77.2%). The mean number of IS treated in each centre in 2004 was 11+/-13.5 (extr. 0 to 70; median 6). Diagnosis of IS required a collaboration between medical and surgical teams in 51.5% of the centres, but in 40.1% the sole medical team was in charge of the diagnosis. Ultrasonography is used for diagnosis by 98.8% of the centres. Reduction with hydrostatic enema and eventually surgery was performed in the same hospital in 44.3%. Other centres systematically or frequently transferred the patients for reduction, mostly towards universitary hospitals (90%). CONCLUSION: The procedures of IS diagnosis are the same everywhere in France but the pathways of therapeutic management do vary, depending on the availability of surgeons and anaesthetists trained in paediatrics on each site. These disparities will probably change with the implementation of the new plan for sanitary organization in children and adolescents in France. Labellized paediatric emergency centres will gather more surgical patients and could eventually constitute an effective surveillance network for IS.

[Pneumococcal meningitis in France: age and medical risk factors in children]. / Méningites à pneumocoque de l'enfant en France: âge de survenue et facteurs de risques médicaux.

Streptococcus pneumoniae (Sp) is an important cause of morbidity and mortality among paediatric infectious diseases. The aim of this study is to analyse specific data on Sp meningitis out of the Bacterial Meningitis (BM) French Surveillance Network about mean age of BM cases and clinical features. Overall 367 Sp BM were reported between January 2001 to January 2004 (sex ratio M/F: 1.3), 69.7% were < 2 years old, median age 0.8 year (minmax 0-16.8 years). Before two years old children, 94.1% had no medical risk factor and no underlying conditions: on the other hand, after two years old, these factors were reported in 27% cases (P < 0.001). Mortality rate was 10.9%. On account of a Sp BM's pic at five months, data of the BM French Surveillance Network confirm the necessity of an early vaccination. The vaccine administration at two, three, four months with a booster during the second year, recommended in the vaccinal french calendar, seems particularly adapted to the Sp BM in France.

[French paediatrician and general practitioner's survey about actual and future BCG use]. / Enquête sur les pratiques actuelles et futures du vaccin contre la tuberculose auprès des pédiatres et généralistes en France.

Within the context of future multipuncture withdrawal, we managed, in April 2005, a survey on BCG vaccine habits. During April 2005, 636 paediatricians and 192 GP took part in a survey about BCG, practices managed by InfoVac-France, InVS and AFPA. Most of physicians (73.6%) don't use Mantoux test before BCG vaccination in children less than 6 months old, and the Monovax is the most frequent vaccine used (93.7%). Less than 30% physicians are thinking to be ready to systematically vaccine children after prospected withdrawal of multipuncture vaccination, and almost 1 pediatrician of 5 and one GP of 7 don't want to vaccine anymore. In future, preferred option after Monovax withdrawal is to vaccinate with BCG only the high risk population for tuberculosis (59%). About 60% physicians think that parents could be opposed to intradermal immunization. More than 2/3 of physicians have not an assistant (except the parents) to contain the children during the intradermal injection (71.6%). It seems not acceptable for 2/3 of physicians to address their patients to colleagues or to specialized structures.

Five vs. ten days of antibiotic therapy for acute otitis media in young children.

BACKGROUND: Many publications in recent years have argued in favor of shortened therapy for acute otitis media. However, doubt persists regarding children younger than 2 years, and some authors therefore restrict short course therapy to children older than 2 years. METHODS: In a prospective, comparative, double blind, randomized, multicenter trial we compared cefpodoxime-proxetil, 8 mg/kg/day in two divided doses for 10 days, with an identical 5-day regimen followed by a 5-day placebo period. RESULTS: Between October, 1996, and April, 1997, 450 children (mean age, 14.3 months) were enrolled, 227 in the 5-day group and 223 in the 10-day group. In the per protocol analysis clinical success was obtained on Days 12 to 14 after the beginning of treatment (main analysis) in 175 (84.1%) of the 208 children receiving the 5-day regimen and 194 (92.4%) of the 210 children receiving the 10-day regimen (P = 0.009). The superiority of the standard regimen was more marked among children cared for outside their homes (92.5% vs. 81.5%). Clinical success persisted on Days 28 to 42 among 134 (85.4%) of the 157 assessable patients in the 5-day group and 144 (83.7%) of the 172 assessable patients in the 10-day group (P = 0.68). CONCLUSIONS: The 10-day regimen resulted in a higher success rate at the conclusion of therapy, but there were no differences between the two study groups 4 to 6 weeks after enrollment in the study protocol.

Six-day amoxicillin vs. ten-day penicillin V therapy for group A streptococcal tonsillopharyngitis.

OBJECTIVE: To compare the efficacy and safety of amoxicillin (50 mg/kg/day divided twice daily) for 6 days and penicillin V (45 mg/kg/day divided into three doses/day) for 10 days in children with group A streptococcal (GAS) tonsillopharyngitis. METHODS: In a prospective, comparative, open, randomized, multicenter trial, children were scheduled to return for visits 4 days (main end point) and 1 month after the completion of treatment for clinical and bacteriologic assessment. Total DNA restriction fragment length polymorphism was used to compare pre- and posttreatment GAS isolates. RESULTS: Between September, 1993, and February, 1995, 321 children (161 amoxicillin, 160 penicillin V) were enrolled, among whom 318 (160 amoxicillin, 158 penicillin V) were evaluable for safety, and 277 were evaluable for efficacy. Four days after the completion of treatment, pretreatment GAS were eradicated from 118 of the 141 children receiving amoxicillin (83.7%) and 116 of the 136 (85.3%) taking penicillin. One month after the outset of treatment, bacteriologic relapses were observed in 9.9% (n = 11) of the children receiving amoxicillin and 5.7% (n = 6) of those treated with penicillin V, bacteriologic recurrences in 5 and 3 patients, respectively. Adverse events related to the study medications were reported in 4 patients in the amoxicillin group and 8 in the penicillin V group. Drug-related adverse events leading to treatment discontinuation occurred in 3 patients, all in the penicillin V group. Compliance, based on diary cards and the weight of study drugs returned, was significantly better in the amoxicillin group. CONCLUSIONS. The efficacy and safety of amoxicillin (50 mg/kg/day twice daily) for 6 days were not statistically different from those of penicillin (45 mg/kg/d three times a day) for 10 days in the treatment of GAS tonsillopharyngitis.

Change in nasopharyngeal carriage of Streptococcus pneumoniae resulting from antibiotic therapy for acute otitis media in children.

BACKGROUND: Acute otitis media is the leading reason for antibiotic prescriptions in childhood. The increase in antibiotic resistance of Streptococcus pneumoniae is generally attributed to the extensive use of antibiotics and the selective pressure on the bacterial strains of the nasopharyngeal flora. OBJECTIVE: To evaluate the change in nasopharyngeal carriage of S. pneumoniae during antibiotic therapy prescribed for acute otitis media. METHODS: Between October, 1993, and March, 1994, we conducted a clinical trial comparing cefpodoxime-proxetil and amoxicillin-clavulanate in acute otitis media. From 364 children, 4 months to 4.5 years old, a nasopharyngeal sample was obtained before and after treatment. Antibiotic susceptibility was established by determining minimal inhibitory concentrations by the agar dilution method. Serotype and randomly amplified polymorphic DNA analysis were used to compare pre- and posttreatment S. pneumoniae strains. RESULTS: The risk for a child to carry penicillin-resistant S. pneumoniae (MIC > or = 0.125 mg/l) did not increase after antibiotic treatment: 84 of 364 (23.1%) before, 70 of 364 (19.2%) after. There was a significant decrease of penicillin-susceptible S. pneumoniae carriage, 117 of 364 (32.1%) before treatment compared with 24 of 364 (6.6%) (P = 0.0001) after treatment. However, among the children carrying S. pneumoniae at the end of the treatment there was an increase in the percentage of penicillin-resistant pneumococci: 84 of 201 (41.8%) before treatment and 70 of 94 (74.5%) after treatment. Among the 94 children carrying S. pneumoniae at the end of the treatment, 22 did not harbor pneumococcus before, 16 carried another genotypically different serotype and 56 harbored the same serotype. Among these 56 children 2 patients harbored strains that had increased MICs for the tested beta-lactam antibiotics. The randomly amplified polymorphic DNA analysis showed that in one case, the strains were genetically different. CONCLUSIONS: These data illustrate that antibiotic therapy did not increase the rate at which children carried penicillin-resistant S. pneumoniae, but there was an increase in the rate of resistance among the children carrying pneumococci at the end of the treatment, mainly as a result of reduction of susceptible strains.

Treatment failure in otitis media: an analysis.

An epidemiological study was conducted in order to monitor the involvement of penicillin-resistant pneumococci (PRP) in treatment failure in acute otitis media (AOM), in an area of France where resistance to antibiotics is high. A total of 293 children presenting to 12 ear, nose and throat (ENT) specialists were included in the study. The mean age of the patients was 15.3 months and most of the children (58.7%) were attending day care centres. Bacteriological sampling demonstrated that in 146 cases (49.8%), no pathogen was present at the time of treatment failure. In the remaining patients Streptococcus pneumoniae was the most frequently recovered pathogen, being isolated from 81/147 (55.1%) of bacteriologically documented cases. Serotype 23F was the predominant strain, representing 53% of all S. pneumoniae isolates recovered. Resistance or reduced susceptibility to the prescribed antibiotic was seen in 70/81 (86.4%) of the S. pneumoniae isolates. In 32 out of 49 children administered a beta-lactam antibiotic, treatment failure involved PRP. Amoxycillin seemed to be the most active oral beta-lactam against these pathogens. The multiresistance of S. pneumoniae poses a serious therapeutic problem and should make myringotomy and bacteriological sampling obligatory in cases of antibiotic treatment failure.

[Exploration of 112 children suspected of amoxicillin allergy. Indications and efficacy of oral provocation test]. / Exploration de 112 enfants suspects d'allergie à l'amoxicilline. Indications et intérêt du test de provocation oral.

BACKGROUND: One to 10% of treatments using betalactams, particularly synthetic penicillin, are complicated by allergic reactions, usually cutaneous, and not easily imputable to immunologic sensitization in children. PATIENTS AND METHODS: The aim of this study was to identify, using cutaneous and biological tests, those from a group of 112 children suspected of amoxicillin allergy (evidenced by rash) who were actually sensitized, and to confirm the absence of allergy in others by an oral provocation test (OPT) associated to a long-term survey. The cutaneous tests were made by prick test and intra-dermo reaction (IDR) with Allergopen and with amoxicillin or amoxicillin + clavulanic acid. The biological tests included examination for penicillin and amoxicillin antibodies by using various techniques including enzyme-linked immunosorbent assay (ELISA) immunoglobulin G (IgG) and IgE, FARR, radioallergo sorbent test (RAST) and a histaminoliberation. When these tests were negative, an OPT with the suspected antibiotic was subsequently performed. RESULTS: Thirty-nine children (36.4%) confidently presented at least one positive cutaneous test (38 Allergopen, ten amoxicillin); 25 biological tests were positive (16 ELISA IgE, one ELISA IgG and eight histaminolibarations), seven times with negative cutaneous test. Forty-five children were judged to be sensitized to amoxicillin, with only one who subsequently took amoxicillin again. Among the 67 others, 52 received an OPT, six of them with moderate cutaneous reactions. Fifty-one (45.5%) children were allergic and 46 (41%) were allowed to take amoxicillin again; 17 did, one of them with a benign cutaneous reaction. CONCLUSION: Efficacy and safety of this type of investigation seems clear; it will have to be confirmed by other studies.