Serious Bacterial Infections in Febrile Young Children: Lack of Value of Biomarkers

Background. Serious infections in children are difficult to determine from symptoms and signs alone. Fever is both a marker of insignificant viral infection; as well as more serious bacterial sepsis. Therefore; seeking markers of invasive disease; as well as culture positivity for organisms; has been a goal of paediatricians for many years. In addition; the avoidance of unnecessary antibiotics is important in this time of emerging multiresistant micro-organisms. Objective. To ascertain whether acute-phase reactant tests predict positive culture results.Methods. A prospective; cross-sectional study over a 1-year period included all documented febrile childre nunder the age of 5 years (with an axillary temperature =38oC) who presented to Steve Biko Academic Hospital; Pretoria; with signs and symptoms of pneumonia; meningitis and/or generalised sepsis. Every child had clinical signs; chest radiograph findings; urine culture; blood testing (full blood count; C-reactive protein; procalcitonin) and blood culture results recorded. Results. A total of 63 patients were enrolled; all of whom had an axillary temperature =38oC. C-reactive protein; procalcitonin and white cell count did not predict the presence of positive blood culture or cerebrospinal fluid culture results; nor infiltrates on chest radiographs. No statistically significant correlations were found between the duration of hospital stay and the degree of fever (p=0.123); white cell count (p=0.611); C-reactive protein (p=0.863) or procalcitonin (p=0.392). Conclusion. Biomarkers do not seem to predict severity of infection; source of infection; or duration of hospitalisation in children presenting to hospital with fever. The sample size is however too small to definitively confirm this viewpoint. This study suggests that clinical suspicion of serious infection and appropriate action are as valuable as extensive testing

Cytokine Profile and Clinical Correlates in HIV-Exposed Infants with Severe (Hypoxic) Pneumonia

Introduction. Severe pneumonia in infants who are HIV-infected is a common problem in many parts of the developing world; especially sub-Saharan Africa. What has been missing from previous studies of severe pneumonia in HIV-infected infants; however; is a description of the host inflammatory response and cytokine/chemokine profile that accompanies this disease. Objective. To describe the cytokine profiles associated with severe hypoxic pneumonia in HIV-infected infants Methods. In a cohort of HIV-infected children diagnosed clinically with severe hypoxic pneumonia; paired serum and sputum cytokines were tested. A control group of HIV-infected children with bronchiectasis contributed matching controls.Results. A total of 100 infants (mean age 2.8 months) with a clinical diagnosis of severe hypoxic pneumonia were included in this study. IP-10 was markedly elevated in both sputum (mean 560.77pg/ml) and serum (mean 9091.14pg/ml); while IP-10 was elevated in serum (mean 39.55 pg/ml); with both these cytokines being significantly higher than in stable children with HIV-related bronchiectasis. Conclusion. This study of HIV-infected infants with severe hypoxic pneumonia suggests that IL-10 and IP-10 are associated with more severe lung disease. However; further investigation of this association is required

"The ""Ten Commandments"" of Treating Preschool Children who Wheeze"

"Wheezing in young children is problematic for most practitioners. Difficulties arise in both the diagnosis and management of this clinical phenotype. Not all preschool children who wheeze have asthma. Therefore; we suggest that the ""Ten Commandments"" of managing preschool wheezing include thinking that in very young infants ( 1 year) wheezing is likely to be viral in origin; realising that allergy testing is mandatory to diagnose the cause of early wheezing; taking a history of asthma and allergy in family members; noting that chronic coughing is a pointer to asthma; using the term ""asthma"" if that is the diagnosis; ensuring that the environmental avoidance of triggers is addressed; using a short course of montelukast for virus-induced wheezing episodes; avoiding steroids to treat virus-induced wheezing; treating associated nasal symptoms; and making sure that the follow-up of children addresses the issue of stopping therapy if it is not working."