Philippine pediatric COVID-19 living clinical practice guidelines as of March 2022

Executive Summary@#The Coronavirus disease 2019 (COVID-19) pandemic has triggered a global crisis and has affected millions of people worldwide. With the evolution of the different variants of concern, the incidence of COVID- 19 in the pediatric population has risen. The Surveillance and Analysis of COVID-19 in Children Nationwide (SALVACION) Registry, developed by the Pediatric Infectious Disease Society of the Philippines (PIDSP) and the Philippine Pediatric Society (PPS), has reported 3,221 cases as of March 31, 2022, with 90.4% requiring hospitalization and 36.2% with moderate to critical disease severity. Given the magnitude of the impact of COVID-19, with most of the clinical recommendations available designed towards adult patients, there was an urgent need for clinicians, public health officials and the government to also prioritize evidence-based clinical practice guidelines for the pediatric population. Hence, the development of the Philippine Pediatric COVID-19 Living Clinical Practice Guidelines was conceptualized. This independent project, funded and supported by the PPS and PIDSP, aimed to formulate up-to-date, evidence-based recommendations on the treatment, diagnosis, infection prevention and control of COVID-19 in children. Following the standard CPG development process outlined in the DOH Manual for CPG Development and the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, 15 evidence summaries and 24 recommendations were generated by 12 consensus panelists representing their specific health organizations and institutions.

Meningococcal disease and carriage in the Philippines: A review of recent data

@#This article reviews recent data on meningococcal disease and carriage in the Philippines. It aims to provide information on the epidemiology of meningococcal disease, its carriage, data on prevention, and the impact of vaccination on disease and carriage. The World Health Organization considers the Philippines as having low endemicity for meningococcal disease. However, current data underestimates the true burden in the country due to many factors. In recent years, data from the Philippines show a high case-fatality rate since only the septicemic form is being reported. Studies on asymptomatic meningococcal carriage rates are sparse, with one study by Gonzales, et al. investigating the prevalence of meningococcal nasopharyngeal carriage in Filipinos aged 5-24 years old living in an urban setting. The study showed that the overall prevalence of carriage was 3.7% and was highest (9%) among the 10-14 age group. Serogroup B was the most common isolate. Effective meningococcal vaccines are available. Although not included in the National Immunization Program, medical societies recommend giving vaccines to individuals at high risk of infection. Data on local epidemiology accounting for the disease and asymptomatic carriage are important to strengthen future programs on immunization and prevention of meningococcal disease.

Clinical characteristics and patient symptoms associated with poor outcomes among children with COVID-19: A rapid review

Objective@#To identify specific clinical characteristics and patient signs and symptoms that increase the risk of developing severe/critical COVID-19 disease or death in the pediatric population, and identify strength of these associations @*Methodology@#A systematic search was done in PubMed, Science Direct, Cochrane Library and grey literature databases focusing on severe and critical COVID-19 disease in the zero to eighteen year old age group until August 26, 2020. Data regarding patient characteristics, signs and symptoms on admission and disease severity were extracted. Outcomes measured were severe or critical COVID-19, Multisystem Inflammatory Syndrome in Children (MIS-C) or death. Results were pooled and meta-analyzed. @*Results@#Four eligible studies with a total of 292 pediatric patients with COVID-19 were examined. Older children (MD=6.62, 95%CI=4.23 to 9.00, p-value<0.00001, I2=33%) significantly present with a higher percentage of severe disease. Shortness of breath (OR=8.14, 95%CI=2.33 to 28.47, p-value=0.001, I2=42%) was also found to be associated with severe COVID-19 disease. The presence of a pre-existing medical condition (OR=4.02, 95%CI=1.55 to 10.43, p-value=0.004, I2=0%), especially cardiac disease (OR=6.40, 95%CI=1.45 to 28.38, p-value=0.01, I 2=13%) and diabetes (OR=7.01, 95%CI=1.54 to 31.95, p-value=0.01, I2=0%) was noted to be a risk factor for severe disease. @*Conclusion@#Based on poor quality observational studies, older age group, shortness of breath, and a pre-existing medical condition, especially cardiac disease or diabetes were found to be associated with poor outcomes in children with COVID-19.

Accuracy of Nasopharyngeal Aspirate GeneXpert Compared to Gastric Aspirate TB Culture and GeneXpert in Diagnosing Pulmonary Tuberculosis in Pediatric Patients

Background@#Pulmonary TB in children remains to be a burden in the Philippines. Diagnosis remains to be a challenge for pediatricians due to its paucibacillary nature, difficulty in obtaining specimens, cost of test as well as the varied sensitivity of the different tests available. Gastric aspirate (GA), commonly used for bacteriological diagnosis of pulmonary tuberculosis (PTB) in children, involves an invasive procedure that may cause discomfort and sometimes require admission. Nasopharyngeal aspirate (NPA), on the other hand, can be easily and non-invasively obtained but is currently not a recommended specimen for testing for PTB. @*Objectives@#This study aims to determine the accuracy of NPA GeneXpert in diagnosing PTB among pediatric patients 0-18 years old with presumptive TB using GA GeneXpert as the initial screening test and GA TB culture as gold standard. @*Methodology@#This prospective, cross-sectional diagnostic study involved collection of single NPA and GA specimens for GeneXpert and TB culture in 100 patients with presumptive PTB seen at a tertiary government hospital in the Philippines. @*Results@#Of the one hundred pediatric patients (mean age 6 ± 5.63 years) enrolled, 50 were clinically diagnosed PTB, 16 bacteriologically-confirmed and 34 were not PTB disease. Sensitivity, specificity and predictive values with 95% confidence intervals of the NPA GeneXpert were determined compared to GA GeneXpert and GA culture. Sensitivity, specificity, positive and negative predictive values of the NPA GeneXpert compared to GA GeneXpert were 70%, 96.67%, 70% and 96.67%, respectively. While NPA GeneXpert compared to GA TB culture were 40%,91.58%, 20% and 96.67%, respectively. @*Conclusion@#GeneXpert testing on a single NPA specimen is a highly specific and rapid test that can be used to diagnose PTB in pediatric patients, particularly where gastric aspiration or mycobacterial culture is not feasible.

A rapid review on the sensitivity of SARS-CoV-2 RT-PCR done on different clinical specimens

Background@#RT-PCR using respiratory tract specimens, most commonly nasopharyngeal swab (NPS), has been used to confirm the diagnosis of COVID-19. NPS is a relatively invasive procedure that causes patient discomfort and risks viral transmission. Other specimens are therefore being investigated for the detection of SARS-CoV-2 RNA. @*Objective@#To determine the sensitivity of non-respiratory tract specimens in detecting SARS-CoV-2 RNA in patients with COVID-19. @*Methodology@#This review summarized the results of eight studies obtained from a literature search done in May 2020 in PubMed MEDLINE, Cochrane Library and MedRxiv. Two independent investigators reviewed and appraised the studies that were included, and pooled estimates of sensitivity for each specimen were determined using Stata’s Metaprop function@*Results@#The sensitivity in detecting SARS-CoV-2 RNA in non-respiratory tract specimens of diagnosed COVID-19 patients are as follows: Saliva 77% (95% CI 71-83%), stool/rectal swab/anal swab 22% (95% CI 22-37%), blood/serum/plasma 2% (95% CI 1-3%), and urine 22% (95% CI 18-25%). @*Conclusion@#SARS-CoV-2 RNA is detected in saliva, stool/rectal swab/anal swab, blood/serum/plasma and urine. Among these, saliva has the highest estimated sensitivity. However, more studies are needed to correct the heterogeneity brought about by factors such as timing of specimen collection, disease severity and treatment.

Intraventricular Antimicrobial Therapy in children with Multi-Drug Resistant Ventriculitis: A tertiary hospital experience and literature review

Background@#Intraventricular antimicrobial therapy (IVT), defined as the direct installation of antimicrobial agents into the lateral ventricles has been utilized as the last therapeutic option for the treatment of multidrug-resistant ventriculitis. The aim of this case series is to report our institution’s experience with IVT in pediatric patients with ventriculitis. @*Material and Methods@#Retrospective chart review was done. The demographic data, cerebrospinal fluid (CSF) culture isolates, treatment regimens, and clinical outcomes of these patients were collected and described. @*Results@#Between 2016 to 2018, seven (7) pediatric patients diagnosed with ventriculitis caused by multidrug-resistant organisms underwent intraventricular antimicrobial therapy in combination with intravenous therapy. The median age was 1 year (range 1 month to 17 years old, mean: 4.4 years). Fifty-seven (57) percent of the patients were females. The isolated pathogens were Acinetobacter baumannii MDRO (n = 3), Klebsiella pneumoniae MDRO (n = 2), Methicillin-resistant Staphylococcus aureus (n = 1), and Methicillin-resistant Staphylococcus epidermidis (n = 2).One patient had mixed isolates on CSF culture (Acinetobacter baumannii and MRSE). The antimicrobial agents for IVT used were colistin (n = 4), vancomycin (n = 2), and gentamicin (n = 1). The mean time to initiation of intraventricular therapy from the diagnosis of ventriculitis was 19 days. The mean duration of IVT therapy was 15 days. The survival rate was 57%. @*Conclusion@#Ventriculitis caused by drug-resistant organisms is an emerging concern. Optimal therapy is not yet established and experience with IVT is limited. This series showed that there were no adverse effects related to IVT thus it may be considered an option for MDRO ventriculitis. Gram negative organisms are more common causes of ventriculitis in our institution.

Clinical profile, microbiology, management, and outcome of Pediatric Brain Abscess at the University of the Philippines- Philippine General Hospital: A 5-year retrospective study (2012-2016)

Objective@#To determine the clinical profile, microbiology, management, and outcome of pediatric brain abscess at a tertiary hospital in the Philippines from 2012 to 2016.@*Methods@#A retrospective study and review of medical records of 50 patients aged 18 years old and below diagnosed with brain abscess from 2012 to 2016 was performed. @*Results@#Majority of patients affected were 10 years old and below (74%), with no gender predilection, and mostly underweight/wasted (68%). Coverage for common vaccine-preventable pathogens was low (38% for H. influenzae type b, 2% for S. pneumoniae). Most common signs and symptoms on admission were fever (62%), vomiting (50%), and headache (50%). The top pre-disposing condition was congenital heart disease (46%), mostly Tetralogy of Fallot (33%). Methicillin-resistant Staphylococcus aureus (MRSA) was isolated in 38%) of cases. Sterile cultures comprised 68% of cases. There were two cases of tuberculous abscess. Empiric antibiotics administered for patients seen in 2012 were penicillin G and chloramphenicol, with a shift to a third-generation cephalosporin and metronidazole in the succeeding years. Aspiration with or without drainage was performed in majority of cases (85%). Six underwent complete excision and had a shorter mean length of stay of 57 days, and a lower morbidity rate of 17% with no mortalities. The overall mean length of hospital stay was 65 days. Residual neurologic deficit was observed in 28%, mostly extremity weakness. Mortality rate was 6.8%. No statistical association was found between a predisposing condition and affectation of a particular area of the brain using the Fisher exact test. @*Conclusion@#There should be a high index of suspicion for brain abscess among patients with pre-disposing conditions (i.e. paracranial infection, cyanotic congenital heart disease) presenting with fever, headache, and vomiting. Common etiologic agents in this study were MRSA and Enterococcus. The isolates were sensitive to the antibiotics recommended for empiric therapy, particularly parenteral third generation cephalosporin + metronidazole for 6 to 8 weeks. Patients with sterile cultures were also continued on this regimen. With the high resistance rates to oxacillin, vancomycin should be considered for abscesses arising from paracranial infections and for those with breaks in the skull post-trauma. There was an overall reduction in mortality due to improved imaging studies andidentification of pathogens for definitive treatment, as well as improved surgical techniques over time. A considerable number of affected children however had neurologic deficits upon discharge.

Effectiveness of daily Chlorhexidine bathing in reducing healthcare associated infections in the Pediatric Intensive Care Unit of a tertiary government hospital

Introduction@#Healthcare-associated infections (HCAIs) are a common complication of prolonged hospital stay, leading to increased morbidity and mortality. This study aims to determine the effectiveness of daily chlorhexidine bathing in reducing HCAIs in the pediatric intensive care unit (PICU).@*Methodology@#This is a randomized controlled, observer-blinded study conducted over a 6-month period. Included were 2 months to 18-year-old patients admitted to the PICU, randomly assigned to daily bathing with 2% chlorhexidine or to the standard practice of bathing with plain soap and water. Primary outcome was the incidence of HCAI in each group. @*Results@#A total of 50 patients were enrolled in the study. Overall incidence of HCAI was lower in the chlorhexidine group compared to the control group (12% versus 36%, RR=0.33, 95% CI 0.10 – 1.09, p=0.047). Incidence density rate was lower in the chlorhexidine group (5.91 versus 21.03 infections per 1000 person-days, p=0.049). Ventilator-associated pneumonia and bloodstream infections were lower in the chlorhexidine group, but results were not statistically significant. There were no significant differences in mortality rates and length of hospital stay. One adverse event of transient rash occurred in the chlorhexidine group. @*Conclusion@#Daily chlorhexidine bathing may be more effective in reducing HCAIs in the PICU compared to standard care.

Procalcitonin-Guided Antibiotic Theraphy in pediatric patients: A systematic review

Background@#Serum procalcitonin is a useful biomarker in establishing the presence of bacterial infections and has been used in algorithms to guide antibiotic treatment among adults. It role in pediatric infections, however, remains unclear. @*Objectives@#This research aims to evaluate the impact of serum procalcitonin in guiding antibiotic therapy among pediatric patients with suspected local or systemic infections. @*Methodology@#Randomized controlled trials comparing procalcitonin-guided antibiotic therapy to clinically guided therapy in pediatric patients with local or systemic infections were searched through MEDLINE, Cochrane, EMBASE, HERDIN and ClinicalTrials.gov. Hand search in various search engines was also done. Outcomes included antibiotic usage, morbidity and mortality. Two reviewers independently assessed potentially relevant studies. Statistical analysis was conducted using RevMan 5.3 using inverse variance weighting and random effects model. @*Results@#Five randomized controlled trials were included. Overall, there was a reduction in antibiotic prescription rate in the procalcitonin group compared to controls for all groups (RD -0.13, 95% CI [-021,0.06]; p <0.00001), however, pooled studies were heterogenous. Subgroup analysis showed that for children with pneumonia, procalcitonin guidance significantly reduced antibiotic prescription rate (RD – 012,95% CI [-021,0.04]; p <0.005 ), and may have potential in reducing the duration of therapy (95% CI [-6.8,2,54], p <0.0001) and antibiotic-related adverse effects (RD- 0.17, 95% CI[-0.24,-0.10], p<0.00001) compared to controls. In one study on neonates with early onset sepsis, procalcitonin guidance reduced antibiotic prescription rate by 27% (p=0.0009) and duration of therapy by 22.4 hours (p=0.0009). Procalcitonin guidance has no significant impact on antibiotic prescription rate in children with fever without a source (RD -0.11, 95% CI[0.28,0.05], p=0.190). @*Conclusion@#Procalcitonin guidance significantly reduces antibiotic prescription rate among children with pneumonia and neonates with early onset sepsis. It has the potential in reducing the duration of antibiotic therapy and antibiotic-related side effects in these populations. ON the other hand, it had no impact among children with fever without a source. These results highlight the need for algorithm-based approaches using procalcitonin cut-off values to guide antibiotic therapy in children.