Community-acquired pneumonia among children: the latest evidence for an updated management / Pneumonia adquirida na comunidade em crianc¸as: as evidências mais recentes para um manejo atualizado

Abstract Objective To provide cutting-edge information for the management of community-acquired pneumonia in children under 5 years, based on the latest evidence published in the literature. Data source A comprehensive search was conducted in PubMed, by using the expressions: "community-acquired pneumonia" AND "child" AND "etiology" OR "diagnosis" OR "severity" OR "antibiotic". All articles retrieved had the title and the abstract read, when the papers reporting the latest evidence on each subject were identified and downloaded for complete reading. Data synthesis In the era of largely implemented bacterial conjugate vaccines and widespread use of amplification nucleic acid techniques, respiratory viruses have been identified as the most frequent causative agents of community-acquired pneumonia in patients under 5 years. Hypoxemia (oxygen saturation ≤96%) and increased work of breathing are signs most associated with community-acquired pneumonia. Wheezing detected on physical examination independently predicts viral infection and the negative predictive value (95% confidence interval) of normal chest X-ray and serum procalcitonin <0.25 ng/dL was 92% (77-98%) and 93% (90-99%), respectively. Inability to drink/feed, vomiting everything, convulsions, lower chest indrawing, central cyanosis, lethargy, nasal flaring, grunting, head nodding, and oxygen saturation <90% are predictors of death and can be used as indicators for hospitalization. Moderate/large pleural effusions and multilobar infiltrates are predictors of severe disease. Orally administered amoxicillin is the first line outpatient treatment, while ampicillin, aqueous penicillin G, or amoxicillin (initiated initially by intravenous route) are the first line options to treat inpatients. Conclusions Distinct aspects of childhood community-acquired pneumonia have changed during the last three decades.

Resumo Objetivo Fornecer informações de ponta para o manejo de crianças menores de cinco anos com pneumonia adquirida na comunidade, com base nas evidências mais recentes publicadas na literatura. Fonte de dados Uma pesquisa abrangente foi feita no PubMed, com as expressões: "community-acquired pneumonia" + "child" + "etiology" ou "diagnosis" ou "severity" ou "antibiotic". Todos os artigos encontrados tiveram o título e o resumo lidos e os artigos que relatavam as evidências mais recentes sobre cada assunto foram identificados e recuperados para leitura completa. Síntese dos dados Na era das vacinas bacterianas conjugadas amplamente usadas e do uso difundido de técnicas de amplificação de ácidos nucléicos, os vírus respiratórios foram identificados como os agentes causadores mais frequentes de pneumonia adquirida na comunidade em pacientes com menos de cinco anos. A hipoxemia (saturação de oxigênio ≤ 96%) e o aumento do esforço respiratório são os sinais mais associados à pneumonia adquirida na comunidade. A sibilância detectada ao exame físico prediz de forma independente a infecção viral e o valor preditivo negativo (intervalo de confiança de 95%) da radiografia de tórax normal e a procalcitonina sérica < 0,25 ng/dL foi de 92% (77-98%) e 93% (90-99%), respectivamente. Incapacidade de beber e se alimentar, vomitar todo o alimento, convulsões, retração torácica subcostal, cianose central, letargia, aleteo nasal, estridor e saturação de oxigênio < 90% são preditores de óbito e podem ser usados como indicadores de hospitalização. Derrames pleurais moderados/grandes e infiltrados multilobulares são preditores de doença grave. A amoxicilina administrada por via oral é a opção de primeira linha para tratar pacientes ambulatoriais e a ampicilina ou penicilina cristalina G ou amoxicilina (administrada inicialmente por via intravenosa) são as opções de primeira linha para tratar pacientes hospitalizados. Conclusões Aspectos distintos da pneumonia adquirida na comunidade durante a infância mudaram durante as últimas três décadas.

Infection by Streptococcus pneumoniae in children with or without radiologically confirmed pneumonia / Infecção por Streptococcus pneumoniae em crianças com ou sem pneumonia radiologicamente confirmada

Abstract Objective: Community-acquired pneumonia is an important cause of morbidity in childhood, but the detection of its causative agent remains a diagnostic challenge. The authors aimed to evaluate the role of the chest radiograph to identify cases of community-aquired pneumonia caused by typical bacteria. Methods: The frequency of infection by Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella catarrhalis was compared in non-hospitalized children with clinical diagnosis of community acquired pneumonia aged 2-59 months with or without radiological confirmation (n = 249 and 366, respectively). Infection by S. pneumoniae was diagnosed by the detection of a serological response against at least one of eight pneumococcal proteins (defined as an increase ≥2-fold in the IgG levels against Ply, CbpA, PspA1 and PspA2, PhtD, StkP-C, and PcsB-N, or an increase ≥1.5-fold against PcpA). Infection by H. influenzae and M. catarrhalis was defined as an increase ≥2-fold on the levels of microbe-specific IgG. Results: Children with radiologically confirmed pneumonia had higher rates of infection by S. pneumoniae. The presence of pneumococcal infection increased the odds of having radiologically confirmed pneumonia by 2.8 times (95% CI: 1.8-4.3). The negative predictive value of the normal chest radiograph for infection by S. pneumoniae was 86.3% (95% CI: 82.4-89.7%). There was no difference on the rates of infection by H. influenzae and M. catarrhalis between children with community-acquired pneumonia with and without radiological confirmation. Conclusions: Among children with clinical diagnosis of community-acquired pneumonia submitted to chest radiograph, those with radiologically confirmed pneumonia present a higher rate of infection by S. pneumoniae when compared with those with a normal chest radiograph.

Resumo Objetivo: Avaliar o papel do raios X de tórax na identificação de casos de pneumonia adquirida na comunidade (PAC) causada por agentes bacterianos. Métodos: A frequência de infecção por Streptococcus pneumoniae, Haemophilus influenzae e Moraxella catarrhalis em crianças com PAC não hospitalizadas foi comparada com a presença de confirmação radiológica da pneumonia (n = 249 crianças com pneumonia radiologicamente confirmada e 366 crianças com raios X de tórax normal). Infecção por S. pneumoniae foi diagnosticada com base na resposta sorológica a pelo menos uma dentre oito proteínas pneumocócicas investigadas (aumento ≥ 2 vezes nos níveis de IgG em relação a Ply, CbpA, PspA1 e 2, PhtD, StkP-C e PcsB-N ou aumento≥ 1,5 vez em relação aPcpA). Infecção por H. influenzae e M. catarrhalis foi definida por aumento ≥ 2 vezes nos níveis de IgG específica a antígenos de cada agente. Resultados: Crianças com pneumonia radiologicamente confirmada apresentaram maior taxa de infecção pelo pneumococo. Além disso, a presença de infecção pneumocócica foi um fator preditor de pneumonia radiologicamente confirmada, o que aumenta sua chance de detecção em 2,8 vezes (IC 95%: 1,8-4,3). O valor preditivo negativo do raios X normal para a infecção por S. pneumoniae foi 86,3% (IC95%: 82,4%-89,7%). Não houve diferença nas frequências de infecção por H. influenzae e M. catarrhalis entre crianças com PAC com ou sem confirmação radiológica. Conclusão: Crianças com diagnóstico clínico de PAC submetidas a um raios X de tórax que apresentam confirmação radiológica têm maior taxa de infecção por S. pneumoniae comparadas com as crianças com raios X normal.

Clinical and bacteriological characteristics of invasive pneumococcal disease after pneumococcal 10-valent conjugate vaccine implementation in Salvador, Brazil

Abstract Invasive pneumococcal disease is a relevant public health problem in Brazil, especially among children and the elderly. In July/2010 a 10-valent pneumococcal conjugate vaccine was introduced to the immunization schedule of Brazilian children under two years of age. Between July/2010 and December/2013 we conducted a case-series study on invasive pneumococcal disease in Salvador, Brazil to describe the clinical and bacteriological profile of invasive pneumococcal disease cases during the post-implementation period. Eighty-two cases were eligible. Mean age was 31 years (interquartile range, 3–42); 17.1% and 30.5% were under 2 years and 5 years, respectively. Pneumococcal meningitis (n = 64, 78.1%), bacteraemic pneumococcal pneumonia (n = 12, 14.6%) and bacteraemia (n = 6, 7.3%) were the clinical syndromes identified. Thirty-three different serotypes were found. Of these, serotype 14 (n = 12, 14.6%) was the most common, followed by 23F (n = 10, 12.2%), 12F (n = 8, 9.8%), 18 C (n = 5, 6.1%) and 6B (n = 5, 6.1%). Investigations conducted in Salvador in the pre-vaccine period did not identify serotype 12F as one of the most prevalent serotypes. Increase of serotype 12F was observed in different regions of Brazil, in the post-vaccine period. Among children under two years of age, the target group for 10-valent pneumococcal conjugate vaccine, 11 (78.6%) of the 14 isolated strains of Streptococcus pneumoniae belonged to vaccine serotypes; at least 50% of these children were not vaccinated. The relatively recent implementation of 10-valent pneumococcal conjugate vaccine in Brazil reinforces the need to maintain an active surveillance of invasive pneumococcal disease cases, considering the possible increase of invasive pneumococcal disease cases related to non-vaccine serotypes and the changes on the clinical presentation of the disease.

Epidemiological aspects of influenza A related to climatic conditions during and after a pandemic period in the city of Salvador, northeastern Brazil

During the influenza pandemic of 2009, the A(H1N1)pdm09, A/H3N2 seasonal and influenza B viruses were observed to be co-circulating with other respiratory viruses. To observe the epidemiological pattern of the influenza virus between May 2009-August 2011, 467 nasopharyngeal aspirates were collected from children less than five years of age in the city of Salvador. In addition, data on weather conditions were obtained. Indirect immunofluorescence, real-time transcription reverse polymerase chain reaction (RT-PCR), and sequencing assays were performed for influenza virus detection. Of all 467 samples, 34 (7%) specimens were positive for influenza A and of these, viral characterisation identified Flu A/H3N2 in 25/34 (74%) and A(H1N1)pdm09 in 9/34 (26%). Influenza B accounted for a small proportion (0.8%) and the other respiratory viruses for 27.2% (127/467). No deaths were registered and no pattern of seasonality or expected climatic conditions could be established. These observations are important for predicting the evolution of epidemics and in implementing future anti-pandemic measures.

Methicillin-resistant and methicillin-susceptible community-acquired Staphylococcus aureus infection among children

Methicillin-resistant Staphylococcus aureus has emerged as a pathogen associated with community-acquired infections worldwide. We report the spectrum of community-acquired S. aureus infections and compare the patients infected with methicillin-susceptible or methicillin-resistant strains among patients aged <20 years. Overall, 90 cases of community acquired S. aureus were detected in an 11-year period. Clinical and microbiological data were registered. Fifty-nine (66%) patients were male and the median age was two years. The majority (87%) of the patients were hospitalized and chronic underlying illnesses were detected in 27 (30%) cases. Overall, 34 (37.8%) patients had skin/soft tissue infections and 56 (62.2%) patients had deep-seated infection. Four (5.1%) patients were transferred to the intensive care unit and two (2.6%) died. Complications were detected in 17 (18.9%) cases, such as pleural effusion (41.2%), osteomyelitis (23.5%), and sepsis (17.6%). Six (6.7%) methicillin-resistant strains were detected. Patients infected with methicillin-susceptible or methicillin-resistant strains had similar baseline characteristics and treatment outcomes. Approximately 93% of the cases received systemic antibiotics, out of which 59 (65.5%) used oxacillin or cefalotin. Both methicillin-susceptible and methicillin-resistant S. aureus strains resulted in morbidity and death among children in this setting where methicillin-resistant strains are infrequent.

Frequência de chiado, características clínicas e tratamento em lactentes / Wheezing in infants: frequency, clinical characteristics and treatment

OBJETIVO: Estimar a frequência de história pregressa de chiado, descrevendo as características clínicas e formas de tratamento utilizadas. MÉTODOS: Coorte retrospectiva incluindo lactentes (6-23 meses de vida) com sintomas de infecção de vias aéreas superiores e relato de episódio prévio de chiado. Os dados foram registrados em questionário anteriormente validado. RESULTADOS: Dos 451 avaliados, 164 (36,4%; IC95% = 31,9-41,0) apresentaram história pregressa de chiado, 148 (32,8%; IC95% = 28,5-37,4) no primeiro ano de vida. A média de idade no primeiro episódio de chiado foi de 5,3±3,9 meses. Para quem começou a chiar no primeiro ano de vida, 38,5% referiram entre três e seis episódios e 14,2% > seis episódios. A média da idade no primeiro episódio foi menor para os que apresentaram > três episódios em comparação aos que apresentaram até dois episódios (3,2±2,7 versus 5,7±2,5 meses, p < 0,001). CONCLUSÃO: Um terço dos lactentes apresentou chiado no primeiro ano de vida. Quanto mais cedo ocorre o primeiro episódio, mais frequente é a recorrência do chiado.

OBJECTIVE: To estimate the frequency and describe the clinical characteristics and respective treatments of previous history of wheezing. METHODS: Infants aged 6-23 months with upper respiratory tract complaints and reporting previous wheezing were followed-up retrospectively. Data were registered on a validated standardized form. RESULTS: Out of 451 infants, 164 (36.4%; 95%CI: 31.9-41.0) had a report of prior history of wheezing, 148 (32.8%; 95%CI: 28.5-37.4) during the first year of life. The mean age at the first episode of wheezing was 5.3±3.9 months. Among those who had had their first episode before 12 months of age, 38.5% reported 3 to 6 episodes and 14.2% > 6 episodes. Mean age at first episode was lower for those with > 3 episodes in comparison with those with < 2 episodes (3.2±2.7 vs. 5.7±2.5 months, p < 0.001). CONCLUSION: One third of the infants reported wheezing during the first year of life. The earlier the first episode occurs, the more frequently wheezing recurs.

Outcome of children hospitalized with community-acquired pneumonia treated with aqueous penicillin G

OBJECTIVE: To describe the evolution and outcome of children hospitalized with community-acquired pneumonia receiving penicillin. METHODS: A search was carried out for all hospitalized community-acquired pneumonia cases in a 37-month period. Inclusion criteria comprised age >2 months, intravenous penicillin G use at 200,000 IU/kg/day for >48 h and chest x-ray results. Confounders leading to exclusion included underlying debilitating or chronic pulmonary illnesses, nosocomial pneumonia or transference to another hospital. Pneumonia was confirmed if a pulmonary infiltrate or pleural effusion was described by an independent radiologist blind to the clinical information. Data on admission and evolution were entered on a standardized form. RESULTS: Of 154 studied cases, 123 (80 percent) and 40 (26 percent) had pulmonary infiltrate or pleural effusion, respectively. Penicilli was substituted by other antibiotics in 28 (18 percent) patients, in whom the sole significant decrease was in the frequency of tachypnea from the first to the second day of treatment (86 percent vs. 50 percent, p = 0.008). Among patients treated exclusively with penicillin G, fever (46 percent vs. 26 percent, p = 0.002), tachypnea (74 percent vs. 59 percent, p = 0.003), chest indrawing (29 percent vs. 13 percent, p<0.001) and nasal flaring (10 percent vs. 1.6 percent, p = 0.001) frequencies significantly decreased from admission to the first day of treatment. Patients treated with other antimicrobial agents stayed longer in the hospital than those treated solely with penicillin G (16±6 vs. 8±4 days, p<0.001, mean difference (95 percent confidence interval) 8 (6-10)). None of the studied patients died. CONCLUSION: Penicillin G successfully treated 82 percent (126/154) of the study group and improvement was marked on the first day of treatment.

Outpatient antibiotic therapy as a predisposing factor for bacterial resistance: a rational approach to airway infections

OBJETIVOS: Apresentar as recomendações baseadas em evidência para uso de antibióticos no tratamento das infecções respiratórias agudas (IRA) mais freqüentes e as informações disponíveis sobre a importância desse tipo de conduta. FONTES DOS DADOS: Bases de dados MEDLINE, LILACS, publicações técnicas de organizações internacionais, diretrizes nacionais e internacionais. Foram utilizados os unitermos acute respiratory infection, otitis, sinusitis, tonsillitis, pneumonia, antibiotic, guidelines, bacterial resistance. Artigos citados pelos artigos incluídos foram analisados quanto à apresentação de informação de interesse. SíNTESE DOS DADOS: A resistência bacteriana tem crescido, sendo atualmente reconhecida como problema mundial de saúde pública. As IRA são a causa mais freqüente para uso de antibiótico na comunidade; grande parte desses casos, tanto nas vias aéreas superiores (otite, sinusite, faringoamidalite) como nas inferiores (pneumonia), são decorrente de infecção viral. As recomendações para racionalizar o uso de antibióticos nos pacientes com IRA têm como objetivo comum minimizar o uso desnecessário de antibióticos, visto que a "pressão antibiótica" é um dos fatores desencadeantes da resistência bacteriana. CONCLUSÕES: É de grande importância a distinção, entre os pacientes com IRA, daqueles que podem se beneficiar do uso de antibióticos. O uso das recomendações para a prescrição de antibióticos é uma estratégia para minimizar a freqüência de resistência bacteriana.

OBJECTIVES: To present evidence-based recommendations for the use of antibiotics for the treatment of the most common acute respiratory infections (ARI) and the available information on the importance of this type of management. SOURCES: MEDLINE and LILACS databases, technical publications by international organizations, national and international directives. The search terms acute respiratory infection, otitis, sinusitis, tonsillitis, pneumonia, antibiotic, guidelines and bacterial resistance were used. Articles cited by the articles selected were analyzed for information of interest. SUMMARY OF THE FINDINGS: Bacterial resistance has grown, to the extent that today it is recognized as a global public health problem. ARI are the most common cause of antibiotic usage within the community; yet a large proportion of these cases, compromising the upper (otitis, sinusitis, tonsillitis) or the lower airways (pneumonia), are the result of viral infections. Recommendations to rationalize the use of antibiotics in patients with ARI have the common objective of minimizing unnecessary antibiotic use, since "antibiotic pressure" is one of the factors triggering bacterial resistance. CONCLUSIONS: It is of great importance to differentiate among ARI patients those who will benefit from the use of antibiotics. The establishment of recommendations for the prescription of antibiotics is one strategy for minimizing the frequency of bacterial resistance.

Nasopharyngeal colonization and penicillin resistance among pneumococcal strains: a Worldwide 2004 update

Surveillance of nasopharyngeal pneumococcus has proven to be a valuable tool for the monitoring of antibiotic resistance. We reviewed the latest information on colonization rate and penicillin resistance by making a MEDLINE search, using the terms "nasopharyngeal carriage" and "Streptococcus pneumoniae". Out of 225 articles found, data from 109 recent publications (89 percent from 1996-2003) were analyzed. Data were reported from 41 countries of six continents. Individuals under the age of five (64.3 percent) or 10 years (85.7 percent) were enrolled, including children attending day-care centers (32.1 percent) or orphanages (3.6 percent), and healthy individuals (78.6 percent) or sick patients (43.6 percent); biological samples were collected mainly by nasopharyngeal swabs (89.3 percent). The highest colonization rates were reported from Africa (85-87.2 percent), where several authors did not find high rates of penicillin resistance. On the other hand, studies conducted in North and Central America reported high-level penicillin resistance at rates of approximately 20-30 percent. Great variation in the rates of pneumococcal colonization and penicillin resistance were observed within regions or continents. There were also considerable differences in similar populations located in different areas of the same country. Data regarding pneumococcal colonization and penicillin resistance are not available from most countries. We also examined the use of antibiotics to treat pneumococcal infections.

Vacinação contra Haemophilus influenzae tipo b: proteção a longo prazo / Haemophilus influenzae type b vaccination: long term protection

OBJETIVO: Identificar as evidências sobre o impacto da vacina conjugada para Haemophilus influenzae tipo b (Hib) na epidemiologia da doença invasiva por Hib. FONTE DOS DADOS: Pesquisa nas bases de dados do MEDLINE, LILACS, publicações técnicas de organizações internacionais, diretrizes nacionais e internacionais, nos últimos 15 anos (1991-2005), utilizando os seguintes unitermos: Haemophilus influenzae type b, immunization, impact, effectiveness. Foram incluídas as publicações que apresentaram informação para atender o objetivo deste artigo. Artigos publicados em período anterior ao da pesquisa e citados em referências dos artigos incluídos foram analisados quanto à apresentação de informação de interesse. SíNTESE DOS DADOS: A introdução da vacina conjugada para Hib produziu grande declínio na incidência de casos de doença invasiva por Hib nos diversos países em que seu uso foi incorporado à rotina de vacinação das crianças. No entanto, o ressurgimento de casos com doença invasiva por Hib tem mobilizado vários investigadores na busca das possíveis explicações para esses eventos, bem como a identificação das medidas a serem implementadas para evitar o reaparecimento da doença. CONCLUSÕES: O uso da vacina conjugada para Hib em escala populacional tem sido extremamente efetivo. No entanto, mudanças no esquema vacinal poderão ser necessárias para a manutenção do controle da doença invasiva por Hib, frente ao atual cenário epidemiológico das infecções pelo Hib.

Neuroschistosomiasis due to Schistosoma mansoni: a review of pathogenesis, clinical syndromes and diagnostic approaches

Neuroesquistossomose (NS) é a segunda forma mais freqüente de apresentação da infecção causada pelo trematódeo Schistosoma mansoni. A inflamação do tipo granulomatosa ocorre como resultado da presença de ovos do S. mansoni que atingiram a medula espinhal ou o encéfalo via o sistema vascular ou pela migração inadvertida de vermes adultos para estes órgãos. Duas síndromes clínicas principais podem ser identificadas: a mielopatia esquistossomótica (aguda ou subaguda) e a neuroesquistossomose cerebral ou cerebelar localizada (comprometimento focal do Sistema Nervoso Central, convulsões, hipertensão intracraniana). O diagnóstico presumido da NS requer a confirmação da presença da infecção por exame microscópico de fezes ou pela biópsia retal em busca de ovos de trematódeo e testes sorológicos no sangue e no líquor. As lesões localizadas são identificadas por sinais e sintomas, e confirmadas por exames de imagem (mielografia contrastada, tomografia computadorizada e ressonância magnética). Algoritmos são apresentados para orientar uma avaliação diagnóstica seqüencial.

Recomendação da Sociedade Brasileira de Pediatria para antibioticoterapia em crianças e adolescentes com pneumonia comunitária / Recommendation of the Brazilian Society of Pediatrics for antibiotic therapy in children and adolescents with community-acquired pneumonia

OBJETIVO: Padronizar o uso dos antibióticos no tratamento das crianças e adolescentes com pneumonia comunitária no Brasil. MÉTODOS: Foram utilizados os dados das bases de dados Medline e Literatura Latino-Americana e do Caribe em Ciências da Saúde (LILACS); documentos da Organização Mundial da Saúde e Organização Pan-Americana da Saúde, de 1980 a 2002; busca na Internet, em português, espanhol e inglês, utilizando-se as palavras-chave "pneumonia, criança, adolescente, etiologia, tratamento"; e questionamentos a pesquisadores com reconhecido saber sobre o assunto. RESULTADOS: As crianças com menos de 2 meses devem ser hospitalizadas sempre e receber tratamento com ampicilina associada a aminoglicosídeo ou a cefalosporina de terceira geração. As crianças maiores de 2 meses devem ser hospitalizadas se apresentarem pneumonia grave (pneumonia e tiragem subcostal). Recomenda-se utilizar taquipnéia como critério para distinguir entre infecção respiratória aguda e pneumonia. Considera-se a pneumonia muito grave quando associada a convulsões, sonolência, estridor em repouso, desnutrição grave, ausência da ingestão de líquidos ou sinais de insuficiência respiratória grave, como cianose central. As crianças com 2 meses ou mais podem ser tratadas ambulatorialmente com amoxicilina ou penicilina procaína. Quando o tratamento for hospitalar, podem ser utilizadas penicilina cristalina ou ampicilina para os casos graves ou oxacilina associada a cloranfenicol ou ceftriaxona para os casos muito graves. Sempre que houver a suspeita de a etiologia ser C. trachomatis, C. pneumoniae, M. pneumoniaeou B. pertussis deve-se utilizar um macrolídeo, preferencialmente a eritromicina. CONCLUSÕES: O diagnóstico de pneumonia pode ser baseado em avaliação clínica, assim como a indicação de hospitalização. Os principais antibióticos a serem utilizados são amoxicilina, penicilina, eritromicina, ampicilina, oxacilina, cloranfenicol, ceftriaxona e aminoglicosídeos, conforme a faixa etária e a gravidade.

Etiology of bacterial meningitis among children aged 2-59 months in Salvador, Northeast Brazil, before and after routine use of Haemophilus influenzae type b vaccine

OBJETIVO: Descrever a freqüência dos agentes etiológicos de meningite bacteriana (MB) em amostra das crianças com idade entre 2 e 59 meses, em Salvador, Nordeste do Brasil, com ênfase na freqüência de MB de etiologia indeterminada (MBEI), antes, durante e após a implementação da imunização rotineira de lactentes com vacina para Haemophilus influenzae tipo b (Hib). MÉTODO: Variáveis demográficas, clínicas e liquóricas (LCR) foram coletadas da ficha de cada paciente com idade entre 2 e 59 meses, cujo exame de LCR foi realizado no Laboratório de LCR - Fundação José Silveira, entre janeiro de 1989 e dezembro de 2001. Cada exame de LCR foi realizado por completo conforme os métodos padronizados. O diagnóstico etiológico foi baseado ou em cultura e ou teste de aglutinação em látex. Quando o agente foi identificado apenas no GRAM, o diagnóstico foi descritivo. MBEI foi definida como glicose < 40mg / dl, proteína > 100 mg / dl, celularidade global > 20 células / mm3 e percentual de neutrófilos > 80%. RESULTADOS: Dos 1519 pacientes, 894 (58,9%) tiveram exames normais e MB foi diagnosticada em 95 (6,2%). Os agentes etiológicos foram: Hib (44,2%), meningococo (13,7%), bacilos Gram-negativos (11,6%), Mycobacterium tuberculosis (6,3%), pneumococo (4,2%), outros agentes (4,2%); MBEI foi diagnosticada em 15,8% dos casos de MB. Ao analisar a freqüência da MBEI e por Hib entre todos os exames realizados a cada ano, os picos foram registrados em 1989 (5,3%) e 1990 (16,9%), respectivamente, diminuindo para 0,7% e 0% em 2001. CONCLUSÃO: É possível que a implementação do uso da vacina conjugada para Hib durante a década de 1990 tenha decrescido não apenas a ocorrência da meningite por Hib mas também a MBEI.

Frequency of lymphocytic meningitis associated with mumps before and after a mass campaign for mumps vaccination in children from Salvador, Northeast Brazil

OBJECTIVE: To describe the frequency of lymphocytic meningitis(LM) concomitant with mumps, before and after the mumps mass immunization campaign in 1997. METHOD: Demographic, clinical and cerebrospinal fluid(CSF) information was collected from the chart of all patients aged from 2 to 59 months, whose CSF exam was performed at the CSF Lab/FJS, between 1989 and 2001. LM was defined as pleocytosis composed by lymphomononuclear cells and negative exams for bacterial or mycologic infection. RESULTS: Of 1,519 patients, 894(58.9 percent) had normal exams. LM was present in 301(19.8 percent) patients, out of which 22(7.3 percent) had concomitant mumps. The frequency of LM ranged from 15.8 percent in 1989 to 19.7 percent in 2001 and of LM with concomitant Mumps ranged from 10.5 percent in 1989 to 4.7 percent in 1995, when the last cases were registered. CONCLUSION: It is probable that the mumps vaccine campaign has influenced the absence of LM with concomitant Mumps, from 1996 to 2001

Clinical and cerebrospinal fluid (CSF) profile and CSF criteria for the diagnosis of spinal cord schistosomiasis

OBJECTIVES: To describe the clinical and CSF findings among patients with presumptive neuroschistosomiasis (NS) and to suggest a classification for the CSF diagnosis of presumptive NS. METHOD: The charts of all patients whose CSF exam was performed at the CSF Lab, José Silveira Foundation, Salvador, Brazil, from 1988 to 2002 were reviewed. Those with clinically suspected NS whose indirect fluorescent antibody test (IFA) and or hemagglutination-inhibiting antibodies test (HAI) were positive to S. mansoni were identified. RESULTS: Of 377 patients, 67.9 percent were males; the median age was 36 years (mean 37 + 16 yrs, range 3-82 yrs). The most frequent complaints were paraparesis (59.9 percent), urinary retention (36.2 percent), lower limb pain (22.8 percent). WBC of CSF (count/mm ) was > 4 in 66.0 percent (mean 83 + 124, median 40, range 4.3-1,100), protein (mg/dl) was > 40 in 84.6 percent (mean 185 + 519, median 81, range 41-6,800) and eosinophils were present in 46.9 percent. IFA and HAI were positive in 75.3 percent. WBC > 4 and presence of eosinophils were associated with IFA and HAI positive (67.3 percent versus 51.4 percent, p 0.014; 49.1 percent versus 23.0 percent, p 0.0001, respectively) and protein > 40 was not (85.4 percent versus 77.0 percent, p 0.09). Presence of WBC > 4, protein > 40 and eosinophils was associated with IFA and HAI positive (71.6 percent versus 38.2 percent, p 0.0003) but presence of eosinophils and any other combination of WBC and protein were not. CONCLUSION: NS should be considered as a possible diagnosis in patients who had had contact with schistosome-infected water and present with spinal cord compromising. Presence of IFA and HAI positive to S. mansoni, WBC > 4, protein > 40 and presence of eosinophils in the CSF may be considered as a criterium of highly probable presumptive diagnosis

Childhood pneumonia: clinical aspects associated with hospitalization or death

OBJECTIVE: To determine which available information at an Emergency Room (ER) consultation is associated with hospitalization or death among children with pneumonia. DESIGN: Prospective cohort study. SETTING: The ER of one university and one private hospital. MEASUREMENT: Using stepwise logistic regression we analyzed factors that showed a univariate association. MAIN RESULTS: Of 2,970 cases, the median age was 1.83 years (range 2 days to 14.5 yrs, mean 2.76 +/- 2.72 yrs); 25.8 were hospitalized and 0.8 died. Age (2-11 mos, OR 0.4 [0.2-0.6]; 12-59 mos, OR 0.2 [0.1-0.4]; > or = 5 yrs, OR 0.1 [0.08-0.3]), malnutrition (OR 2.0 [1.4-2.7]), underlying chronic illness (OR 1.4 [1.1-1.8]), tachypnea (OR 1.8 [1.4-2.4]), chest indrawing (OR 1.7 [1.4-2.2]), and somnolence (OR 1.8 [1.4-2.4]) were associated with hospitalization and age (2-11 mos, OR 0.3 [0.08-0.8]; > or = 12 mos, OR 0.06 [0.02-0.2]), malnutrition (OR 3.1 [1.2-7.7]) and underlying chronic illness (OR 4.3 [1.6-11.0]) were associated with death in the multivariate analysis. CONCLUSIONS: Several clinical aspects may be used in assessing need for hospitalization (i.e. young age, malnutrition, underlying chronic illness, tachypnea, chest indrawing and somnolence) for children with pneumonia seen at the ER. Individual intrinsic factors such as age, malnutrition and underlying chronic illness were independently associated with death. Pneumonia should be considered a treatable disease and complete recovery can be achieved in the majority of the cases.

Etiology od childhood community acquired pneumonia and its implications for vaccination

Pneumonia is an important cause of morbidity and mortality among children throughout the world. Vaccines are available for some organisms, but they are underutilized and/or still development. To evaluate the potential impact of vaccines, we review studies in which the etiology of childhood community-acquired pneuminia was recorded. In North America and Europe (9 studies), the etiology of pneumonia was established in 62 percent of studied children (range 43 percent-88 percent) by use of noninvasive specific methods for microbiologic diagnosis. The most often identified agents were S.pneumoniae (22 percent), respiratory syncytial virus (RSV) (20 percent), Haemophilus influenzae (7 percent), and Mycoplasma pneumoniae (15 percent). In Africa and South America (8 studies), bacteria were recovered from 56 percent (range 32 percent-68 percent) of severely ill children studied by lung aspirate. The most often isolated bacteria were Streptococcus pneumoniae (33 percent) and Hemophilus influenzae (21 percent). A high percentage of H.influenzae strains were not serotype b. Throughout the world, children requiring hospitalization were most likely to have infection caused by pneumococcus H.influenzae or RSV. Out patient also had Mycoplasma pneumoniae. Countries in Africa and Asia recorded 2 to times more children with pneumonia (7 to 40/100 annually) than in the USA. Widespread use of pneumococcal and H.influenzae type b conjugate vaccines could reduce the frequency of children pneumoniae by one-third. Further reduction will require development of non-type b H.influenzae, RSV and M.pneumoniae vaccines. This could result in a > 50 percent reduction of pneumonia in children. This goal should be sought achieved as soon as possible.