Hemolytic uremic syndrome associated with streptococcus pneumoniae in pediatrics: a case series / Síndrome hemolítico-urêmica associada com streptococcus pneumoniae em pediatria: série de casos

ABSTRACT Objective: To describe a case series of four (4) patients with hemolytic uremic syndrome due to Streptococcus pneumoniae in a level four complexity institution in the city of Bogotá, D.C., Colombia. Cases description: We describe cases of four patients who presented respiratory symptoms and fever. All four patients were in regular conditions on hospital admission, after which they required intensive care and ventilatory support. Upon admission, three cases showed evidence of pleuropulmonary complication. Penicillin-sensitive Streptococcus pneumoniae was isolated in all cases. All patients presented anemia, severe thrombocytopenia, schistocytes on peripheral blood smear, and hyperazotemia. They required blood transfusion and renal replacement therapy during their hospitalization. The patients were diagnosed with hemolytic uremic syndrome due to S. pneumoniae. Three of the four patients had a progressive recovery of the renal function and were discharged after an average of 36 days of hospital stay. The remaining patient had two amputations in the extremities due to thrombotic vascular complications and was discharged after 99 days of hospital stay, requiring hemodialysis every other day. Comments: Hemolytic uremic syndrome due to Streptococcus pneumoniae is a rare but severe complication of invasive pneumococcal disease. Complicated pneumonia is the main condition associated with this entity. It is noteworthy the short period in which these cases were presented, considering the low annual incidence of the disease.

RESUMO Objetivo: Descrever uma série de casos de quatro pacientes com síndrome hemolítico-urêmica por pneumococo em uma instituição de referência em Bogotá, Colômbia. Descrição dos casos: Descrevemos os casos de quatro pacientes que apresentaram sintomas respiratórios e febre. Todos estavam em estado geral regular à admissão hospitalar e necessitaram de cuidados intensivos e suporte ventilatório. Na admissão, em três dos casos foi evidenciada a complicação pleuropulmonar. Isolamento de Streptococcus pneumoniae sensível à penicilina foi realizado em todos os casos. Os quatro pacientes precisaram de transfusão sanguínea e terapia de reposição renal durante a hospitalização. Nos testes laboratoriais, observou-se anemia, trombocitopenia grave, presença de esquizócitos em esfregaço de sangue periférico e hiperazotemia. Com esse quadro, o diagnóstico foi de síndrome hemolítico-urêmica associada à infecção por S. pneumoniae. Houve recuperação progressiva da função renal em três dos quatro pacientes, que tiveram alta após 36 dias de internação hospitalar, em média. Um paciente teve complicações vasculares trombóticas, resultando em duas amputações nas extremidades, e teve alta após 99 dias de internação, com necessidade de hemodiálise em dias alternados. Comentários: A síndrome hemolítico-urêmica por Streptococcus pneumoniae é uma complicação rara, mas grave, da doença invasiva pneumocócica. A pneumonia complicada é a principal condição associada a essa entidade. Destaca-se o curto período em que esses casos foram apresentados, levando em conta a baixa incidência anual de síndrome hemolítico-urêmica.

Neumonía neumocócica bacteriémica en adultos en hospital regional de Chile / Bacteremic pneumococcal pneumonia in adults admitted to a general hospital: experience in 60 cases

Background: Bacteremic pneumococcal pneumonia (BPP) is a preventable disease with high morbimortality. Aim: To evaluate clinical aspects and mortality on BPP patients admitted to a Chilean regional hospital. Patients and Methods: We looked for adult patients with Streptococcus pneumoniae isolated from blood cultures between 2010 and 2014 years and reviewed clinical records of those who were admitted with pneumonia. Results: We identified 70 BPP patients: 58% were men, mean age was 56 years, 30% were > 65 years, 70% with basic public health insurance, 26% were alcoholics, 86% had comorbidities. Only two patients were vaccinated against S. pneumoniae. CURB-65 severity index for community acquired pneumonia was > 3 in 37% of patients. Twenty-four patients were admitted to ICU, twenty required mechanical ventilation and twenty-four died (34%). Mortality was associated with an age over 65 years, presence of comorbidities and complications of pneumonia. A total of 22 serotypes of S. pneumoniae were identified, five of them (1,3,7F,14 y 9V) were present in 57% of cases. Conclusions: Elevated mortality of our BNN patients was associated with comorbidities and possibly with socio economic factors, which conditioned a late access to medical care.

Síndrome de Austrian en endocarditis infecciosa: reporte de un caso y manejo médico quirúrgico exitoso / Austrian syndrome in infective endocarditis

Resumen: El Síndrome de Austrian, corresponde al cuadro clínico descrito por Robert Austrian en 1957, definido por la triada de Neumonía, Endocarditis Infecciosa (EI) y Meningitis, causado por Streptococcus pneumoniae. En la mayoría de los casos el vicio valvular presente, es la insuficiencia valvular aórtica, cuyo tratamiento médico y resolución quirúrgica de acuerdo con su gravedad, deben ser realizados precoz y oportunamente. Un paciente de 51 años, sin antecedentes de valvulopatía, con historia de poli consumo de alcohol y cocaína comenzó dos semanas previo a su ingreso hospitalario con síndrome febril, neumonía, y meningitis bacteriana por Streptococcus pneumoniae. Sus hemocultivos fueron negativos. El ecocardiograma transesofágico (ETE) fue compatible con EI valvular aórtica con insuficiencia moderada a severa. Se trató como EI a microorganismo desconocido y se efectuó un reemplazo valvular aórtico electivo con prótesis biológica a la 5° semana después de terminado el tratamiento médico antibiótico, cuyo resultado fue exitoso.

Abstract: A syndrome including Infective endocarditis, pneumonia and Meningitis caused by S pneumoniae was described by Robert Austrian in 1957. The aortic valve is affected in most cases. Medical followed by surgical treatment should be promptly implemented. The clinical case of a 51 year old man with a history of multiple drug consumption developing fever, pneumonia, and meningitis caused by S pneumoniae is presented. Blood cultures were negative and trans esophageal echocardiography showed aortic valve vegetations and moderate regurgitation. After multiple antibiotic treatment the patient underwent aortic valve replacement and recovered satisfactorily. Clinical and epidemiological characteristics of this syndrome are discussed.

Neumonía adquirida de la comunidad en adultos: Recomendaciones sobre su atención / Guidelines for management of community-acquired pneumonia in adults

La neumonía adquirida en la comunidad (NAC) en adultos es causa frecuente de morbilidad y mortalidad, especialmente en adultos mayores y en sujetos con comorbilidades previas. La mayoría de los episodios son de etiología bacteriana, Streptococcus pneumoniae es el patógeno aislado con mayor frecuencia. La vigilancia epidemiológica permite conocer los cambios en los microorganismos productores y su sensibilidad a los antimicrobianos; recientemente se ha observado un incremento en aislamientos de Staphylococcus aureus resistente a la meticilina y Legionella sp. La radiografía de tórax resulta imprescindible como herramienta diagnóstica. El score CURB-65 y la oximetría de pulso permiten estratificar a los pacientes en aquellos que requieren manejo ambulatorio, hospitalización en sala general o unidad de terapia intensiva. Los estudios diagnósticos y el tratamiento antimicrobiano empírico también se basan en esta estratificación. Los biomarcadores tales como procalcitonina o proteína-C reactiva no son parte de la evaluación inicial dado que su utilización no demostró modificar el manejo de los episodios de NAC. El tratamiento antibiótico sugerido para pacientes ambulatorios menores de 65 años sin comorbilidades es amoxicilina; pacientes ≥ 65 años o con comorbilidades: amoxicilina-clavulánico/sulbactam; hospitalizados en sala general: ampicilina sulbactam con o sin claritromicina; pacientes admitidos a unidad de terapia intensiva: ampicilina-sulbactam más claritromicina. La duración del tratamiento es de 5 a 7 días para tratamiento ambulatorio y 7 a 10 para los hospitalizados. En época de circulación del virus de la influenza se sugiere el agregado de oseltamivir para los pacientes hospitalizados y para aquellos con comorbilidades.

Community-acquired pneumonia in adults is a common cause of morbidity and mortality particularly in the elderly and in patients with comorbidities. Most episodes are of bacterial origin, Streptococcus pneumoniae is the most frequently isolated pathogen. Epidemiological surveillance provides information about changes in microorganisms and their susceptibility. In recent years there has been an increase in cases caused by community-acquired meticillin resistant Staphylococcus aureus and Legionella sp. The chest radiograph is essential as a diagnostic tool. CURB-65 score and pulse oximetry allow stratifying patients into those who require outpatient care, general hospital room or admission to intensive care unit. Diagnostic studies and empirical antimicrobial therapy are also based on this stratification. The use of biomarkers such as procalcitonin or C-reactive protein is not part of the initial evaluation because its use has not been shown to modify the initial approach. We recommend treatment with amoxicillin for outpatients under 65 year old and without comorbidities, for patients 65 years or more or with comorbidities amoxicillin-clavulanic/sulbactam, for patients hospitalized in general ward ampicillin-sulbactam with or without the addition of clarithromycin, and for patients admitted to intensive care unit ampicillin-sulbactam plus clarithromycin. Suggested treatment duration is 5 to 7 days for outpatients and 7 to 10 for those who are hospitalized. During the influenza season addition of oseltamivir for hospitalized patients and for those with comorbidities is suggested.

Predictores clínicos de bacteriemia en adultos inmunocompetentes hospitalizados por neumonía adquirida en la comunidad / Clinical predictors of bacteremia in immunocompetent adult patients hospitalized for community-acquired pneumonia

Background: The clinical usefulness of blood cultures in the management of patients hospitalized with community-acquired pneumonia (CAP) is controversial. Aim: To determine clinical predictors of bacteremia in a cohort of adult patients hospitalized for community-acquired pneumonia. Material and Methods: A prospective cohort of 605 immunocompetent adult patients aged 16 to 101 years (54% male) hospitalized for CAP was studied. The clinical and laboratory variables measured at admission were associated with the risk of bacteremia by univariate and multivariate analysis using logistic regression models. Results: Seventy seven percent of patients had comorbidities, median hospital stay was 9 days, 7.6% died in hospital and 10.7% at 30 days. The yield of the blood cultures was 12.6% (S. pneumoniae in 69 patients, H. influenzae in 3, Gram negative bacteria in three and S. aureus in one). These results modified the initial antimicrobial treatment in one case (0.2%). In a multivariate analysis, clinical and laboratory variables associated with increased risk of bacteremia were low diastolic blood pressure (Odds ratio (OR): 1.85, 95% confidence intervals (CI) 1.02 to 3.36, p < 0.05), leukocytosis e" 15,000/mm³ (OR: 2.18, 95% CI 1.22 to 3.88, p < 0.009), serum urea nitrogen e" 30 mg/dL (OR: 2.23, 95% CI 1.22 to 4.05, p < 0.009) and serum C-reactive protein e" 30 mg/dL (OR: 2.20, 95% CI 1.22 to 3.97, p < 0.01). Antimicrobial use before hospital admission significantly decreased the blood culture yield (OR: 0.14, 95% CI 0.04 to 0.46, p < 0.002). Conclusions: Blood cultures do not contribute significantly to the initial management of patients hospitalized for community-acquired pneumonia. The main clinical predictors of bacteremia were antibiotic use, hypotension, renal dysfunction and systemic inflammation.

Austrian syndrome in the context of a fulminant pneumococcal native valve endocarditis

This is the case of a young male suffering from Austrian syndrome, which is the triad of endocarditis, meningitis, and pneumonia due to invasive S. pneumoniae infection. He reported recurrent fever for six months without any antibiotic treatment, which may have determined the further course of the syndrome. Echocardiography revealed massive native valve endocarditis, and the patient was considered for ultima-ratio cardiac surgery. Intraoperative aspect presented extensive affection of the aortic root with full destruction of aortic valve, mitral valve, and aortomitral continuity. The myocardium showed a phlegmonlike infiltration. Microbiologic testing of intraoperatively collected specimens identified penicillin-sensitive Streptococcus pneumoniae. S. pneumoniae is a very uncommon cause for infective infiltrative endocarditis and is associated with severe clinical courses. Austrian syndrome is even more rare, with only a few reported cases worldwide. In those patients, only early diagnosis, immediate antibiotic treatment, and emergent cardiac surgery can save lives.

Estudo da colonização na asofaringeana por Streptococcus pneumoniae em crianças com suspeita clínica de pneumonia / Naasofaringeana study of colonization by Streptococcus pneumoniae in children with clinical suspicion of pneumonia

Streptococcus pneumoniae constitui um dos mais importantes patógenos bacterianos do trato respiratório, podendo causar infecções invasivas e não invasivas, levando a altas taxas de morbi-mortalidade, particularmente em crianças menores de cinco anos de idade. A bactéria ganha acesso ao hospedeiro através da colonização da nasofaringe, que representa um importante reservatório para a transmissão deste patógeno na comunidade, contribuindo para a disseminação horizontal de S. pneumoniae entre os indivíduos de uma população. No presente estudo, procuramos caracterizar o perfil de colonização nasofaringeana por S. pneumoniae em pacientes menores de cinco anos de idade com suspeita clínica de pneumonia, atendidos na Unidade de Saúde de São Marcos, Bairro de Pau da Lima, Salvador, no ano de 2009. Um total de 205 swabs foram coletados entre as crianças consideradas elegíveis para o estudo. Os isolados de S. pneumoniae foram identificados através de métodos microbiológicos clássicos e a determinação do sorogrupo/sorotipo foi realizada empregando-se a técnica de Multiplex-PCR. A sensibilidade a sete antimicrobianos foi testada através da técnica de microdiluição em caldo, sendo que os isolados com CIM para penicilina ≥ 0,125 μg/mL foram considerados não-susceptíveis. A técnica de PFGE foi realizada para 26 isolados correspondentes aos sorotipos mais frequentes e associados a não-sensibilidade à penicilina (sorotipos 14, 19F e 23F). Um total de 72 (35,1%) crianças foram diagnosticadas com pneumonia, sendo 39 (54,2%) menores de dois anos de idade. A taxa de colonização geral foi de 50,2%, não havendo diferença entre essas taxas quando se considerou o grupo de crianças confirmadas e suspeitas para pneumonia. Crianças na faixa etária de 36 a 47 meses formaram o grupo com maior risco de ter pneumonia bacteriana (OR: 3.17 [1.29-7.88]). Entre os sorotipos encontrados, o sorogrupo 6 (6A/6B) (17,3%) foi predominante, seguido dos sorotipos 14 (15,4%), 19F (10,6%), sorogrupo 15 (15B/15C) (9,6%), 23F (6,7%) e o sorotipo 19A (6,7%). Os demais sorotipos e sorogrupos compreenderam 33,7%. O padrão de sorotipos foi semelhante aqueles encontrados nos casos de meningite pneumocócica na cidade de Salvador. Um total de 41 isolados (39,8%) apresentaram CIM ≥ 0,125 μg/mL para penicilina e a resistência a SMX-TMP foi identificada em 69,2% dois isolados. A tipagem por PFGE identificou 11 padrões eletroforéticos, sendo que a maioria dos isolados do sorotipo 14 estavam relacionados a clones amplamente disseminados entre os casos de doença pneumocócica (“A” e “GK”). Um total de 50,5% dos isolados foram de sorotipos inclusos na vacina decavalente (PCV10) e considerando os isolados não-susceptíveis à penicilina, esta representatividade foi de 90,2%. O estudo ressalta a importância de um contínuo monitoramento do perfil de sorotipos na colonização nasofaringeana por S. pneumoniae, no período pós-vacina e da necessidade de busca.

The Difference in Clinical Presentations between Healthcare-Associated and Community-Acquired Pneumonia in University-Affiliated Hospital in Korea

PURPOSE: Healthcare-associated pneumonia (HCAP) has been proposed as a new category of pneumonia. However, epidemiological studies for HCAP in South Korea are limited. This study aimed to reveal the differences between HCAP and community-acquired pneumonia (CAP), especially in elderly patients, in university-affiliated hospital in South Korea. MATERIALS AND METHODS: We conducted a retrospective observational study of patients with HCAP and CAP (older than 60 years old) who were hospitalized between January 2007 and December 2008. We compared the baseline characteristics, comorbidities, severity, pathogen distribution, antibiotics, and clinical outcomes. RESULTS: A total of 210 patients were evaluated, including 35 patients with HCAP (17%) and 175 with CAP (83%). The most common causative organism was Streptococcus pneumoniae in CAP (33.3%), whereas, Staphylococcus aureus was most common pathogen in HCAP (40.0%). Initial inappropriate antibiotics (6.3% vs. 22.9%; p < 0.005) and initial treatment failure (15.4% vs. 31.4%; p = 0.018) were more frequent in HCAP than CAP. However, mortality (11.4% vs. 5.7%; p = 0.369) was not different between the two groups. CONCLUSION: The present study provides additional evidence that HCAP should be distinguished from CAP, even in elderly patients, in South Korea. Physicians should consider S. aureus and MDR pathogens in selecting initial empirical antibiotics of HCAP in South Korea.

Infección neumocóccica invasora y neumonía consolidante en lactantes: Un año de vigilancia en tres centros hospitalarios chilenos / Invasive pneumococcal disease and consolidated pneumonia in infants: One year of surveillance in three Chilean health care centers

Objetivo: Describir la frecuencia y tipo de enfermedad neumocóccica invasora (ENI) y neumonía consolidante (NC) en lactantes chilenos. Pacientes y Métodos: Vigilancia prospectiva durante un año en tres centros. Vigilancia de ENI: hemocultivo en lactantes con sospecha clínica de enfermedad bacteriana invasora (EBI) o fiebre > 39 °C axilar, sin foco o con otitis media aguda. Vigilancia de NC: hemocultivo y evaluación independiente de la radiografía en lactantes con sospecha clínica de neumonía. Resultados: ENI: en 4.369 lactantes enrolados se detectaron 58 casos de EBI, 37 (64 por ciento) por Streptococcus pneumoniae. Tasas de ENI: 110/100.000 (Chillan) y 288/100.000 (Valparaíso). Serotipos de S. pneumoniae identificados: 18C (n: 8), 14 (n: 8), 19A (n: 5), otros (n: 12). NC: en 3.005 niños enrolados se detectaron 762 NC. Tasas de NC: 2.918/ 100.000 (Chillan) y 5.547/100.000 (Valparaíso). Discusión: Se confirma la relevancia de S. pneumoniae como agente de EBI así como la elevada frecuencia de NC en lactantes en Chile.

Objective: To describe frequency and type of invasive pneumococcal diseases (IPD) and consolidated pneumonia (CP) in Chilean infants. Patients and Methods: One-year prospective surveillance in three health care centers. PID surveillance: blood culture in infants with suspected invasive bacterial disease or with fever higher than 39°C axillary without focus or with acute otitis media. CP surveillance: blood culture and independent evaluation of chest X-ray in infants with suspected pneumonia. Results: IPD: in 4,369 infants studied, 58 cases of invasive bacterial diseases were identified, 37 (64 percent) due to S. pneumoniae. Rates of IPD: 110/100,000 (Chilian) and 288/100,000 (Valparaiso). Serotypes identified: 18C(n: 8), 14 (n: 8), 19A(n: 5), others (n: 12). CP: in 3,005 infants 762 CP were detected. Rates of CP: 2,918/100,000 (Chilian) and 5,547/100,000 (Valparaiso). Discussion: Results support the relevance of S. pneumoniae as the main cause of invasive bacterial disease and the high frequency of CP in this age group in Chile.

Community-acquired pneumonia in the childhood: analysis of the diagnostic methods

Immunological assays such as CIE, LA, and Dot-ELISA were compared in order to diagnose community-acquired pneumonia. Serum, pleural fluid and urine samples were comparatively employed for bacterial antigen detection. Dot-ELISA proved to be an original and practical alternative procedure for detecting bacterial polysaccharide antigens from pleural fluid and/or concentrated urine samples, providing a rapid diagnosis for pediatric patients with community-acquired pneumonia.

Evaluation of a nested-PCR assay for Streptococcus pneumoniae detection in pediatric patients with community-acquired pneumonia / Evaluación de una PCR anidada en pacientes pediátricos para diagnóstico de neumonía neumocócica adquirida en la comunidad

The aim of the present work was to evaluate the usefulness of a simplified method for DNA extraction coupled to a nested-PCR protocol, based on the amplification of pneumolysin gene fragments for the diagnosis of pneumococcal pneumonia in pediatric patients with clinical and radiological evidence of bacterial infection. Bacterial DNA was extracted from sera by boiling and used without further purification in the PCR for the pneumolysin gene. None toxic reagents were used and the necessary steps to obtain the DNA were left at a minimum; furthermore, it overcomes the use of expensive commercial kits for DNA purification. The total procedure can be completed the same day of sampling and, most important, it avoids the use of sophisticated technology. Both in vitro analytical specificity and sensitivity (10 CFU/ml) of the assay were similar to those previously reported. When clinical samples were tested, the rate of positivity was shown to be 83.3% and 71% in pediatric patients with positive (group a) and negative blood cultures (group b), respectively. In group a, DNA detection was successful in samples from children without treatment or with less than 48 h of antibiotic therapy. None amplification was obtained from sera patients with viral infection or in samples from healthy controls. The application of the strategy described in this paper substantially seems to improve the diagnostic process in a determinate group: blood culture-negative children with pneumonia.

El objetivo del presente trabajo fue evaluar la utilidad de un método simplificado para extracción de ADN, acoplado a un protocolo de PCR anidada, basada en la amplificación de fragmentos del gen de la neumolisina para el diagnóstico de neumonía neumocócica en niños con evidencias clínicas y radiológicas de infección bacteriana. El ADN bacteriano fue extraído del suero por calentamiento y utilizado en la PCR para el gen de la neumolisina sin purificación posterior. Para la obtención de ADN no se utilizan reactivos tóxicos ni costosos "kits" comerciales. El procedimiento completo puede ser realizado en el día y lo que es más importante, evita el uso de tecnología sofisticada. La especificidad analítica in vitro y la sensibilidad (10 UFC/ml) del ensayo fueron similares a lo hallado en publicaciones anteriores. El porcentaje de muestras positivas fue del 83,3% y del 71% en los pacientes con hemocultivos positivos (grupo a) y negativos (grupo b), respectivamente. En el grupo a, sólo se obtuvieron resultados positivos mediante la PCR anidada en los pacientes no tratados o con menos de 48 hs de tratamiento antibiótico. No se obtuvieron señales de amplificación en los sueros de los pacientes con infecciones virales ni en las muestras del grupo control. La aplicación de la estrategia descripta incrementa la posibilidad diagnóstica de neumonía neumocócica en niños con hemocultivos negativos.

Complicaciones neurológicas de la infección por mycoplasma pneumoniae / Neurological complications related to mycoplasma pneumoniae infection

Las manifestaciones neurológicas asociadas a infecciones por M. Pneumoniae corresponden al 0,1 por ciento, siendo la encefalitis la manifestación más frecuente en los niños, que se caracteriza por presentar trastorno de conciencia, convulsiones y ocasionalmente ataxia y coreoatetosis, que regresan en forma espontánea, sin dejar secuelas en la gran mayoría de los casos. Sin embargo, existen algunos casos fatales.- Objetivo: Sensibilizar al pediatra general sobre esta patología y su oportuna derivación al especialista.- Caso clínico: Niño de 5 años que cursa con trastorno de conciencia, convulsiones, trastorno de la marcha, sin fiebre, concomitantemente con una neumonía lobar izquierda. IgM M. Pneumoniae, método Elisa rápido positivo. Tomografía axial computarizada cerebral normal. Se realiza tratamiento con anticonvulsivante endovenoso por 48 h., continuando con ácido valproico oral, el que se suspende luego de una semana, al obtener EEG normal. Se completa tratamiento con macrólido por 14 días resolviéndose la neumonía. Evoluciona con ataxia y trastorno del lenguaje, que se normalizan en el trascurso de una semana, sin repetir crisis convulsiva.- Conclusión: Se presenta este caso debido a la infrecuencia de esta complicación neurológica en niños e infecciones respiratorias por M. Pneumoniae, cuya causa aún se discute, siendo la teoría autoinmunitaria la más aceptada actualmente.

Meningitis and pneumonia in Guatemalan children: the importance of Haemophilus influenzae type b and Streptococcus pneumoniae

OBJECTIVE: To determine the epidemiology of Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae invasive infections in hospitalized Guatemalan children. This is an important issue since Hib vaccine has not been incorporated into the routine immunization program in Guatemala and information from hospital records in 1995 indicated a low incidence of Hib and S. pneumoniae as causes of meningitis and invasive infections. METHODS: Children who were hospitalized in Guatemala City with clinical signs compatible with bacterial infections were evaluated for evidence of Hib or S. pneumoniae infection. Normally sterile body fluids were cultured, and antigen detection was performed on cerebrospinal fluid (CSF) and pleural fluid. RESULTS: Of 1 203 children 1-59 months of age hospitalized over a 28-month period, 725 of them (60.3 percent) had a primary diagnosis of pneumonia, 357 (29.7 percent) of meningitis, 60 (5.0 percent) of cellulitis, and 61 (5.1 percent) of sepsis and other conditions. Hib was identified in 20.0 percent of children with meningitis and S. pneumoniae in 12.9 percent. The average annual incidence of Hib meningitis was 13.8 cases per 100 000 children under 5 years of age, and 32.4 percent of meningitides caused by Hib and 58.7 percent of S. pneumoniae meningitides occurred prior to 6 months of age. Case fatality rates were 14.1 percent, 37.0 percent, and 18.0 percent, respectively, for children with Hib, S. pneumoniae, and culture-negative and antigen-negative meningitis. Prior antibiotic therapy was common and was associated with significant reductions in CSF-culture-positive results for children with other evidence of Hib or S. pneumoniae meningitis. CONCLUSIONS: Improvements in case detection, culture methods, and latex agglutination for antigen detection in CSF resulted in identification of Hib and S. pneumoniae as important causes of severe disease in Guatemalan children. Using a cutoff of > 10 white blood cells per cubic millimeter in CSF would improve the sensitivity for detection of bacterial meningitis and help estimate the burden of bacterial meningitis in Guatemala and other developing countries.

Neumonía bacteriana adquirida en la comunidad en niños hospitalizados / Community-acquired bacterial pneumonia in hospitalized children

Introducción: la neumonía bacteriana es causa frecuente de internación en pediatría. En Uruguay se utiliza, desde 1997, una pauta de tratamiento adaptada a la realidad epidemiológica. Objetivos: describir las características clínicas, radiológicas y etiológicas de los niños ingresados con diagnóstico de neumonía bacteriana adquirida en la comunidad y evaluar el cumplimiento y vigencia de la pauta de tratamiento con penicilina y derivados y/o macrólidos. Método: entre el 19 de mayo de 1999 y el 18 de mayo de 2000 se estudiaron en forma prospectiva los niños, entre un mes y 14 años de edad, ingresados con diagnóstico de neumonía bacteriana adquirida en la comunidad al Centro Hospitalario Pereira Rossell. Se realizó al ingreso radiografía de tórax, hemocultivo y estudio del líquido pleural cuando correspondió. Se trataron de acuerdo a la pauta. Resultados: se incluyeron 697 niños (7,7 por ciento del total de egresos del período). Predominaron los menores de cinco años. La radiografía de tórax mostró bloque de consolidación homogénea en 95 por ciento. Se confirmó la causa bacteriana en 77 niños, 76 correspondieron a S. pneumoniae, predominaron los serotipos 5, 14 y 1; las cuatro cepas resistentes a penicilina (CIM mayor igual 2 @g/ml) correspondieron al serotipo 14. El 16 por ciento de los niños presentó empiema. El 93 por ciento de los pacientes se trató según la pauta. Fallecieron ocho niños; en cuatro se identificó S.pneumoniae no resistente a penicilina. Conclusiones: la pauta de tratamiento mantiene su vigencia. Se necesitan estudios para identificar factores de riesgo de empiema. Para disminuir la morbimortalidad por neumonía se requiere reforzar las acciones en el primer nivel de atención y conocer los serotipos de S.pneumoniae prevalentes con vistas a la posible aplicación de una vacuna.

Invasive pneumococcal infection and drug-resistant Streptococcus pneumoniae in Thai children.

Sixty-eight children with systemic Streptococcus pneumoniae infection were identified by hospital chart review between 1986-1997. The age distribution varied from 2 days to 15 years, with a mean age of 3.3 years. There were 35 boys and 33 girls. Four clinical entities included 30 cases of meningitis, 20 cases of pneumonia, 10 cases of peritonitis and 8 cases of septicemia/bacteremia. Forty patients (58.8%) had underlying diseases. Seventeen patients (25.0%) developed early complications and the mortality rate was 8.8 per cent. The percentage of susceptible isolates to penicillin, chloramphenicol, cefotaxime/ceftriaxone, ciprofloxacin, imipenem and vancomycin were 69.6, 91.3, 100.0, 87.2, 100.0 and 97.1 per cent, respectively. There were six cases of drug-resistant S. pneumoniae (DRSP) infection; 3 cases of meningitis, one case of pneumonia, one case of infective endocarditis and one case of purpura fulminans. Our data indicate that S. pneumoniae infection is relatively serious and life-threatening. There is a trend of increasing prevalence of invasive pneumococcal and DRSP infections.

Community acquired Pneumonia among pediatric outpatients in Salvador, northeast Brazil, with emphasis on the role of pneumococcus

Pneumonia is one of the leading causes of hospitalization and death among children in developing counties,, and mortality due to pneumoniae has been associated with S. pneumoniae infection. This investigation was designed to describe the antimicrobial susceptibility and serotype patterns of pneumococcal strains recovered from the blood of children with community-acquired pneumonia (CAP) and to acess the clinical findings of pneumococcal bacteremic patients with pneumonia. In a 26 month prospective study, blood cultures were obtained as often as possible from children(<16 years of age) diagnosed with CAP in two emergency rooms. Antimicrobial drug susceptibility tests and serotyping were performed when pneumococcus was identified. We studied 3,431 cases and cultured blood samples from 65.5 percent of those. Pneumococcus was recovered from 0.8 percent of the blood samples. The differences in age, somnolence, wheezing and hospitalization among children with and without pneumococcal bacteremia were statistically significant. Pneumococcal bacteremia was age-related (mean 1.63 +1.55; median 0.92) and associated with somnolence and hospitalization among children with CAP. One strain was recovered from pleural fluid. Penicillin resistance was detected in 21.0 percent(4/19) of the strains at an intermediate level, whereas 63.0 percent of the strains were resistant to trimethoprim-sulfamethoxazole. The most common serotypes were 14 and 6B, and these serotypes included the resistant strains. Eight of our 18 isolates from blood were of types included in the heptavalent conjugate pneumococcal vaccine, recently licensed in the USA.

Detection of antipneumolysin in invasive childhood pneumococcal infections.

Antibody levels against pneumolysin, a virulence factor in pneumococcal infections were evaluated by a neutralization test, using crude pneumolysin. A study population of 28 hospitalised children with culture proven pneumococcal meningitis and pneumonia were tested for detection of antipneumolysin antibodies in their serum. Results were compared with age and sex matched controls who were admitted with infections other than pneumococcal. Geometric mean titer (GMT) of antipneumolysin in serum of patients with pneumococcal infections showed a significant difference when compared with controls, GMT of 196.1 and 185.2 were noted in patients with meningitis and pneumonia respectively, in contrast to a titer of 40.32 among controls. A difference of more than 4-fold antibody titers between patients and controls was considered significant. Detection of antipneumolysin in serum can therefore be considered as a useful laboratory investigation in diagnosing invasive pneumococcal infections.