Una regla de predicción clínica ¿anticipa el diagnóstico de la faringitis estreptocóccica en niños de 2 a 15 años? / Does a clinical prediction rule anticipate the diagnosis for streptococcal pharyngitis in children aged 2 to 15?

Resumen Introducción: La etiología estreptocóccica de una faringitis debe ser confirmada con métodos de laboratorio para evitar un sobre-tratamiento antimicrobiano, exámenes que agregan costo a la atención del paciente. Los scores diseñados para aplicar en niños y adultos son imperfectos. Objetivo: Desarrollar una regla de predicción clínica para contribuir al diagnóstico de la faringitis estreptocóccica (FE) en niños. Pacientes y Métodos: Se incluyeron 318 pacientes de 2 a 15 años que fueron evaluados por sospecha de FE en el Servicio de Urgencias Pediátricas y la Unidad de Pediatría Ambulatoria de la Red Salud UC-Christus. Se obtuvo un cultivo faríngeo y una prueba rápida de detección de antígeno para Streptococcus pyogenes de cada paciente. Los datos se analizaron para posibles predictores clínicos de FE con análisis de regresión múltiple. Resultados. Setenta y tres casos de FE fueron diagnosticados (23,9%). En el análisis univariado, la fiebre se asoció inversamente con FE (p = 0,002). La odinofagia, las petequias palatinas y la estación del año (otoño e invierno) se asociaron positivamente con FE (p = 0,007, p < 0,001 y p = 0,03 respectivamente). En el análisis de regresión múltiple, los modelos no tuvieron suficiente poder para predecir etiología por S. pyogenes. Conclusión: Los predictores clínicos analizados, incluso los incluidos sistemáticamente en reglas de predicción clínica, no mostraron suficiente poder predictor para incluir o excluir de forma segura la FE en este contexto y, por lo tanto, sería necesario mejorar el acceso a las pruebas de confirmación.

Background: The etiology of a streptococcal pharyngitis must be documented by laboratory techniques to avoid unnecessary antimicrobial treatment, but this strategy increases cost for the patient. Available scores applied in children or adults are imperfect. Aim: To develop a clinical prediction rule to aid the diagnostic process of streptococcal pharyngitis (SP) in children in a low-resource setting. Methods: Three hundred and eighteen patients aged 2 to 15 years who were evaluated for suspected SP at the Pediatric Emergency Department and the Pediatric Ambulatory Unit of Red Salud UC-Christus entered the study. A throat culture and a rapid antigen detection test for Streptococcus pyogenes were obtained from each patient. Data were analyzed for possible clinical predictors of SP with univariate and multiple regression analyses. Results: Seventy-three cases of SP were diagnosed (23.9%). In the univariate analysis, fever was inversely associated with SP (p = 0.002). Odynophagia, palatal petechiae, and season of the year (autumn and winter) were positively associated with SP (p = 0.007, p < 0.001 and p = 0.03 respectively). In multiple regression analysis the models did not have sufficient power to predict streptococcal etiology. Conclusion: Clinical predictors, even those systematically included in clinical prediction rules, did not show sufficient predictive power to safely include or exclude SP in this setting, and thus, it is necessary to improve access to confirmatory tests.

Niños y adolescentes con necesidades especiales de atención en salud: prevalencia hospitalaria y riesgos asociados / Children with special health care needs: prevalence in a pediatric hospital and associated

Background: "Children with special health care needs" (CSHCN) is a novel definition for pediatric patients with chronic diseases, adopted by the Chilean Pediatric Society in 2008. As life expectancy in Chile increases, prevalence of CSHCN is progressively growing, leading to higher health costs. Aim: To describe the epide-miological profile and clinical characteristics of hospitalized CSHCN, and compare the risk assessment of adverse events during hospitalization using two definitions for CSHCN. Patients and Methods: A cohort of hospitalized CSHCN in a Pediatric Center at Santiago, Chile, was followed from September to December 2009. Clinical and demographic data were registered in a database, including admission to intensive care unit (ICU), nosocomial infections and prolonged hospitalization (> 7 days). Incidence ratios for these events were compared between CSHCN and non-CSHCN, and between children attended by three or more health care professionals (CSHCN-3) and non-CSHCN. Results: Nine hundred twenty patients were included (54% male), with a median age 14 months (0-221) and median days of hospitalization 4 days (1-229). Prevalence of CSHCN was 60.8% of hospitalized children. When using CSHCN definition and comparing with non-CSHCN, no excess of risk was documented. On the other hand, prevalence of CSHCN-3 was 19.9%. Compared to non-CSHCN, these patients had a higher risk of ICU admission (relative risk (RR) 1.58; 95% confidence intervals (CI) = 1.22-2.05; p < 0.01), nosocomial infections (RR 2.28; 95% CI = 1.54-3.39; p < 0.001) and prolonged hospitalization (RR 1.99; 95% CI = 1.52-2.60; p < 0.001). Conclusions: One in five hospitalized children met CSHCN-3 definition. These patients had an increased risk of adverse events during their hospitalization compared to non-CSHCN.