Usefulness of C-Reactive Protein and Clinical Characteristics in Identifying Severe Bacterial Infection in Children with Fever without Source.

OBJECTIVE: Fever continues to be the most frequent cause of care in the pediatric population. The uses of invasive and unnecessary tests result in discomfort to the patients. Local epidemiological data could help to refine screening strategies, especially in low resources settings. The present study aims to describe the prevalence of serious bacterial infections in infants with fever without source and to evaluate the usefulness of clinical and laboratory parameters in the identification of serious bacterial infections. MATERIALS AND METHODS: We included all children aged 0-36 months presenting with fever without source between January 2015 and December 2017. Demographic and clinical characteristics, investigations, and management procedures were recorded at the time of inclusion. Potential predictors of serious bacterial infections were compared between patients with and without serious bacterial infections. RESULTS: In total, 137 patients were included. Serious bacterial infections were diagnosed in 41 patients (29.9%; 95% CI, 22%-38%). The most frequent diagnosis in serious bacterial infection patients was urinary tract infection (78%). Serum C-reactive protein levels greater than 80 mg/L (odds ratio, 2.79 [1.14,6.86]) and total days with fever (odds ratio, 2.56 [1.81,3.62]) showed a significant association to predict serious bacterial infections. CONCLUSION: Most infants with fever without source presented self-limited febrile syndromes without evidence of severe bacterial infection. C-reactive protein levels greater than 80 mg/L and the number of previous days with fever were variables associated with the presence of serious bacterial infections. Our results need to be validated in other tropical countries.

[Cost-effectiveness of an alternative tuberculosis treatment: home-based guardian monitoring of patients]. / Costo-efectividad de un tratamiento antituberculoso alternativo: seguimiento a convivientes residenciales de los pacientes.

OBJECTIVE: Estimate the cost-effectiveness ratio of the directly observed treatment short course (DOTS) for treatment of tuberculosis (TB), comparing it to a variation of this treatment that includes increased home-based guardian monitoring of patients (DOTS-R). METHODS: Taking a social perspective that includes the costs for the health institutions, the patients, and their family members, and for other entities that contribute to making operation of the program effective, the costs incurred with each of the two strategies were evaluated and the cost-effectiveness ratios were estimated adopting the measures of effect used by the control programs. The estimate of the cost of each of the two strategies includes the cost to the health institutions that administer treatment, the patients and their family members, and the cost to the Ministry of Health that manages public health programs on the municipal level. Based on these costs and the number of cases cured and treatments completed as outcome measures of each of the strategies evaluated, the cost-effectiveness ratio and incremental cost were calculated. RESULTS: The DOTS-R was found to be more cost-effective for achievement of successful treatments than the DOTS. The DOTS-R recorded costs of US$ 1 122.40 to US$ 1 152.70 for each case cured compared to values of US$ 1 137.00 to US$ 1 494.30 for the DOTS. The percentage of cases treated successfully was higher with DOTS-R than with DOTS. CONCLUSIONS: The DOTS-R is a promising cost-effective alternative for improved control of TB in endemic areas. It is recommended that the health authorities include home-based guardian monitoring of patients in their institutional management of the TB program, with the participation of health workers and the physical and financial resources that currently support this program.

Costo-efectividad de un tratamiento antituberculoso alternativo: seguimiento a convivientes residenciales de los pacientes / Cost-effectiveness of an alternative tuberculosis treatment: home-based guardian monitoring of patients

Objetivo. Estimar la relación de costo-efectividad del tratamiento de corta duración bajoobservación directa (DOTS), comparándolo con una variación de dicho tratamiento, que incluyeun mayor seguimiento a los convivientes residenciales de los pacientes (DOTS-R) parael tratamiento de tuberculosis (TB).Métodos. Tomando una perspectiva social que incluye los costos para las institucionesde salud, para los pacientes y sus familiares, y para otras entidades que contribuyen a hacerefectiva la operación del programa, se evaluaron los costos incurridos con cada una de las dosestrategias y se estimaron razones costo-efectividad adoptando las medidas de efecto usadas porlos programas de control. La estimación de los costos de cada una de las dos estrategias incluyelos correspondientes a las instituciones de salud que administran el tratamiento, los pacientesy sus familiares, y los de la secretaría de salud que gestiona los programas de salud pública anivel municipal. Con base en estos costos y el número de casos curados y tratamientos terminadoscomo medidas de resultado de cada una de las estrategias evaluadas, se calcularon lasrazones costo-efectividad y costo incremental.Resultados. El DOTS-R se halló más costo-efectivo para lograr tratamientos exitosos queel DOTS. El DOTS-R registró costos de entre US$ 1 122,4 y US$ 1 152,7 por caso curado,comparados con valores de entre US$ 1 137,0 y US$ 1 494,3 correspondientes al DOTS. Laproporción de casos tratados con éxito fue mayor con DOTS-R que con DOTS.Conclusiones. El DOTS-R es una alternativa costo-efectiva promisoria para mejorar elcontrol de la TB en sitios endémicos. Se recomienda a las autoridades del sector salud incorporaren su gestión institucional del programa contra la TB, acciones de seguimiento de losconvivientes de pacientes, con la participación del personal de salud y los recursos físicos yfinancieros que apoyan actualmente dicho programa.

Objective. Estimate the cost-effectiveness ratio of the directly observed treatmentshort course (DOTS) for treatment of tuberculosis (TB), comparing it to a variation ofthis treatment that includes increased home-based guardian monitoring of patients(DOTS-R).Methods. Taking a social perspective that includes the costs for the healthinstitutions, the patients, and their family members, and for other entities thatcontribute to making operation of the program effective, the costs incurred with eachof the two strategies were evaluated and the cost-effectiveness ratios were estimatedadopting the measures of effect used by the control programs. The estimate of the costof each of the two strategies includes the cost to the health institutions that administertreatment, the patients and their family members, and the cost to the Ministry ofHealth that manages public health programs on the municipal level. Based on thesecosts and the number of cases cured and treatments completed as outcome measuresof each of the strategies evaluated, the cost-effectiveness ratio and incremental costwere calculated.Results. The DOTS-R was found to be more cost-effective for achievement ofsuccessful treatments than the DOTS. The DOTS-R recorded costs of US$ 1 122.40 toUS$ 1 152.70 for each case cured compared to values of US$ 1 137.00 to US$ 1 494.30for the DOTS. The percentage of cases treated successfully was higher with DOTS-Rthan with DOTS.Conclusions. The DOTS-R is a promising cost-effective alternative for improvedcontrol of TB in endemic areas. It is recommended that the health authorities includehome-based guardian monitoring of patients in their institutional management of theTB program, with the participation of health workers and the physical and financialresources that currently support this program.

Tratamiento para la infección latente por tuberculosis en niños: recomendaciones internacionales y para Colombia / Latent Tuberculosis Infection Treatment in Children: international recommendation and to Colombia

Mediante una revisión narrativa de la literatura, se pretende discutir las recomendaciones vigentes para Colombia con relación al tratamiento para infección latente por tuberculosis (LTBI: latent tuberculosis infection), según las guías y hallazgos internacionales. Los niños menores de 5 años en contacto con pacientes con tuberculosis (TB) pulmonar bacilífera tienen un riesgo mayor de desarrollar TB. El tratamiento con isoniazida ha demostrado disminuir este riesgo y está indicado durante al menos 6 meses. Las guías para el tratamiento de LTBI de la Organización Mundial de la Salud y los Centros para el Control y la Prevención de Enfermedades indican tratamiento a menores de 5 años en contacto con pacientes con TB pulmonar bacilífera, una vez se ha descartado TB activa, independientemente del estado de vacunación con bacilo de Calmette-Guérin. La norma colombiana considera, además de la vacuna bacilo de Calmette- Guérin, el resultado de la prueba de tuberculina. Existe el temor de la posible generación de cepas resistentes de Mycobacterium tuberculosis por el uso de monoterapia. Se recomienda el seguimiento estricto durante el tratamiento para mitigar la aparición de efectos adversos y de cepas resistentes. Los menores de 5 años en contacto con pacientes con TB pulmonar bacilífera en Colombia deberían recibir tratamiento para LTBI con isoniazida, según los estándares internacionales de diagnóstico de la TB activa, y seguimiento del tratamiento para LTBI.

By mean a narrative review of literature, it is pretended to discuss the actual Colombian recommendations in relation with latent tuberculosis infection (LTBI) treatment, according to international guidelines and findings. Children under 5 years old in contact with pulmonary tuberculosis (TB) patients have a greater risk to develop tuberculosis. Isoniazid treatment had demonstrated to diminish that risk, and it is indicated for at least 6 months. The WHO and CDC guidelines for LTBI treatment indicate treatment to under 5 years old children in contact with bacilliferous pulmonary TB patients, once has been discarded active TB, regardless the BCG vaccination state. The Colombian policy consider besides the vaccine BCG, the result of the tuberculin skin test. There is an pprehensiveness about the possibility of resistant strain generation of M. tuberculosis due to monotherapy use. During the treatment, it is recommended the strict follow-up, to mitigate the adverse effects and resistant strain appearance. Children under 5 years old in contact with bacilliferous pulmonary TB patients in Colombia should receive LTBI treatment with isoniazid under the international diagnosis standards of active TB and follow-up to the LTBI treatment.