Antimicrobial treatment of diarrhea/acute gastroenteritis in children.

Acute gastroenteritis (AGE) are usually caused by viruses, especially Rotavirus and Norovirus. Among the bacterial causes, very few warrant antibiotic treatment, mainly Shigella, Vibrio cholerae, Campylobacter (only for severe cases, particularly in the initial phase) and severe cases of Salmonella infection. The antimicrobial treatments proposed in this guide follow the latest guidelines of the European Society of Pediatric Infectious Diseases and the European Society of Pediatric Gastroenterology and Nutrition. Azithromycin is the preferred antibiotic for infections due to Shigella and Campylobacter. Ceftriaxone and ciprofloxacin are recommended for salmonellosis when antibiotic treatment is indicated. In most cases, empirical treatment without bacteriological documentation should be avoided.

Clinical severity and molecular characteristics of circulating and emerging rotaviruses in young children attending hospital emergency departments in France.

Group A rotavirus (RVA) is the leading cause of acute gastroenteritis in young children worldwide. A prospective surveillance network has been set up to investigate the virological and clinical features of RVA infections and to detect the emergence of potentially epidemic strains in France. From 2009 to 2014, RVA-positive stool samples were collected from 4800 children <5 years old attending the paediatric emergency units of 16 large hospitals. Rotaviruses were then genotyped by RT-PCR with regard to their outer capsid proteins VP4 and VP7. Genotyping of 4708 RVA showed that G1P[8] strains (62.2%) were predominant. The incidence of G9P[8] (11.5%), G3P[8] (10.4%) and G2P[4] (6.6%) strains varied considerably, whereas G4P[8] (2.7%) strains were circulating mostly locally. Of note, G12P[8] (1.6%) strains emerged during the seasons 2011-12 and 2012-13 with 4.1% and 3.0% prevalence, respectively. Overall, 40 possible zoonotic reassortants, such as G6 (33.3%) and G8 (15.4%) strains, were detected, and were mostly associated with P[6] (67.5%). Analysis of clinical records of 624 hospitalized children and severity scores from 282 of them showed no difference in clinical manifestations or severity in relation to the genotype. The relative stability of RVA genotypes currently co-circulating and the large predominance of P[8] type strains may ensure vaccine effectiveness in France. The surveillance will continue to monitor the emergence of new reassortants that might not respond to current vaccines, all the more so as all genotypes can cause severe infections in infants.

[Safety of oral ivermectin in children]. / Tolérance de l'ivermectine orale chez l'enfant.

Ivermectin is an antiparasitic drug, a derivate of avermectins, and a product of fermentation of an actinomycete, Streptomyces avermitilis. Its structure associates two avermectins. Ivermectin acts on the chloride-dependent channels of both glutamate and γ-aminobutyric acid, interrupting neurotransmission in invertebrates. In humans, several mechanisms of brain protection exist, including P-glycoprotein, present on the apical face of endothelial cells of the blood-brain barrier and coded by the MDR1 gene. Ivermectin is presently used in mass treatment of onchocerciasis, other filariasis, some intestinal nematode infections, but also in scabies, and more rarely in resistant head lice. The side effects described are related to the release of antigen and cause an inflammatory reaction. Studies conducted in children or infants have shown good tolerance of ivermectin. However, its use in infants who weigh less than 15kg is a problem because of the absence of marketing authorization for this age group. However, the risk of excessive and uncontrolled use in head lice requires close surveillance.

Markers of a recent bocavirus infection in children with Kawasaki disease: "a year prospective study".

BACKGROUND: Retrospective studies and case-reports have suggested the possible role of various viruses in the pathogenesis of the Kawasaki disease. OBJECTIVES: To determine prospectively the incidence of Kawasaki diseases associated with a recent bocavirus infection in the course of a year. STUDY DESIGN: Thirty-two children with Kawasaki disease were enrolled in a 13 months prospective study to assess the frequency of human bocavirus type 1 infections. Seasonal shedding of virus, markers of recent infection such as viraemia, viral load, and serum interferon alpha were analyzed. RESULTS: Three of 32 (9%) children had HBoV-DNA in the serum suggesting a recent infection. HBoV-DNA was detected in naso-pharyngeal aspiration of 7/32 (21.8%) children with Kawasaki Disease and six of them (18%) had an increased viral load. No common respiratory viruses were isolated from the 32 patients with the exception of one adenovirus. The seven bocaviruses were identified during the winter-spring season. In addition, 4 of 7 of Kawasaki disease patients shedding bocavirus had detectable interferon alpha in the blood, indicating a possible active or recent viral infection. CONCLUSIONS: This study shows that a recent bocavirus infection is concomitant with the onset of some cases of Kawasaki disease. Bocavirus may be a cofactor in the pathogenesis of this disease as previously reported for other infectious agents.

Impact of travel on the seroprevalence of hepatitis A in children.

BACKGROUND: Recent data about hepatitis A virus (HAV) seroprevalence in industrialized countries and the impact of travels to endemic areas are sparse or absent, particularly for children. OBJECTIVE: To determine the impact of travel to endemic areas on HAV seroprevalence and estimate the overall HAV seroprevalence in children in France. To identify risk factors for positive HAV serologic results. STUDY DESIGN: This prospective multicentre cross-sectional seroprevalence study took place in eight paediatric emergency units throughout France. Children 1-16 years of age following all inclusion and exclusion criteria were included. Demographic, socioeconomic, and travel data were prospectively collected with a standardized questionnaire before measurement of specific HAV antibodies. HAV seroprevalence was determined and its association with diverse variables assessed by univariate and multivariate analyses. RESULTS: 430 children were included, of whom 116 had travelled to endemic areas. The HAV seroprevalence in the overall population was 5% (95%CI, 3-7) and was higher among the travellers (12% [95%CI, 6-18]) than among the others (2% [95%CI, 0-3]), OR=7.0 [95%CI, 2.6-18.8]. Risk factors identified for positive serologic results for HAV were travel to an endemic area >7 days (adjusted OR [aOR]=4.3 [95%CI, 1.5-12]), age of 14-16 years (aOR=7.7 [95%CI, 1.6-38.3]) and mother's birth in an endemic area (aOR=5.2 [95%CI, 1.8-14.8]). CONCLUSION: Statistical evidence showed that travel to endemic areas and parents' place of birth both play a role in HAV serologic results in children with a significant difference of HAV seroprevalence between traveller and non-traveller children in France.

[Counsel for traveling children]. / Conseils pour enfants voyageurs.

Consultation of child traveler has two main objectives: to assess of health risk related to the child's health status and history and also the risk related to travel environment; to counsel and prescribe preventive measure to reduce these travel health risks. The evaluation is based on physical examination and a detailed interview including personal history and information regarding the regions of proposed travel. Up to date knowledge of the epidemiology of visited sites, preventive measures and presumptive treatment is required. Essential health recommendations include, in case of exposure, prevention of malaria, arthropod borned diseases and vaccine preventable diseases. For all destinations advice regarding prevention of diarrhea, accident risks and aggravation of preexisting chronic diseases is needed. Universal primary prevention counselling is valuable for all travellers regardless of their age. In the case of children, special attention must be given to food and water hygiene, sun and heat exposure, swimming risks and transports security measures. Evaluation of risk and health education take time and often several visits are needed to complete the immunization schedule before departure.

[Escherichia coli, a pathogen under fire from the news]. / Escherichia coli, un pathogène sous les feux des projecteurs.

Escherichia coli is both a gastrointestinal tract commensal and a major pathogen. In recent years, E. coli is under fire from the news due to a better understanding of pathogenic factors, outbreaks of infections caused by enterohaemorrhagic strains, and last but not least, the worrying development of antibiotic resistance. Due to the absence of new compounds active against these strains, producing extended-spectrum ß-lactamases (ESBL) and frequently multiresistant to other antibiotics, their emergence will pose therapeutic problems for practitioners of all pediatric specialties. The gold standard treatment for severe infections due to ESBL-E. coli family is the penem class. The frequent use of penems promotes the emergence of strains resistant to carbapenems. Sparing carbapenems should be a clear objective for non life-threatening infections.

[Anti-meningococcal vaccines: diversity of vaccination policies and recommendations]. / Vaccins anti-méningococciques: des politiques vaccinales et des recommandations hétérogènes.

In European Country, Canada, Australia and Brazil immunization program with conjugate meningococcal C, including universal vaccination of infants or toddlers, with a catch-up program up to 19 y in several areas, have been successful in reducing disease incidence through direct and indirect protection. In USA, quadrivalent conjugate vaccines targeting serogroups ACYW135 are used in programs of adolescent immunization at 10 and 15 years because serotype Y is frequent. A mass immunization campaign against serogroupe A disease with a conjugate vaccine is beginning in African belt of meningitis. Polysaccharide vaccines A, C or ACYW135 are used in travelers but quadrivalent conjugate vaccine, with larger targets, gives higher titers after booster and must be preferred. Some questions are pending: immunize before or after one year of age, a booster dose in adolescence and the routine use of quadrivalent conjugate vaccine in Europe if the incidence of serotype Y is growing.

[Pneumococci isolated from vaccinated children with pneumonia]. / Pneumocoques isolés dans les pneumonies d'enfants vaccinés.

Among 76 children fully vaccinated with 7-valent conjugate vaccine and subsequently hospitalized from 2006 to 2009 for community-acquired pneumonia, isolated or with empyema or pleuritis, 10 had confirmed pneumococcal infections. All pneumococci isolated with blood or pleural culture were non vaccine serotypes (1, 5, 7F, and 19A). The proportion of pneumococcal pneumonias was similar to that in two series from the same hospital before the vaccine era. These data show that the 13-valent conjugate vaccine could be useful in prevention of community-acquired pneumonia and that bacteriologic survey of community-acquired pneumonia remains necessary.

[Anti-hepatitis A virus seropositivity in children of immigrant parents living in France and vaccination recommendations]. / Séroprévalence de l'hépatite A chez les enfants issus de familles immigrées vivant en France et conséquences pour la vaccination.

The hepatitis A-seropositivity rate for children born in France is very low: 0 of 81 born to two French-born parents and 5 of 126 (4 %) infants for whom at least one parent was born in an endemic area. In contrast, the rate was high (28.8 %, 17/59) for children born in an endemic area. Hence, recommendations to vaccinate children who could be exposed during overseas trips to visit family or by visiting family members coming from endemic areas are fully justified.

Epidemiology and clinical features of gastroenteritis in hospitalised children: prospective survey during a 2-year period in a Parisian hospital, France.

Rotavirus is recognised as the most important agent of severe acute gastroenteritis (AGE) in young children. In a 2-year prospective survey, we investigated the epidemiology and clinical features of the viral and bacterial pathogens in children hospitalised for AGE. The study was performed in a Parisian teaching hospital from November 2001 to May 2004. Clinical data were prospectively collected to assess the gastroenteritis severity (20-point Vesikari severity score, the need for intravenous rehydration, duration of hospitalisation). Stools were systematically tested for group A rotavirus, norovirus, astrovirus and adenovirus 40/41, sapovirus and Aichi virus and enteropathogenic bacteria. A total of 457 children (mean age 15.9 months) were enrolled. Viruses were detected in 305 cases (66.7%) and bacteria in 31 cases (6.8%). Rotaviruses were the most frequent pathogen (48.8%), followed by noroviruses (8.3%) and adenoviruses, astroviruses, Aichi viruses and sapoviruses in 3.5%, 1.5%, 0.9% and 0.4%, respectively. Cases of rotavirus gastroenteritis were significantly more severe than those of norovirus with respect to the Vesikari score, duration of hospitalisation and the need for intravenous rehydration. Rotaviruses were the most frequent and most severe cause in children hospitalised for AGE, and noroviruses also account for a large number of cases in this population.

[Epidemics of gastroenteritis caused by norovirus in Parisian children]. / Épidémies parisiennes de gastro-entérites à norovirus.

During the months of October and November 2006-2008, norovirus was detected in the stools of 14 children hospitalized with acute diarrhea (no sapovirus). Nine of these noroviruses belonged to a unique GGII4 strain, which produced severe clinical symptoms, present only in 2007 and 2008 and absent in 2006. This strain, identified in Europe mainly in the elderly, seems to be on the rise in children in the Paris area over the past few years.

[Pneumococcal pneumonia highly probable in immunized children cared for in-group settings]. / Pneumonies à pneumocoque hautement probables chez les enfants vaccinés gardés en collectivité.

Invasive pneumococcal diseases were reduced after introduction of pneumococcal conjugate vaccine, but infections due to non-vaccine serotypes persisted. The pneumococcal origin of community-acquired pneumonia remains difficult to affirm, but high procalcitonin and C-reactive protein blood levels and duration of fever 48 h or less after initial antibiotic treatment are excellent predictors of pneumococci. Among 259 patients under 7 years of age hospitalized from 2003 to 2008 for community-acquired pneumonia, 47 met these criteria, including 27 of 141 hospitalized between 2006 (date of vaccine generalization) and 2008. Of these 27, 21 had previously received pneumococcal conjugate vaccine and 19 of 21 were attendees of nursery school or day care centers versus only 2 in 2003-2006. These data show that pneumococcal pneumonias are possible in immunized children cared for in-group settings.

[Imported malaria: diagnostic traps and rapid tests]. / Paludisme d'importation: pièges diagnostiques et tests de diagnostic rapide.

Imported malaria is a disease prevalent in France: 6,000 to 8,000 cases a year, of which 15% are pediatric cases. Despite this high incidence, the diagnosis is often delayed. The patient may then evolve to a severe form. This diagnostic delay is due to non-specific clinical symptoms in children. The most common symptoms are fever and digestive disorders (diarrhea, vomiting). In the absence of thrombocytopenia, the laboratory tests are not very useful for diagnosis. Parasitological examinations are dependent on the experience of the biologist, particularly in cases of low parasitemia as those observed in children who have received partial chemoprophylaxis. The recent introduction of rapid tests based on the detection of Plasmodium proteins, allows emergency remedy to this problem. The blood smears remains the gold standard and has to be used to confirm the results of rapid tests. If rapid tests improve the detection of Plasmodium in 2009, it remains mandatory to evoke the diagnosis of malaria in any febrile child coming from an endemic area.

Knowledge, attitudes and vaccination coverage of healthcare workers regarding occupational vaccinations.

OBJECTIVES: Immunization of healthcare workers (HCWs) is a major issue for infection control in healthcare facilities. The aim of this study was to evaluate knowledge regarding occupational vaccinations, HBV, varicella and influenza vaccination rates and attitudes towards influenza vaccine among HCWs. DESIGN AND SETTING: A cross-sectional survey was conducted in two wards (Medicine and Paediatrics) of a 1182-bed teaching hospital in Paris, France. METHODS: A standardized, anonymous, self-administered questionnaire was used. RESULTS: Of 580 HCWs, 395 (68%) completed the questionnaire. Knowledge about the occupational vaccinations of HCWs was low. HBV (69%), tuberculosis (54%) and influenza (52%) were the most cited vaccinations. Paediatric staff was more aware of influenza and pertussis immunizations (p<.05). HBV vaccination rate was 93%, among whom 65% were aware of their immune status. Influenza vaccination rate for 2006-2007 was 30% overall, ranging from 50% among physicians to 20% among paramedical staff (p<.05). Physicians based their refusal on doubts about vaccine efficacy, although paramedics feared side effects. Influenza vaccination was associated with knowledge of vaccine recommendations [OR=1.75, 95% CI: 1.13-2.57] and contact with patients [OR=3.05, 95% CI: 1.50-5.91]. CONCLUSIONS: Knowledge of recommended occupational vaccinations is insufficient in HCWs, except for HBV and influenza. Although the HBV vaccine coverage of HCWs is satisfactory, a large proportion of them is unaware of immune status. Influenza vaccine coverage remains low, especially among paramedical staff because of fear of side effects. As vaccine coverage is associated with knowledge, educational campaigns should be strengthened to increase the adhesion of HCWs to vaccinations.