Antimicrobial survey of urinary tract isolates from a pediatric department.

The epidemiology of urinary tract colonization/infection in children admitted during 1996 to the Pediatric Department of the University of Verona has been studied; 501/1959 urine cultures were positive (25.57%). 584 microorganisms (64.89% Gram-negative, 24.82% Gram-positive, 10.27% fungi) were isolated. The highest rate of Gram-negative isolation (80.0%) was observed in infants, while the highest rate of Gram-positive isolation (29.6%) was found in newborns admitted to the neonatal intensive care unit. Escherichia coli was the most frequently isolated microorganism in infants and children, but not in newborns. A 3-fold increase in resistant E. coli strains to cotrimoxazole/sulfamethoxazole and amoxicillin/clavulanic acid was documented during the last 3 years in this pediatric population. Our observations underline the importance of the survey of microbial maps in pediatric departments in order to optimize therapeutic and preventive choices.

[Hematuria in pediatric clinical practice]. / L'ematuria in età pediatrica nella pratica clinica.

Haematuria, which was known at the time of Hippocrates, is defined as the presence of an anomalous number of red globules in the urine. It may present itself in a macroscopic or microscopic form. The latter is frequently found and is present in 1-2% of children. The pathogenesis of haematuria has been the object of recent acquisitions. The diagnosis is based in the first instance on the association of a positive urinary stick and confirmation of the presence of red globules in an assay of the sediment. The study of erythrocytic morphology is still the most useful test to identify the site of bleeding, even if more recently other markers, such as an excessive presence of acanthocytes or reduced mean corpuscle volume, together with the traditional study of cylindruria may represent elements to differentiate between glomerular and non-glomerular haematuria. Both family and personal medical history as well as objective examination play an important role in the definition of haematuria. Abdominal ultrasonography and biohumoral tests may, in association with the earlier data, allow a rapid and correct diagnosis of children with haematuria. A more detailed diagnosis using biopsy should be taken into consideration in selected cases, for example in familial forms that are not clearly defined and forms associated with altered renal function tests, as well as in persistent microhaematuria lasting for more than one year.

Candida infections in newborns: a review.

Despite adequate treatment, nosocomial fungal infections have become an increasingly important cause of morbidity, extended hospitalization, and mortality in critically ill newborn babies. Furthermore, the high incidence of central nervous system involvement in septic newborns frequently results in serious neurological damage and psychomotorial sequelae. The prevention of fungal colonization in the population at risk, together with prompt diagnosis and treatment, are an efficient combination which lead to a better outcome of neonatal fungal infections. New drugs characterized by great efficacy and tolerance have recently been employed in clinical practice. This article summarizes certain aspects of Candida spp. infections in the neonatal period with regard to multisystemic presentation and involvement.

Transient hyperechogenicity of the renal medullary pyramids: incidence in the healthy term newborn.

A screening program was performed on 1881 clinically healthy term newborns, aimed at detecting eventual pathological conditions not diagnosed during pregnancy. Seventy-three cases of transient hyperechogenicity of the renal medullary pyramids were observed, involving one or both kidneys with either sectorial or diffuse pattern. None of the neonates examined had evidence of renal dysfunction and follow-up ultrasound scans demonstrated complete resolution of the sonographic picture. Medullary hyperechogenicity is not rare in healthy term newborns (3.9%); it presents rapid resolution and should be considered in differential diagnosis of pathological conditions.

[Renal polycystosis in pediatrics]. / La policistosi renale in pediatria.

Inherited polycystic kidney disease (PKD) in children is a disorder characterized by diffuse cystic involvement of both kidneys, without evidence of dysplasia. Both forms, autosomal recessive (ARPKD) and autosomal dominant (ADPKD) have considerable overlap in clinical presentation and radiographic features in the pediatric population. At present, a prenatal diagnosis is possible with ultrasound examination. A brief review of the literature is here reported. The knowledge of pathophysiological and clinical data is requested, since PKD represents a major cause of renal failure in pediatrics.

Renal tolerability of teicoplanin in a case of neonatal overdose.

The literature does not contain reports regarding teicoplanin overdose in newborns. In a neonate with a history of recent postasphyctic acute renal failure which recovered within 7 days of life, antibiotic therapy with teicoplanin was started for sepsis due to Staphylococcus hominis. However, for 5 days the dosage was excessive (20 mg/kg twice daily instead of an initial dose of 16 mg/kg and then doses of 8 mg/kg once daily). Once this error had been noted, therapy was immediately suspended. Clinically the newborn had improved and blood culture at the end of the therapy was negative. Biohumoral tests revealed constantly normal levels of serum creatinine, serum cystatin C and blood nitrogen. Urinary parameters of tubulotoxicity were also within normal values. Urinary epidermal growth factor was increased. Teicoplanin was well tolerated at the renal level in the newborn even in this case of excessive dosage.

[Vesico-ureteral reflux in pediatrics]. / Il reflusso vescico-ureterale in pediatria.

Vesico-ureteral reflux (VUR) is the most frequent uropathy involving 1-2% of children. Genetics, familiarity, race gender and age intervene in the pathogenesis of VUR. In particular, neonatal VUR seems to represent a specific entity. Different factors determine a renal damage due to RVU: direct action of VUR (back pression), urinary tract infection (UTI), inflammatory mechanisms and renal dysplasia. Micturing cystourethrography and nuclear cystography are currently performed for the diagnosis of VUR, being ultrasound examination aspecific. Functional parameters are now investigated in association with new morphologic studies. The strict relationship of VUR and UTI is discussed. The treatment (medical, surgical) of VUR is not well established, although some guidelines can be suggested. Finally an adequate support must be given to the family for an optimal management.

[Renal calculosis in pediatrics]. / La calcolosi renale in pediatria.

Urinary stones (calculi) are not a rare problem in pediatrics, presenting a prevalence of 1 case/20,000 children/year. Both nephrocalcinosis (deposition of calculi within the renal parenchyma) and urolithiasis (stone formation in the calyces, renal pelvis and bladder) may occur. Etiology of urinary stones involves metabolic, infectious, anatomic and idiopathic causes. Diagnosis and treatment require knowledge of a wide range of diseases. After urinary stones have been suspected, biohumoral tests and ultrasound examination should be routinely performed.

[Glycopeptides and the newborn infant's kidney]. / Glicopeptidi e rene del neonato.

The aim of this paper was to evaluate glycopeptide nephrotoxicity in the newborn. The exact mechanism of nephrotoxicity has not been defined. Basal mechanism of vancomycin nephrotoxicity seems related to the energy-dependent tubular transport of the drug from blood to tubular cell across the basolateral membrane. Moreover a tubular reabsorption is probably involved, but it is not relevant for nephrotoxicity. Considering the widespread use of this antibiotic, the question of nephrotoxic side effects in humans is of great importance. However, the results of studies published to date are controversial. Results differ considerably depending on the period considered and on the sensitivity of the methods used to indicate renal damage. In paediatric patients (including neonates) the nephrotoxicity of vancomycin appears to be less than that in adults, thus confirming a number of experimental observations. It is commonly suggested that pharmacokinetic monitoring of doses in children should minimize nephrotoxicity. The most important risk factors for the development of the nephrotoxic action of vancomycin are: pre-dose values > 10 mg/l, prolonged therapy (> 21 days), and concomitant treatment with aminoglycosides. In most cases nephrotoxicity associated with vancomycin is reversible, even after high doses. In conclusion it could be speculated that vancomycin nephrotoxicity relates to the combined effect of a large area under the concentration-time curve and duration of therapy. Teicoplanin is a new glycopeptide that is effective in the treatment of both children and neonates and offers the advantages of once daily administration, choice of administration route (intramuscular or rapid intravenous bolus) and lack of requirement for routine therapeutic drug monitoring. Finally it seems less nephrotoxic than vancomycin. In the neonatal age bracket, none of the 173 patients treated presented abnormalities of traditional kidney function parameters.

[Sepsis caused by Candida in the neonatal period]. / Sepsi da Candida nel periodo neonatale.

Fungal pathogens have become increasingly important as causes of mortality and in newborn infants, especially preterm with very law birth weight, admitted to a neonatal intensive care unit. We report here the cases of 26 neonates (19 VLBW) with systemic fungal infections. Average birth weight and gestational age were 1405 +/- 977 g (range 595-4180 g) and 29 +/- 5 weeks (range 24-41 weeks) respectively. 24 newborn infants required endotracheal intubation and mechanical ventilation and 6 were affected by a severe congenital malformation. An umbilical e/o central intravascular catheter was inserted in all infants and each of them received antibiotics (one or more courses). The Candida species isolated were: C. albicans (n. 23; 88.5%), C. parapsilosis (n. 2; 7.6%) and C. glabrata (n. 1; 3.8%). Frequently encountered symptoms and signs in our neonates included: vasomotor instability with peripheral hypoperfusion (92%), gastro-intestinal disturbances (69%), respiratory distress and increasing ventilatory requirements (65%). Other symptoms were less frequent. 20 newborn infants had leucocytosis, 19 thrombocytopenia, 14 presented both signs. Factors found to be frequently associated with fungal infection included: use of broad-spectrum antibiotic therapy, presence of central venous or umbilical artery catheter, endotracheal intubation and mechanical ventilation, surgical abdominal intervention. After antifungal systemic therapy, clinical cure and microbiological eradication were achieved in 81% of cases, only 1 out of 11 deaths was directly attributed to Candida infection. In our experience the association of amphotericin B+ 5 glucytosine proved to be an effective and well-tolerated therapy for the treatment of severe fungal infections in neonates. A high index of suspicion, especially in premature infants (VLBW), a rapid diagnosis and early initiation of antifungal therapy still remain the essential features in treating neonatal fungal infections.

[Nutrition in chronic renal insufficiency in the first year of life]. / Nutrizione nell'insufficienza renale cronica nel primo anno di vita.

In the first year of life, period of maximal anabolism, optimal metabolic and nutritional conditions are strictly required. In fact growth retardation of the infant is seldom recoverable in the following pediatric ages. Conservative management of chronic renal failure in the first year of life is essentially dietetic. Normal growth is warranted by adequate protein intake (6-8% of total calories) and optimal caloric support (> 75-80% of RDA). Water requirements (evaluated on the basis of diuresis, hydratation and weight variations) must be administrated during the whole 24-hours period to avoid dehydration. Sodium and potassium limitations are not generally indicated and only in advanced phases must be carefully evaluated. On the contrary, in early stages, a reduction of phosphorus intake and calcium and vitamin D supplementation are commonly suggested. Maternal milk is the nutritional gold standard during the first year of life. Hyposmolar formula with normal Na and low P content (Ca/P ratio = 1.4-2) and a protein content comprised between 1.4 and 1.8 g/100 ml represent the second choice.

[Pilot studies on the effect of desmopressin on the personality of enuretic children]. / Studio pilota sugli effetti della desmopressina sulla personalità di bambini enuretici.

The aim of this paper was to establish if there is a correlation between desmopressin administration and modification of psychological experience in enuretic children. 22 enuretic children (18 treated with desmopressin, 4 not treated) were enrolled in the study. They underwent a complete psychological examination, differentiated on the basis of chronological age, before the beginning and at the end of the treatment (duration 4 months). The psychologist was not informed if they were treated or not. In the 17 of 18 treated children with basal psychological problems, 14 became normal, 2 demonstrated a significative amelioration and 1 remained pathologic at the end of the treatment. No modification was observed in not treated patients, all presenting psychological problems. 6 emblematic cases with psychological findings and paintings are presented. The results seem interesting, despite the low number of children enrolled.

[Aminoglycosides, risk factors and neonatal kidney]. / Aminoglicosidi, fattori di rischio e rene neonatale.

Antibiotics are the leading cause of drug-induced kidney disease, and among them the aminoglycosides (AMG) are the main nephrotoxic agents, bringing about kidney damage via a direct dose-dependent mechanism. The combination of an aminoglycoside and a penicillin derivative is still the most commonly recommended and used first-line treatment modality in the empirical therapy of neonatal sepsis, despite the low therapeutic index of AMG. The immaturity of neonatal kidney function, particularly in preterm neonates, makes newborn infants particularly susceptible to AMG-induced kidney damage. Numerous factors intervene in bringing about AMG-induced kidney damage, such as factors related to the antibiotic itself (intrinsic toxicity, administration route, type of monitoring of blood concentrations), those related to the subject treated (neonatal age, constitutional sensitivity), and others related to associated pathology (neonatal anoxia, renal hypoperfusion, respiratory distress/mechanical ventilation, hyperbilirubinaemia/phototherapy, electrolyte disorders, and even the acute sepsis calling for antibiotic therapy), as well as pharmacological factors (concomitant therapies such as diuretics, indomethacin and other antibiotics, particularly glycopeptides and cephalosporins).

[Neonatal ultrasonic screening and follow up of urinary tract malformations]. / Screening ecografico neonatale e follow-up delle uropatie malformative.

1881 consecutive healthy newborn babies underwent abdominal ultrasonography on day 4-6. 228 subjects presented an echographic abnormality. Renal abnormalities were diagnosed in 213 newborn. Of those, 134 had dilatative uropathy with a pelvic diameter greater than 5 mm, 73 renal medulla hyperechogenicity, 3 ectopics, 2 unilateral renal agenesis and one horseshoe kidney. Extrarenal findings were present in 15 neonates: 11 with surrenal gland haemorrhage and 4 with hepatic ultrasonographic alterations. Grignon classification was used for evaluation of the dilatative urinary tract abnormalities. In 173 renal pelvis (134 neonates) the anteroposterior diameter was found > 5 mm: 97 were classified as GI (5-10 mm), 45 as GII (10-15 mm), 13 as GIII ( > 15 mm), 11 as GIV (moderate dilatation of the calyces with easily identified residual renal cortex) and 7 as GV (severe dilatation of the calyces with atrophic cortex). The follow-up of 72.3% of these abnormalities showed a spontaneous normalization in 90% of GI, 73% of GII and 58% of GIII. Only one patient with GIII demonstrated progressive dilatation and he underwent corrective surgery. 15 of the 17 newborn with severe uropathy (GIV-GV), had regular follow-up. 8 underwent surgery and 7 showed a progressive spontaneous recovery and in 4 of these cases a complete resolution. The ultrasound follow-up of all cases of renal medulla hyperechogenicity and surrenal gland haemorrhage shows a spontaneous resolution without any clinical or biochemical complication.

[Staphylococcal infection in the newborn: teicoplanin therapy]. / Sepsi da stafilococco nel neonato: terapia con teicoplanina.

Infections caused by Gram-positive bacteria, particularly in neonatal patients, have increased dramatically over the past 10 years. In the present study 19 newborns (7 at term, 12 preterm) with proven staphylococcal infection were treated with teicoplanin, after a previous ineffective antibiotic treatment (amikacin+oxacillin or third-generation cephalosporin). Bacterial eradication and clinical cure were achieved in all neonates. No adverse events related to the drug occurred. No significant change was observed in serial biochemical and hematological tests. Our results suggest that teicoplanin is highly effective and safe in neonatal staphylococcal infections.