Trends in the epidemiology of childhood tuberculosis in Greece.

SETTING: A hospital referral center for childhood tuberculosis (TB). OBJECTIVE: To evaluate the epidemiological and clinical features of childhood TB in the Greater Athens area in the last decade. DESIGN: We retrospectively reviewed the medical records of patients aged <14 years treated for active TB between January 2000 and December 2009 at our pediatric TB clinic and compared the results with the patient turnover during the previous decade (1990-1999). Data concerning demographic and clinical characteristics were analyzed. RESULTS: A total of 321 children (median age 5.57 years, 157 males) with active TB were identified. About one third originated from areas where TB was previously recognized to be highly endemic. Twenty-three children (7%) had extra-pulmonary TB, and 61% of them originated from TB-endemic areas. Bacteriological confirmation was obtained in 40% of patients from whom specimens were obtained: 1 of 26 (3.8%) strains was multidrug-resistant. Most cases with drug-resistant Mycobacterium tuberculosis were noted among immigrant children. The average annual TB incidence was estimated at 5.37 per 100 000 for children aged <14 years in the Greater Athens area. Time trend analysis for the 20-year period revealed a significant reduction in the total number of TB cases (P = 0.002) and in TB among children from low-incidence countries (P < 0.0001). CONCLUSIONS: In our settings, active TB is decreasing among children of Greek origin; disease epidemiology and drug resistance is influenced by the increasing influx of immigrants from areas where the disease is highly prevalent.

Latent tuberculosis infection in children: diagnostic approaches.

Tuberculosis (TB) remains an important public health problem and a leading infectious cause of death. Diagnosis and treatment of latent tuberculosis infection (LTBI) is important for TB control and elimination. Nevertheless, the diagnosis of LTBI in both adults and children remains complex, since there is no gold standard. The development of interferon gamma release assays was a major breakthrough in the diagnosis of LTBI. The evaluation of IGRAs in the diagnosis of LTBI in children is proven to be difficult since childhood TB differs from adults as immune responses vary with age. Separate studies assessing IGRAs performance in children are still limited, and only a few of them divide results by narrow age groups Nevertheless, new approaches are being exploited by the ongoing research for the development of more efficient diagnostic tools. It is likely that many changes in both the diagnosis and management of LTBI will occur in the near future. We believe that better understanding of the immunopathology of latency can ultimately lead to the development of more effective strategies in TB control. In the present review we summarize current data on diagnosis of LTBI in children, underscoring the existing challenges and limitations.

Impact of influenza infection on children's hospital admissions during two seasons in Athens, Greece.

A prospective epidemiologic surveillance of hospitalizations associated with influenza was conducted in order to calculate population-based hospitalization rates. Eligible children were 6 months to 13 years of age and were admitted to one of the two large children's hospitals in the Athens area during two influenza seasons. Nasopharyngeal aspirates were tested for influenza by a polymerase reaction assay. Influenza accounted for 9.9-11.8% of all admissions during the influenza season and the overall annual rate of hospitalizations was 13.6-16.8 cases per 10,000 children being highest for children under 5 years of age (26-31.2/10,000 children). Febrile seizures and acute otitis media were the two most common complications associated with influenza and antibiotics were administered to 61% of flu positive patients. Influenza is associated with high hospitalization rates among young children and these may be substantially reduced with the introduction of routine immunization.

Impact of influenza infection in healthy children examined as outpatients and their families.

Decisions regarding the introduction of influenza immunization in healthy children require an accurate evaluation of influenza disease burden not only in the inpatient but also in the outpatient setting. We prospectively examined the impact of virologically confirmed influenza in 1462 outpatient children (> or = 6 months to < 14 years) and their families, during two consecutive influenza seasons. Influenza was documented in 573/1462 (39%) outpatients with febrile respiratory illness and accounted for 13.5% of all outpatient visits during the 14 weeks of each season. Acute otitis media (AOM) was the most common complication (18.5%) and about 40% of influenza positive patients received antibiotics. AOM and antibiotic use were more common in children younger than 5 years of age who accounted for 58% of all patients. For each child sick with influenza a mean of 1.34 workdays were lost by the parents. Family members of influenza positive children were more likely to develop a secondary respiratory illness and to require medical visits and antibiotic prescriptions. Influenza is associated with a heavy morbidity burden in the community that may be reduced considerably with the implementation of immunization in children younger than 5 years of age.

Treatment of paediatric visceral leishmaniasis: amphotericin B or pentavalent antimony compounds?

Pentavalent antimony compounds and amphotericin B lipid formulations have been found highly active for the treatment of visceral leishmaniasis. This study focuses on which treatment is preferable in the best interests of the child. Records were reviewed of children in our hospital aged 0-14 years, diagnosed with visceral leishmaniasis, during the last 4 years. Twenty-nine children were identified. Ten were treated with meglumine antimonate (20 mg/kg/day for 21 days) and remained in hospital for 11-28 days (median 19 days), while 19 patients received liposomal amphotericin B at four different dosage schemes and were in hospital for 6-11 days (median 7 days). All of the patients were cured regardless of the treatment regime they followed. No relapses were noted. Liposomal amphotericin B would be preferable to meglumine antimonate if the reduction in hospital stay and hence the convenience of the patient balance the cost of medication. The optimal duration of treatment with liposomal amphotericin B remains to be determined.

Acute diarrhoea in children treated in an outpatient setting in Athens, Greece.

OBJECTIVE: To describe the epidemiology and aetiology of acute diarrhoea among children treated exclusively in an outpatient setting in Greece. METHODS: During 1999, children with acute diarrhoea who attended the emergency department of our hospital were prospectively studied. Patients requiring hospitalization were excluded. Stool specimens were tested microscopically, for bacterial enteropathogens by standard and selective medium cultures and for rotavirus and adenovirus by latex agglutination test. RESULTS: One hundred and thirty-two children (median age: 2 years) were included in the study; an enteropathogen was detected in 63 (48%) of them. Isolates included rotavirus (19 patients), Salmonella sp (12), Campylobacter sp (10), Aeromonas sp (9), enteropathogenic Escherichia coli (6), adenovirus (6), Giardia lamblia (4), Yersinia enterocolitica (2) and Shigella sp (1). Half of the bacterial cases occurred from August to October, and two rotavirus-associated peaks occurred during February and August. Acute diarrhoea caused by viruses affected exclusively children under six years of age, mainly those attending day care centres. Macroscopic blood in stools was reported only among patients with a bacterial infection. Socioeconomic characteristics were not helpful in differentiating disease due to specific enteropathogens. CONCLUSIONS: Bacterial enteropathogens account for a significant proportion of acute diarrhoea in children treated in the outpatient setting in Greece. Rotavirus is also a frequent cause affecting mostly younger children and those attending day care centers. The presence of blood in stools and the seasonality of bacterial infections may enable their presumptive diagnosis.

Visceral leishmaniasis during childhood in southern Greece.

Records were reviewed of 82 immunocompetent children (median age, 2. 5 years) from southern Greece who were diagnosed with visceral leishmaniasis from 1986 through 1998. Forty-nine (58%) patients originated from the city of Athens; of them, 46 (94%) lived by hills bordering the city. The median interval from the onset of symptoms to admission was 10 days. Fever and splenomegaly were observed in >95% of the patients. Thrombocytopenia was the most frequent hematological finding (80%). All patients were treated with meglumine antimonate; 20 (24%) of them were partially treated on an outpatient basis. Rapid clinical response was noted in all patients but one. Five patients relapsed; 3 responded to reintroduction of meglumine antimonate, 1 responded to liposomal amphotericin B, and 1 underwent splenic artery ligation. We conclude that pentavalent antimonials remain the first choice of treatment for visceral leishmaniasis in immunocompetent children in areas where resistance has not become a problem. It is possible to treat affected patients with outpatient administration of these agents, making them feasible options for therapy.

Isepamicin versus amikacin for the treatment of acute pyelonephritis in children.

In this study we compared the efficacy and safety of isepamicin versus amikacin at a dose of 7.5 mg/kg i.v. q12h for 10-14 days in children with pyelonephritis. Sixteen children were enrolled in the study; ten received isepamicin and six amikacin. Urine cultures grew Escherichia coli in all patients. All patients were treated successfully with either isepamicin or amikacin. Clinical and bacteriological response rates were 100% for both groups. No adverse events occurred. Peak serum levels ranged from 9.05 to 30.70 mg/l (median: 16.165) and from 12.20 to 25.90 mg/l (median: 19.05) for isepamicin and amikacin, respectively. Trough serum levels ranged from 0.11 to 3.20 mg/l (median: 0.75) and from 0.1 to 2.1 mg/l (median: 0.655), respectively. Isepamicin was shown to be as effective and safe as amikacin in the treatment of children with pyelonephritis and might prove an advantageous alternative in areas with high incidence of resistance to other aminoglycosides.