Estudio descriptivo de los hemocultivos positivos en un servicio de urgencias pediátrico / Positive blood cultures in a pediatric emergency department: a descriptive analysis

Se describe las patologías y los microorganismos que causan bacteriemia y la influencia del hemocultivo (HC) positivo en urgencias en el manejo posterior. Se trata de un estudio retrospectivo de los HC positivos realizados en urgencias durante 2008 y 2009. Se consideró el cambio de la actitud terapéutica, el inicio o modificación del antibiótico y/o el ingreso hospitalario. Se realizaron 7.582 HC. En 382 (5,0%) hubo crecimiento bacteriano, 88 (23,0%) fueron verdaderos positivos. La neumonía y la infección urinaria fueron las principales patologías asociadas a bacteriemia y S. pneumoniae y E. coli los microorganismos más frecuentes. El HC positivo condicionó cambio de actitud terapéutica en un tercio de los episodios, principalmente en pacientes con fiebre sin foco. Se concluye que la positividad del HC condicionó un cambio de actitud terapéutica en un número significativo de pacientes, aunque dada la baja prevalencia de bacteriemia el impacto global fue bajo (AU)

We describe the infections and microorganisms causing bacteremia in an emergency department and to analyze the influence of a positive blood culture on subsequent management. It is a retrospective study of positive blood cultures ordered in the emergency department in 2008 and 2009. A change in therapeutic approach was defined as the initiation or modification of antibiotic therapy and/or hospital admission. A total of 7582 blood cultures were ordered. Bacteria grew in 382 (5.0%); 88 (23.0%) were true positives. Pneumonia and urinary tract infection were the main diagnoses associated with bacteremia. The pathogens implicated most often were Streptococcus pneumoniae and Escherichia coli. A positive blood culture led to a change in therapeutic approach in a third of the cases, mainly in patients with fever of unknown origin. We conclude that the management changed on the basis of blood culture findings in a significant number of cases although given the low prevalence of bacteremia, the overall impact was low (AU)

[Complications of bladder catheterization to obtain a urine sample in the emergency department]. / Complicaciones del cateterismo vesical realizado en un servicio de urgencias para obtener una muestra de orina.

INTRODUCTION: Bladder catheterization (BC) is frequently performed to diagnose urinary tract infection (UTI) (the most common serious bacterial infection among young children). The purposes of this study were to evaluate performance and complications of BC to obtain a urine specimen. MATERIAL AND METHODS: This was a prospective study conducted in an urban children's hospital on patients who had a urine specimen obtained in the emergency department (ED) by BC between November 1, 2009 and December 15, 2009. Epidemiological data and the medical reasons why the BC was performed were reviewed. Finally, to determine the complications we contacted the family by telephone at least one month after the BC. RESULTS: A total of 126 BC were performed in 124 patients, 45 males (35.7%) and 81 female (64.3%). A urine sample was obtained in all cases. The median age was 7 months (5 days-35 months). Of the 126 urine cultures collected, 34 were positive (26.98%) and 1 was considered contaminated (0.8%). Escherichia coli was the most common pathogen (27, 79.41%). Fever (76.2%) was the main reason why BC was performed in children. Of the 116 patients contacted by telephone, only 5 mentioned complications: genital pain (3), unconfirmed hematuria (1) and UTI 12 days after (1). CONCLUSIONS: BC performed in ED to obtain a urine sample in non toilet-trained children is effective and safe. BC is an invasive method which needs to be quality controlled.

[Hospitalization criteria in urinary tract infections]. / Criterios de ingreso hospitalario en las infecciones urinarias.

A review of the scientific evidence available on the indications for hospitalization in pediatric patients with urinary tract infection is presented. We found no studies that specifically evaluated the utility of hospitalization in children with urinary tract infection. Only indirect data were found on the identification of high risk infections, but none of the clinical-laboratory parameters evaluated had sufficient sensitivity and specificity to support their use as the basis for decision making. However, in clinical practice, identification of the location of the infection is not important when considering hospitalization. Some studies have shown that ambulatory treatment with oral antibiotics is safe and effective in patients with pyelonephritis with good general status and with no history of uropathy. Consequently, the decision to admit the patient should be mainly based on evaluation of the patient's clinical status and on the estimated risk of general complications.

Criterios de ingreso hospitalario en las infecciones urinarias / Hospitalization criteria in urinary tract infections

Se presenta una revisión de la evidencia científica disponible sobre las indicaciones de ingreso hospitalario de pacientes pediátricos con infección urinaria. No hemos encontrado estudios que valoren de forma específica la utilidad del ingreso en niños con infección urinaria. Tan sólo disponemos de información indirecta relacionada con la identificación de infecciones de alto riesgo, pero ninguno de los parámetros clínicos analíticos evaluados presenta la suficiente sensibilidad y especificidad como para sustentar exclusivamente en ellos la toma de decisiones. No obstante, en la práctica clínica, la identificación de la localización de la infección no es relevante para decidir el ingreso hospitalario, ya que algún estudio ha mostrado que en los pacientes con pielonefritis, buen estado general y sin antecedentes de uropatía, el tratamiento ambulatorio con antibióticos por vía oral es eficaz y seguro. Por ello, la decisión de ingreso se debería basar fundamentalmente en la valoración de la situación clínica del paciente y el riesgo estimado de complicaciones generales

A review of the scientific evidence available on the indications for hospitalization in pediatric patients with urinary tract infection is presented. We found no studies that specifically evaluated the utility of hospitalization in children with urinary tract infection. Only indirect data were found on the identification of high risk infections, but none of the clinical-laboratory parameters evaluated had sufficient sensitivity and specificity to support their use as the basis for decision making. However, in clinical practice, identification of the location of the infection is not important when considering hospitalization. Some studies have shown that ambulatory treatment with oral antibiotics is safe and effective in patients with pyelonephritis with good general status and with no history of uropathy. Consequently, the decision to admit the patient should be mainly based on evaluation of the patient's clinical status and on the estimated risk of general complications

Aprendiendo a tratar la anemia drepanocítica

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Actitud de los padres ante la fiebre. Alternancia de antitérmicos / Parent's attitude towards fever. Alternating antipyretics

Objetivo: Averiguar cómo perciben los padres la fiebre, los métodos que utilizan para su tratamiento y la frecuencia con que alternan antitérmicos. Pacientes y métodos: Encuesta de 13 preguntas realizada a los padres que consultaron en el Servicio de Urgencias Pediátricas del Hospital Niño Jesús de Madrid en junio de 1999. Resultados: Se analizaron 376 encuestas. La mayoría (88,29 por ciento) considera que la fiebre puede ser peligrosa si alcanza determinados valores. Las convulsiones (40,16 por ciento) y la meningitis (16,22 por ciento) son los principales temores; el 11 por ciento no siente ningún miedo. Utilizan medidas físicas para bajar la fiebre el 67,28 por ciento de los encuestados, casi siempre asociadas a antipiréticos. Habitualmente se administra antitérmico a partir de 38° (61,96 por ciento). El paracetamol es el medicamento más utilizado. El 34,57 por ciento alternan antitérmicos, habitualmente o cuando la temperatura no baja con un solo fármaco. La combinación ibuprofeno-paracetamol es la más empleada (76,92 por ciento). Hasta el 44,07 por ciento de las personas que utilizan un solo antitérmico administran dosis incorrectas, y hasta el 58,91 por ciento cuando los alternan. Conclusiones: La alternancia de antitérmicos es una práctica frecuente. Un número importante de padres utiliza dosis inadecuadas, sobre todo cuando los combina. Muchos temen que la persistencia de la fiebre provoque convulsiones o meningitis (AU)

[Utility of Boyer's score modified for the differential diagnosis of bacterial and viral meningitis]. / Utilidad del score de Boyer modificado para el diagnóstico diferencial de las meningitis bacterianas y víricas.

BACKGROUND: Many studies have been performed to establish criteria for the differential diagnosis between bacterial and viral meningitis. In 1980, Thome and Boyer proposed a score that has been widely used. OBJECTIVES: The aim of this study was to assess the utility of this score when applied to our patients with meningitis and to evaluate the diagnostic yield after adding other laboratory tests. METHODS: We retrospectively studied the children diagnosed with meningitis in the Hospital Niño Jesús between January 1993 and February 2000. In all patients, Boyer's score and the following laboratory variables were applied: reactive C protein levels, percentage of neutrophils in the cerebrospinal fluid depending on age, and the ratio of immature cells/total neutrophils in the blood. We calculated the sensitivity and specificity of Boyer's score and the laboratory variables. RESULTS: Of the 476 children with meningitis, 402 had viral meningitis and 74 had bacterial meningitis. All the children with bacterial meningitis except seven had a score higher than 3 (a doubtful indication for antibiotic treatment). The sensitivity and specificity of Boyer's score was 90 % and 99 % respectively. When laboratory variables were added, sensitivity was 100 % and specificity was 98 %. CONCLUSIONS: Boyer's score is a useful tool for the differential diagnosis of meningitis, but its diagnostic yield is considerably increased when the results of laboratory tests are added.

[Complications of varicella in children]. / Complicaciones de la varicela en niños.

OBJECTIVE: The purpose of this study was to describe varicella complications that result in the hospitalization of children in our hospital, as well as the associated cost. PATIENTS AND METHODS: A retrospective study involving 84 children hospitalized for complications due to varicella between January 1993 and December 1997 was carried out. Oncology patients were excluded. Data about age, sex, previous health conditions, complications developed, days of admission and treatments, amongst others, was collected and descriptive statistics performed. We also estimated the costs of hospitalization. RESULTS: We identified 84 children hospitalized for complications of varicella, which represents 2.67% of the total cases of varicella attended in the Emergency Room (3,135). Of these children, 72.6% were healthy before the onset of varicella. The mean age was 3.3 +/- 2.6 years. Skin or soft tissue infections were the most common complication, with all of the cases occurring in children under 5 years of age. Central nervous system complications were found in 19.27%, with involvement of the cerebellum accounting for the majority of the cases of encephalitis. Bilateral facial palsy was observed in one patient. Respiratory complications (14.45%) included pneumonia, bronchitis and croup. Other types of complications, such as gastrointestinal (9.63%), musculo-skeletal (4.76%) and hematological were less frequent. The mean hospital stay was 7.7 +/- 4.8 days. The cost associated with the admission of these children was 43,681,528 pesetas. CONCLUSIONS: Varicella complications represent an important morbidity for a disease that has long been considered benign and inevitable in children. The implementation of a varicella vaccine program for healthy children would be beneficial for the prevention of complications and the reduction in their associated cost to the health care system.

[Pediatric primary care seen through a hospital emergency service]. / La asistencia primaria pediátrica vista a través de un servicio de urgencias hospitalario.

We have studied the procedures for taking care of the 1,044 patients who arrived in the Emergency Room at the Niño Jesus Hospital on weekday mornings, in order to evaluate the operation of primary pediatric care as the possible generator of the demand for emergency hospital care. We also took into account the motivations which the parents of the children gave for not having gone to their doctors. The diagnosis and/or prior treatment were considered adequate in 83.81% of cases, and in 64.63% of cases in which these were known for a fact. 35.7% of the children were periodically checked out by their doctors even though they were not ill. Among the motives given by the parents for going directly to the Emergency Room, only 5.69% and 8.41% respectively said that it was due to an emergency situation or a worsening of the patient's state. 35.89% pointed out that their pediatricians had afternoon hours, and 20.91% that they went to the Emergency Room systematically regardless of the problem. Only 10.27% said that they were unhappy with their doctor. From our data it would seem that the demand for emergency pediatric hospital care is due more to a lack of health education of the population than to deficiencies in primary care.

[Usefulness of sectorization of pediatric hospital emergency units in the community of Madrid]. / Utilidad de la sectorización de las urgencias hospitalarias pediátricas en la comunidad de Madrid.

We have studied the procedence of the children that came to the Emergency Department of the Niño Jesús Hospital, analyzing if they belonged to the pediatric emergency area corresponding to this hospital, the procedence from the different postal districts of Madrid, from other localities of the Madrid Community, or from the Health Areas of this Community. We found that only 12.42% of the children came from the corresponding area of the emergency care sectorization, and that they came from very disperse zones, having no clear relation with any of the Health Care Areas. We conclude that current sectorization of the pediatric emergencies in hospitals is not being usefull, and we suggest alternative solutions.

[Demand for care in the emergency service department of a pediatric hospital]. / Estudio de la demanda asistencial de un servicio de urgencias hospitalario de pediatría.

We have done a prospective study of the emergencies that arrived to a Children's Hospital from 8 to 15 hours in labour day 987 enquires were filled, which represents 53.53% of those who came. Males were predominant and also the younger ones with 24.58% less than 1 year of age, and progressively diminishing with age. Frequency was higher on Mondays, Thursdays and Fridays, with a significant reduction on Tuesdays. The hourly distribution demonstrated an accumulation in the intermediate hours in the morning, with a reduction before 10 and after 14 hours. 83.58% arrived due to personal initiative, and 22.28% of them had been with their pediatrician in the previous 48 hours. 3.64% of patients were admitted to hospital; considering a justified reason for hospital emergency care in 14.69% of the cases, and dubious reasons in 16.61%. The socioeconomic status was slightly higher than that of the Madrid Community in which the hospital is situated. Our data show that the majority of children that come to the emergency department present problems that could have been solved in another level of care. We also found indirect signs, may evidentiate that the family members are conscious in many cases that they are making an unjustified use of this level of care.