In-hospital mortality risk stratification in children aged under 5 years with pneumonia with or without pulse oximetry: A secondary analysis of the Pneumonia REsearch Partnership to Assess WHO REcommendations (PREPARE) dataset.

OBJECTIVES: We determined the pulse oximetry benefit in pediatric pneumonia mortality risk stratification and chest-indrawing pneumonia in-hospital mortality risk factors. METHODS: We report the characteristics and in-hospital pneumonia-related mortality of children aged 2-59 months who were included in the Pneumonia Research Partnership to Assess WHO Recommendations dataset. We developed multivariable logistic regression models of chest-indrawing pneumonia to identify mortality risk factors. RESULTS: Among 285,839 children, 164,244 (57.5%) from hospital-based studies were included. Pneumonia case fatality risk (CFR) without pulse oximetry measurement was higher than with measurement (5.8%, 95% confidence interval [CI] 5.6-5.9% vs 2.1%, 95% CI 1.9-2.4%). One in five children with chest-indrawing pneumonia was hypoxemic (19.7%, 95% CI 19.0-20.4%), and the hypoxemic CFR was 10.3% (95% CI 9.1-11.5%). Other mortality risk factors were younger age (either 2-5 months [adjusted odds ratio (aOR) 9.94, 95% CI 6.67-14.84] or 6-11 months [aOR 2.67, 95% CI 1.71-4.16]), moderate malnutrition (aOR 2.41, 95% CI 1.87-3.09), and female sex (aOR 1.82, 95% CI 1.43-2.32). CONCLUSION: Children with a pulse oximetry measurement had a lower CFR. Many children hospitalized with chest-indrawing pneumonia were hypoxemic and one in 10 died. Young age and moderate malnutrition were risk factors for in-hospital chest-indrawing pneumonia-related mortality. Pulse oximetry should be integrated in pneumonia hospital care for children under 5 years.

An analysis of clinical predictive values for radiographic pneumonia in children.

INTRODUCTION: Healthcare providers in resource-limited settings rely on the presence of tachypnoea and chest indrawing to establish a diagnosis of pneumonia in children. We aimed to determine the test characteristics of commonly assessed signs and symptoms for the radiographic diagnosis of pneumonia in children 0-59 months of age. METHODS: We conducted an analysis using patient-level pooled data from 41 shared datasets of paediatric pneumonia. We included hospital-based studies in which >80% of children had chest radiography performed. Primary endpoint pneumonia (presence of dense opacity occupying a portion or entire lobe of the lung or presence of pleural effusion on chest radiograph) was used as the reference criterion radiographic standard. We assessed the sensitivity, specificity, and likelihood ratios for clinical findings, and combinations of findings, for the diagnosis of primary endpoint pneumonia among children 0-59 months of age. RESULTS: Ten studies met inclusion criteria comprising 15 029 children; 24.9% (n=3743) had radiographic pneumonia. The presence of age-based tachypnoea demonstrated a sensitivity of 0.92 and a specificity of 0.22 while lower chest indrawing revealed a sensitivity of 0.74 and specificity of 0.15 for the diagnosis of radiographic pneumonia. The sensitivity and specificity for oxygen saturation <90% was 0.40 and 0.67, respectively, and was 0.17 and 0.88 for oxygen saturation <85%. Specificity was improved when individual clinical factors such as tachypnoea, fever and hypoxaemia were combined, however, the sensitivity was lower. CONCLUSIONS: No single sign or symptom was strongly associated with radiographic primary end point pneumonia in children. Performance characteristics were improved by combining individual signs and symptoms.

Meningitis por Streptococcus pyogenes: informe de un caso pediátrico / Streptococcus pyogenes meningitis: a pediatric case report

La meningitis por estreptococo beta hemolítico, en particular del grupo A, o Streptococcus pyogenes, es una rara localización del grupo de infecciones invasivas por este microorganismo. Se presenta con frecuencia en niños sanos, sin factores predisponentes. Representa el 0,2-1 % de todas las meningitis. Generalmente, se instala por diseminación de la infección de un foco cercano. El agregado de clindamicina mejora la eficacia del tratamiento por su acción de inhibición de la síntesis proteica, que incluye la producción de toxina. La clindamicina incrementa la acción bactericida al actuar sobre el ribosoma bacteriano. La patogenia de la enfermedad no es clara; se propuso la asociación con exotoxinas. La coinfección con el virus influenza favorecería infecciones invasivas. Se presenta el caso de un niño de 6 años de edad previamente sano con diagnóstico de meningitis por estreptococo beta hemolítico del grupo A, localización poco frecuente en niños.

Beta hemolytic particularly of group A Streptococcus meningitis, is a rare site of the group of invasive infections caused by this microorganism. It occurs frequently in healthy children, without predisposing factors. It represents 0.2-1 % of all meningitis. It is usually installed by dissemination from a nearby focus. The addition of clindamycin improves the treatment efficacy by inhibition of bacterial protein synthesis, including toxin production. The pathogenesis of the disease is not clear, the association with exotoxins was proposed. Co-infection with the influenza virus would favor invasive infections. We present this case of a previously healthy 6-year-old boy with a diagnosis of beta hemolytic Streptococcus meningitis group A, a rare location in children.

[Streptococcus pyogenes meningitis: a pediatric case report]. / Meningitis por Streptococcus pyogenes: informe de un caso pediátrico.

Beta hemolytic particularly of group A Streptococcus meningitis, is a rare site of the group of invasive infections caused by this microorganism. It occurs frequently in healthy children, without predisposing factors. It represents 0.2-1 % of all meningitis. It is usually installed by dissemination from a nearby focus. The addition of clindamycin improves the treatment efficacy by inhibition of bacterial protein synthesis, including toxin production. The pathogenesis of the disease is not clear, the association with exotoxins was proposed. Co-infection with the influenza virus would favor invasive infections. We present this case of a previously healthy 6-year-old boy with a diagnosis of beta hemolytic Streptococcus meningitis group A, a rare location in children.

La meningitis por estreptococo beta hemolítico, en particular del grupo A, o Streptococcus pyogenes, es una rara localización del grupo de infecciones invasivas por este microorganismo. Se presenta con frecuencia en niños sanos, sin factores predisponentes. Representa el 0,2-1 % de todas las meningitis. Generalmente, se instala por diseminación de la infección de un foco cercano. El agregado de clindamicina mejora la eficacia del tratamiento por su acción de inhibición de la síntesis proteica, que incluye la producción de toxina. La clindamicina incrementa la acción bactericida al actuar sobre el ribosoma bacteriano. La patogenia de la enfermedad no es clara; se propuso la asociación con exotoxinas. La coinfección con el virus influenza favorecería infecciones invasivas. Se presenta el caso de un niño de 6 años de edad previamente sano con diagnóstico de meningitis por estreptococo beta hemolítico del grupo A, localización poco frecuente en niños.

Community acquired pneumonia incidence among children less than 5 years of age in Concordia, Argentina: vaccination impact

[ABSTRACT]. Objective. To measure the effectiveness of pneumococcal conjugated vaccine (PCV13) against Community Acquired Pneumonia (CAP) and invasive pneumococcal disease, 2 years after the vaccine (2+1) was included into the National Immunization Program of Argentina, and to describe variables associated with bacterial pneumonia and hospitalization. Methods. This was a prospective, population-based surveillance study of CAP incidence (ambulatory and hospitalized) among children less than 5 years of age in the Department of Concordia (Entre Rios, Argentina) from April 2014 – March 2016. The diagnosis of probable bacterial pneumonia (PBP) was determined following the standardized WHO protocol. Incidence during the post-vaccine introduction period was compared with the results from a previous study that used similar methodology for the pre-PCV13 introduction period from 2002 – 2005. Results. During the study period, 330 patients had a clinical diagnosis of CAP, of which 92 were PBP (6 with pleural effusion). S. pneumoniae was not isolated from any sample. No factors associated with PBP were found in multivariable analysis. The decrease in PBP and pleural effusion was significant in relation to the previous study: 63% (P < 0.0001) and 80.9% (P < 0.003), respectively. PCV13 uptake was 97.3% for the 1st dose and 84.8% for the booster dose. Conclusions. PCV13 was effective to reduce incidence of consolidated pneumonia and pleural effusion, among children less than 5 years of age in Concordia, Argentina. Vaccination is a very effective public health strategy for reducing vaccine preventable diseases, with impact on burden of disease and hospitalization.

[RESUMEN]. Objetivo. Medir la efectividad de la vacuna antineumocócica conjugada (VNC13) contra la neumonía extrahospitalaria y las enfermedades neumocócicas invasoras, dos años después de que se incorporara la vacuna (2+1) en el Programa Nacional de Vacunación de Argentina, y describir las variables asociadas con la neumonía bacteriana y la hospitalización. Métodos. Se llevó a cabo un estudio prospectivo de vigilancia poblacional de la incidencia de la neumonía extrahospitalaria (pacientes ambulatorios y hospitalizados) en menores de 5 años en el departamento Concordia (Entre Ríos, Argentina) desde abril del 2014 hasta marzo del 2016. Se determinó el diagnóstico de probable neumonía bacteriana según el protocolo estandarizado de la OMS. Se comparó la incidencia durante el período posterior a la incorporación de la vacuna con los resultados de un estudio anterior en el que se usó una metodología similar para el período previo a la incorporación de la VNC13 entre el 2002 y el 2005. Resultados. Durante el estudio, 330 pacientes presentaron un diagnóstico clínico de neumonía extrahospitalaria, de los cuales 92 presentaron probable neumonía bacteriana (6 con derrame pleural). No se aisló ninguna muestra del S. pneumoniae. No se encontraron factores asociados con la neumonía bacteriana probable en el análisis multivariante. La disminución de la neumonía bacteriana probable y el derrame pleural fue significativa en relación con el estudio anterior: 63 % (P < 0,0001) y 80,9 % (P < 0,003), respectivamente. La absorción de la VNC13 fue de 97,3 % para la primera dosis y de 84,8 % para la dosis de refuerzo. Conclusiones. La VNC13 fue efectiva para reducir la incidencia consolidada de derrame pleural y neumonía en menores de 5 años en Concordia (Argentina). La vacunación es una estrategia de salud pública muy efectiva para reducir las enfermedades prevenibles por vacunación, con repercusión en la carga de enfermedad y la hospitalización.

[RESUMO]. Objetivo. Avaliar a efetividade da vacina pneumocócica conjugada (PCV13) em prevenir pneumonia adquirida na comunidade (PAC) e doença pneumocócica invasiva (DPI) após 2 anos da incorporação da vacina (2 + 1) ao Programa Nacional de Vacinação da Argentina e descrever as variáveis associadas à ocorrência de pneumonia bacteriana e internação hospitalar. Métodos. Estudo prospectivo de base populacional de vigilância da incidência de PAC (atendimento ambulatorial e em internação hospitalar) em crianças menores de 5 anos de idade realizado no Departamento de Concordia, Entre Rios, na Argentina, de abril de 2014 a março de 2016. O diagnóstico de provável pneumonia bacteriana foi determinado segundo o protocolo padronizado da OMS. A incidência no período pós-introdução da vacina foi comparada aos resultados de um estudo anterior realizado com metodologia semelhante no período pré-introdução da PCV13 de 2002 a 2005. Resultados. No período de estudo, foi feito o diagnóstico clínico de PAC em 330 pacientes, dos quais 92 foram casos de provável pneumonia bacteriana (6 com derrame pleural). A bactéria Streptococcus pneumoniae não foi isolada em nenhuma amostra. Não foi observado nenhum fator associado à provável pneumonia bacteriana na análise multivariada. Houve uma redução significativa da ocorrência de provável pneumonia bacteriana e derrame pleural em relação ao estudo anterior: 63% (P < 0,0001) e 80,9% (P < 0,003), respectivamente. A cobertura vacinal de PCV13 foi de 97,3% para a primeira dose e 84,8% para a dose de reforço. Conclusões. A PCV13 foi efetiva em reduzir a incidência de pneumonia com consolidação e derrame pleural em crianças menores de 5 anos em Concordia, na Argentina. A vacinação é uma estratégia de saúde pública muito efetiva para reduzir doenças que podem ser evitadas com vacina, com impacto na morbidade e nas internações hospitalares.

Community acquired pneumonia incidence among children less than 5 years of age in Concordia, Argentina: vaccination impact.

OBJECTIVE: To measure the effectiveness of pneumococcal conjugated vaccine (PCV13) against Community Acquired Pneumonia (CAP) and invasive pneumococcal disease, 2 years after the vaccine (2+1) was included into the National Immunization Program of Argentina, and to describe variables associated with bacterial pneumonia and hospitalization. METHODS: This was a prospective, population-based surveillance study of CAP incidence (ambulatory and hospitalized) among children less than 5 years of age in the Department of Concordia (Entre Rios, Argentina) from April 2014 - March 2016. The diagnosis of probable bacterial pneumonia (PBP) was determined following the standardized WHO protocol. Incidence during the post-vaccine introduction period was compared with the results from a previous study that used similar methodology for the pre-PCV13 introduction period from 2002 - 2005. RESULTS: During the study period, 330 patients had a clinical diagnosis of CAP, of which 92 were PBP (6 with pleural effusion). S. pneumoniae was not isolated from any sample. No factors associated with PBP were found in multivariable analysis. The decrease in PBP and pleural effusion was significant in relation to the previous study: 63% (P < 0.0001) and 80.9% (P < 0.003), respectively. PCV13 uptake was 97.3% for the 1st dose and 84.8% for the booster dose. CONCLUSIONS: PCV13 was effective to reduce incidence of consolidated pneumonia and pleural effusion, among children less than 5 years of age in Concordia, Argentina. Vaccination is a very effective public health strategy for reducing vaccine preventable diseases, with impact on burden of disease and hospitalization.

Community acquired pneumonia incidence among children less than 5 years of age in Concordia, Argentina: vaccination impact / Incidencia de la neumonía extrahospitalaria en menores de 5 años en Concordia (Argentina): repercusión de la vacunación / Incidência de pneumonia adquirida na comunidade em crianças menores de 5 anos em Concordia, Argentina: impacto da vacinação

ABSTRACT Objective To measure the effectiveness of pneumococcal conjugated vaccine (PCV13) against Community Acquired Pneumonia (CAP) and invasive pneumococcal disease, 2 years after the vaccine (2+1) was included into the National Immunization Program of Argentina, and to describe variables associated with bacterial pneumonia and hospitalization. Methods This was a prospective, population-based surveillance study of CAP incidence (ambulatory and hospitalized) among children less than 5 years of age in the Department of Concordia (Entre Rios, Argentina) from April 2014 - March 2016. The diagnosis of probable bacterial pneumonia (PBP) was determined following the standardized WHO protocol. Incidence during the post-vaccine introduction period was compared with the results from a previous study that used similar methodology for the pre-PCV13 introduction period from 2002 - 2005. Results During the study period, 330 patients had a clinical diagnosis of CAP, of which 92 were PBP (6 with pleural effusion). S. pneumoniae was not isolated from any sample. No factors associated with PBP were found in multivariable analysis. The decrease in PBP and pleural effusion was significant in relation to the previous study: 63% (P < 0.0001) and 80.9% (P < 0.003), respectively. PCV13 uptake was 97.3% for the 1st dose and 84.8% for the booster dose. Conclusions PCV13 was effective to reduce incidence of consolidated pneumonia and pleural effusion, among children less than 5 years of age in Concordia, Argentina. Vaccination is a very effective public health strategy for reducing vaccine preventable diseases, with impact on burden of disease and hospitalization.

RESUMEN Objetivo Medir la efectividad de la vacuna antineumocócica conjugada (VNC13)contra la neumonía extrahospitalaria y las enfermedades neumocócicas invasoras, dos años después de que se incorporara la vacuna (2+1) en el Programa Nacional de Vacunación de Argentina, y describir las variables asociadas con la neumonía bacteriana y la hospitalización. Métodos Se llevó a cabo un estudio prospectivo de vigilancia poblacional de la incidencia de la neumonía extrahospitalaria (pacientes ambulatorios y hospitalizados) en menores de 5 años en el departamento Concordia (Entre Ríos, Argentina) desde abril del 2014 hasta marzo del 2016. Se determinó el diagnóstico de probable neumonía bacteriana según el protocolo estandarizado de la OMS. Se comparó la incidencia durante el período posterior a la incorporación de la vacuna con los resultados de un estudio anterior en el que se usó una metodología similar para el período previo a la incorporación de la VNC13 entre el 2002 y el 2005. Resultados Durante el estudio, 330 pacientes presentaron un diagnóstico clínico de neumonía extrahospitalaria, de los cuales 92 presentaron probable neumonía bacteriana (6 con derrame pleural). No se aisló ninguna muestra del S. pneumoniae. No se encontraron factores asociados con la neumonía bacteriana probable en el análisis multivariante. La disminución de la neumonía bacteriana probable y el derrame pleural fue significativa en relación con el estudio anterior: 63 % (P < 0,0001) y 80,9 % (P < 0,003), respectivamente. La absorción de la VNC13 fue de 97,3 % para la primera dosis y de 84,8 % para la dosis de refuerzo. Conclusiones La VNC13 fue efectiva para reducir la incidencia consolidada de derrame pleural y neumonía en menores de 5 años en Concordia (Argentina). La vacunación es una estrategia de salud pública muy efectiva para reducir las enfermedades prevenibles por vacunación, con repercusión en la carga de enfermedad y la hospitalización.

RESUMO Objetivo Avaliar a efetividade da vacina pneumocócica conjugada (PCV13) em prevenir pneumonia adquirida na comunidade (PAC) e doença pneumocócica invasiva (DPI) após 2 anos da incorporação da vacina (2 + 1) ao Programa Nacional de Vacinação da Argentina e descrever as variáveis associadas à ocorrência de pneumonia bacteriana e internação hospitalar. Métodos Estudo prospectivo de base populacional de vigilância da incidência de PAC (atendimento ambulatorial e em internação hospitalar) em crianças menores de 5 anos de idade realizado no Departamento de Concordia, Entre Rios, na Argentina, de abril de 2014 a março de 2016. O diagnóstico de provável pneumonia bacteriana foi determinado segundo o protocolo padronizado da OMS. A incidência no período pós-introdução da vacina foi comparada aos resultados de um estudo anterior realizado com metodologia semelhante no período pré-introdução da PCV13 de 2002 a 2005. Resultados No período de estudo, foi feito o diagnóstico clínico de PAC em 330 pacientes, dos quais 92 foram casos de provável pneumonia bacteriana (6 com derrame pleural). A bactéria Streptococcus pneumoniae não foi isolada em nenhuma amostra. Não foi observado nenhum fator associado à provável pneumonia bacteriana na análise multivariada. Houve uma redução significativa da ocorrência de provável pneumonia bacteriana e derrame pleural em relação ao estudo anterior: 63% (P < 0,0001) e 80,9% (P < 0,003), respectivamente. A cobertura vacinal de PCV13 foi de 97,3% para a primeira dose e 84,8% para a dose de reforço. Conclusões A PCV13 foi efetiva em reduzir a incidência de pneumonia com consolidação e derrame pleural em crianças menores de 5 anos em Concordia, na Argentina. A vacinação é uma estratégia de saúde pública muito efetiva para reduzir doenças que podem ser evitadas com vacina, com impacto na morbidade e nas internações hospitalares.

Experiencia educativa para estudiantes de medicina de la Universidad de Buenos Aires (UBA) en la evaluación del Calendario Nacional de Vacunación de niños que concurrieron a Hospitales de la Ciudad Autónoma de Buenos Aires (CABA) / Educational experience for medical students at the University of Buenos Aires (UBA) in the evaluation of the National Vaccination Calendar of children who attended hospitals of the Autonomous City of Buenos Aires (CABA)

Objetivos: La participación de alumnos en estudios que evalúan el cumplimiento del programa de Inmunizaciones (PAI) y sus causales representa una experiencia relevante. La evaluación del cumplimiento del PAI permite proponer estrategias para aumentar coberturas.Métodos: Estudio observacional, analítico, transversal. Población: Neonatos a 11 años de edad, realizado en 6 hospitales de la CABA. Período: 1/06-31/12/2014. Participaron estudiantes del internado anual rotatorio capacitados sobre PAI,supervisados por docentes.Criterio de inclusión: Presentar el carné de vacunación, no tener condiciones que impidieran indicación del PAI.Resultados: Encuestas 531. Esquema incompleto o no recibió ninguna vacuna 25,7 por ciento. Se asociaron a incumplimiento las siguientes variables: Edad <1 año, edad materna <28 años, escasa educación materna, embarazo no controlado, ausencia de control de salud, internados, consulta porenfermedad. Análisis multivariado: falta de control de salud: RR 2,1(IC 95 por ciento:1,4-2,9).Como motivo de OPV predominó olvido (71,8 por ciento). Los alumnos refirieron útil su participación. Consideraron positivo aprender a investigar, contacto con pacientes y familiares, trabajar en equipo. Negativo: restó tiempo para estudiar.Conclusiones: Interactuar con la comunidad permitiría eliminar barreras que condicionan OPV. La comunicación es valiosa para lograr este objetivo. La participación supervisada de alumnos fue una experiencia innovadora, al introducirlos en la investigación clínica.

Introduction: The participation of students in research studies is a valuable teaching objective. Particularly evaluating implementation of the National immunization Program and their causal, allowing to propose strategies to increase coverage.Methods: An observational, analytical, crosssectional study. Population: Newborn to 11 years old, conducted in 6 hospitals of Buenos Aires city. Period: 1/06-31/12/2014. Pediatrics students belonging to the pediatric annualtraining in pediatrics, supervised by their teachers. Inclusion criteria: Presentation the vaccination card, have no conditions that would prevent indication of the vaccines.Results: 531 surveys were completed.Incomplete scheme, or no received vaccine 25.7 percent. The following variables were associated with non-compliance schedule: Age <1 year, maternal age <28 years, lowmaternal education, uncontrolled pregnancy, lack of health control, boarding, ambulatory consult for disease. Multivariate analysis: lackof control health: RR 2.1 (95 percent CI: 1.4-2.9).Family forgot vaccinate the child prevailed (71.8 percent). Students reported their participation useful. They considered positive learning how to research, contact with patients andfamilies, teamwork. As negative: Rest time to study.Conclusions: Interacting with the community enable barriers that condition not comply with the scheme. Communication is valuable to achieving this aim. Supervised student participation was an innovative experience to introduce in clinical research.

Empyema and bacteremic pneumococcal pneumonia in children under five years of age.

We compared bacteremic pneumococcal pneumonia (BPP) and pneumococcal empyema (PE), in terms of clinical, radiological, and laboratory findings, in under-fives. A cross-sectional nested cohort study, involving under-fives (102 with PE and 128 with BPP), was conducted at 12 centers in Argentina, Brazil, and the Dominican Republic. Among those with PE, mean age was higher; disease duration was longer; and tachypnea, dyspnea, and high leukocyte counts were more common. Among those with BPP, fever and lethargy were more common. It seems that children with PE can be distinguished from those with BPP on the basis of clinical and laboratory findings. Because both conditions are associated with high rates of morbidity and mortality, prompt diagnosis is crucial.

Global and regional burden of hospital admissions for severe acute lower respiratory infections in young children in 2010: a systematic analysis.

BACKGROUND: The annual number of hospital admissions and in-hospital deaths due to severe acute lower respiratory infections (ALRI) in young children worldwide is unknown. We aimed to estimate the incidence of admissions and deaths for such infections in children younger than 5 years in 2010. METHODS: We estimated the incidence of admissions for severe and very severe ALRI in children younger than 5 years, stratified by age and region, with data from a systematic review of studies published between Jan 1, 1990, and March 31, 2012, and from 28 unpublished population-based studies. We applied these incidence estimates to population estimates for 2010, to calculate the global and regional burden in children admitted with severe ALRI in that year. We estimated in-hospital mortality due to severe and very severe ALRI by combining incidence estimates with case fatality ratios from hospital-based studies. FINDINGS: We identified 89 eligible studies and estimated that in 2010, 11·9 million (95% CI 10·3-13·9 million) episodes of severe and 3·0 million (2·1-4·2 million) episodes of very severe ALRI resulted in hospital admissions in young children worldwide. Incidence was higher in boys than in girls, the sex disparity being greatest in South Asian studies. On the basis of data from 37 hospital studies reporting case fatality ratios for severe ALRI, we estimated that roughly 265,000 (95% CI 160,000-450,000) in-hospital deaths took place in young children, with 99% of these deaths in developing countries. Therefore, the data suggest that although 62% of children with severe ALRI are treated in hospitals, 81% of deaths happen outside hospitals. INTERPRETATION: Severe ALRI is a substantial burden on health services worldwide and a major cause of hospital referral and admission in young children. Improved hospital access and reduced inequities, such as those related to sex and rural status, could substantially decrease mortality related to such infection. Community-based management of severe disease could be an important complementary strategy to reduce pneumonia mortality and health inequities. FUNDING: WHO.

Penicillin-resistant pneumococcus and risk of treatment failure in pneumonia.

OBJECTIVE: To determine whether the presence of in vitro penicillin-resistant Streptococcus pneumoniae increases the risk of clinical failure in children hospitalised with severe pneumonia and treated with penicillin/ampicillin. DESIGN: Multicentre, prospective, observational study. SETTING: 12 tertiary-care centres in three countries in Latin America. PATIENTS: 240 children aged 3-59 months, hospitalised with severe pneumonia and known in vitro susceptibility of S pneumoniae. INTERVENTION: Patients were treated with intravenous penicillin/ampicillin after collection of blood and, when possible, pleural fluid for culture. The minimal inhibitory concentration (MIC) test was used to determine penicillin susceptibility of the pneumococcal strains isolated. Children were continuously monitored until discharge. MAIN OUTCOME MEASURES: The primary outcome was treatment failure (using clinical criteria). RESULTS: Overall treatment failure was 21%. After allowing for different potential confounders, there was no evidence of association between treatment failure and in vitro resistance of S pneumoniae to penicillin according to the Clinical Laboratory Standards Institute (CLSI)/National Committee for Clinical Laboratory Standards (NCCLS) interpretative standards ((adj)RR = 1.03; 95%CI: 0.49-1.90 for resistant S pneumoniae). CONCLUSIONS: Intravenous penicillin/ampicillin remains the drug of choice for treating penicillin-resistant pneumococcal pneumonia in areas where the MIC does not exceed 2 microg/ml.

Penicillin resistance and serotyping of Streptococcus pneumoniae in Latin America.

Streptococcus pneumoniae (Strep. pneumoniae) is the main cause of bacterial pneumonia in children less than 5 years of age, with high mortality rates in developing countries. In 1993, the Regional System for Vaccines Group (SIREVA) of the pan-American Health Organisation (PAHO) began a study involving six Latin American countries to identify serotypes and their representativity in the new conjugated vaccines, and to determine the degree of resistance to penicillin. Serotypes 14 (highest resistance level), 5, 1, 6A/B, 23F, 7F, 9V, 19F, 18C, 19A, 9N, were prevalent in the region, with some differences among countries. Although resistance to penicillin ranged from 2% (Brazil) to 21.1% (Mexico), studies have shown that pneumonia caused by Strep. pneumoniae with diminished sensitivity to penillin can be treated with this antibiotic. Only 58% of the serotypes isolated in the region studied were represented in the seven-valent vaccine. Continual surveillance is essential to determine which formulation of conjugated vaccine will be suitable for use in Latin America.