Botulismo del lactante en Argentina. Trabajo multicéntrico / Infant botulism in Argentina. Multicentric work

Resumen El botulismo del lactante (BL), es la forma más frecuente del botulismo humano en la actualidad, es una enfermedad "rara" o "huérfana" ya que afecta a menos del 0,05 % de la población. El objetivo del presente trabajo es determinar la Incidencia del BL en la Argentina, evaluar el diagnóstico y tratamiento realizado, comparar la evolución y las secuelas al alta en pacientes con y sin tratamiento específico y, considerar las características climáticas (precipitaciones y vientos) y los estudios de muestras de suelos de las provincias con mayor cantidad de casos de BL. Presentamos un estudio multicéntrico, de cohorte (longitudinal) observacional, retrospectivo analizando las historias clínicas de los pacientes con BL, que ingresaron a Unidades de Cuidados Intensivos Pediátricos con asistencia respiratoria mecánica, desde el 1 de enero de 2010 hasta 31 de diciembre de 2013. Se consideró: edad, sexo, días previos al ingreso hasta diagnóstico por laboratorio, total internación en Unidades de Cuidados Intensivos Pediátricos con asistencia respiratoria mecánica, alimentación por sonda nasogástrica, tratamiento y secuelas. En Argentina entre 2010 al 2013 se registraron 216 casos de BL. En este trabajo se analizaron 79 pacientes provenientes de 11 provincias, que ingresaron a Unidades de Cuidados Intensivos Pediátricos. La edad promedio de los pacientes ingresados fue de 4 meses, de los cuales 90% recibía alimentación materna. Dieciocho pacientes de seis provincias recibieron antitoxina botulínica equina. El promedio de días de enfermedad previos al ingreso fue de 2 días en los pacientes que recibieron tratamiento con antitoxina botulínica equina y 4 días en los pacientes no tratados. Diagnóstico de laboratorio (Toxina A y Clostridium botulinum) a los 5 días en los tratados con antitoxina botulínica equina, y a los 11,5 en los no tratados. En los pacientes tratados con antitoxina botulínica equina, el promedio de días de internación fue de 30 versus 70 días en los no tratados (p=0,0001). El promedio días en las Unidades de Cuidados Intensivos Pediátricos de los pacientes tratados fue de 20 versus 54 días en los no tratados (p=0,0001). Los días de asistencia respiratoria mecánica en los tratados fue de 16 versus 43 días en los no tratados (p=0,0001) y los tratados requirieron 29 días de alimentación por sonda nasogástrica versus 70 días en los no tratados (p=0,0001). El 40% de los pacientes tratados presentaron neumonía asociada a respirador versus el 56% de los no tratados (p=0,0038), sepsis el 11% versus el 34% (p=0,005) y secuelas al alta 6% versus 64% (p=0,0001), respectivamente. En zonas con mayor número de casos, se observó una alta frecuencia de esporas en los suelos, asociado a clima seco y ventoso. Los resultados sugieren que el tratamiento precoz con antitoxina botulínica equina es una alternativa hasta disponer de inmuno-globulina botulínica humana. Los climas secos y ventosos favorecen la enfermedad.

Abstract Infant botulism (BL), the most common form of human botulism today, is a "rare" or "orphan" disease as it affects less than 0.05% of the population. The objective of this work is to determine the incidence of BL in Argentina. Evaluate the diagnosis and treatment performed. To compare evolution and sequelae at discharge in patients with and without specific treatment. Consider the climatic characteristics (precipitations and winds) and the studies of soil samples from the provinces with the highest number of BL cases. We present a retrospective, observational, multicenter, cohort (longitudinal) study analyzing the medical records of patients with BL, who were admitted to Pediatric Intensive Care Units with mechanical ventilation, from January 1,2010 to December 31,2013. The following were considered: age, sex, days prior to admission, until laboratory diagnosis, Pediatric Intensive Care Units, me-chanical respiratory assistance, average hospital days, nasogastric tube feeding, treatment and sequelae. In the country, 216 cases of BL were registered between 2010 and 2013. We analyzed 79 who were admitted to Pediatric Intensive Care Units from 11 provinces. Average age 4 months. Maternal nutrition 90%. Eighteen patients (6 provinces) received equine botulinum antitoxin .Mean days of illness prior to admission: 2 in those treated with equine botulinum antitoxin and 4 in those not treated. Laboratory diagnosis (Toxin A and Clostridium botulinum) at 5 days in treated with equine botulinum antitoxin, at 11.5 in untreated. Patients with equine botulinum antitoxin average hospital days 30 vs 70 in untreated patients (p=0.0001). Mean Pediatric Intensive Care Unit days 20 vs 54 (p=0.0001) of mechanical respiratory assistance 16 vs 43 (p=0.0001) and nasogastric tube feeding 29 vs 70 (p=0.0001). Those treated presented ventilator-associated pneumonia 40% vs 56% (p=0.0038) and sepsis 11% vs 34% (p=0.005). Sequelae at discharge 6% vs 64% (p=0.0001) in those not treated. In areas with a higher number of cases, high frequency of spores in soils, dry and windy weather. The results suggest that early treatment with equine botulinum antitoxin is an alternative until human botulinum immunoglobulin is available. The dry and windy climates favor the disease.

Intensive care treatments associated with favorable discharge outcomes in Argentine children with severe traumatic brain injury: For the South American Guideline Adherence Group.

OBJECTIVE: Little is known about the critical care management of children with traumatic brain injury (TBI) in low middle income countries. We aimed to identify indicators of intensive care unit (ICU) treatments associated with favorable outcomes in Argentine children with severe TBI. METHODS: We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with severe TBI who were admitted to an ICU in one of the seven study centers. Severe TBI was defined by head AIS ≥ 3, head CT with traumatic lesion, and admission GCS < 9. Seven indicators of best practice TBI care were examined. The primary outcome was discharge Pediatric Cerebral Performance Category Scale [PCPC] and Pediatric Overall Performance category Scale [POPC]. We also examined variation in ICU care and in-patient mortality. RESULTS: Of the 117 children, 67% were male and 7.5 (4.3) years on average, 92% had isolated TBI. Hypotension (54%) was more common than hypoxia (28%) and clinical or radiographic signs of high intracranial pressure (ICP) were observed in 92%. Yet, ICP monitoring occurred in 60% and hyperosmolar therapy was used in only 36%. Adherence to indicators of best TBI practice ranged from 55.6% to 83.7% across the seven centers and adherence was associated with favorable discharge PCPC (aRR 0.98; 95% CI [0.96, 0.99]), and POPC (aRR 0.98; 95% CI [0.96, 0.99]). Compared to patients whose adherence rates were below 65%, patients whose adherence rates were higher between 75%-100% had better discharge PCPC (aRR 0.28; 95% CI [0.10, 0.83]) and POPC (aRR 0.32; 95% CI [0.15, 0.73]. Two indicators were associated with favorable discharge PCPC: Avoidance of hypoxia (aRR 0.46; 95% CI [0.23, 0.93]), and Nutrition started in 72 hours (aRR 0.45; 95% CI [0.21, 0.99]). Avoiding hypoxia was also associated with favorable discharge POPC (aRR 0.47; 95% CI [0.22, 0.99]). CONCLUSION: There is variation in Argentine ICU practice in the care of children with severe TBI. Second insults are common and hyperosmolar therapy use is uncommon. Adherence to best practice TBI care by avoiding hypoxia and providing timely nutrition were associated with significantly favorable discharge outcomes. Implementing strategies that prevent hypoxia and facilitate early nutrition in the ICUs are urgently needed to improve pediatric TBI outcomes.

Benchmarking Prehospital and Emergency Department Care for Argentine Children with Traumatic Brain Injury: For the South American Guideline Adherence Group.

OBJECTIVE: There is little information on the type of early care provided to children with traumatic brain injury (TBI) in low middle income countries. We benchmarked early prehospital [PH] and emergency department [ED] pediatric TBI care in Argentina. METHODS: We conducted a secondary analysis of data from patients previously enrolled in a prospective seven center study of children with TBI. Eligible participants were patients 0-18 years, and had diagnosis of TBI (admission Glasgow Coma scale score [GCS] < 13 or with GCS 14-15 and abnormal head CT scan within 48 hours of admission, and head AIS > 0). Outcomes were transport type, transport time, PH and ED adherence to best practice, and discharge Pediatric Cerebral Performance Category Scale (PCPC) and Pediatric Overall Performance category Scale (POPC). RESULTS: Of the 366 children, mean age was 8.7 (5.0) years, 58% were male, 90% had isolated TBI and 45.4% were transported by private vehicle. 50 (34.7%) of the 144 children with severe TBI (39.3% of all TBI patients) were transported by private vehicle. Most (267; 73%) patients received initial TBI care at an index hospital prior to study center admission, including children with severe (81.9%) TBI. Transport times were shorter for those patients who were directly transported by ambulance to study center than for the whole cohort (1.4 vs.5.5 hours). Ambulance blood pressure data were recorded in 30.9%. ED guideline adherence rate was higher than PH guideline adherence rate (84.8% vs. 26.4%). For patients directly transferred from scene to study trauma centers, longer transport time was associated with worse discharge outcome (PCPC aOR 1.10 [1.04, 1.18] and (POPC aOR 1.10 [1.04, 1.18]). There was no relationship between PH or ED TBI guideline adherence rate and discharge POPC and PCPC. CONCLUSION: This study benchmarks early pediatric TBI care in Argentina and shows that many critically injured children with TBI do not receive timely or best practice PH care, that PH guideline adherence rate is low and that longer transport time was associated with poor discharge outcomes for patients with direct transfer status. There is an urgent need to improve the early care of children with TBI in Argentina, especially timely transportation to a hospital.

Postdischarge Care of Pediatric Traumatic Brain Injury in Argentina: A Multicenter Randomized Controlled Trial.

OBJECTIVE: To develop, in partnership with families of children with traumatic brain injury, a postdischarge intervention that is effective, simple, and sustainable. DESIGN: Randomized Controlled Trial. SETTING: Seven Level 1 Pediatric Trauma Centers in Argentina. PATIENTS: Persons less than 19 years of age admitted to one of the study hospitals with a diagnosis of severe, moderate, or complicated mild traumatic brain injury and were discharged alive. INTERVENTIONS: Patients were randomly assigned to either the intervention or standard care group. A specially trained Community Resource Coordinator was assigned to each family in the intervention group. We hypothesized that children with severe, moderate, and complicated mild traumatic brain injury who received the intervention would have significantly better functional outcomes at 6 months post discharge than those who received standard care. We further hypothesized that there would be a direct correlation between patient outcome and measures of family function. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was a composite measured at 6 months post injury. There were 308 patients included in the study (61% men). Forty-four percent sustained a complicated mild traumatic brain injury, 18% moderate, and 38% severe. Sixty-five percent of the patients were 8 years old or younger, and over 70% were transported to the hospital without ambulance assistance. There was no significant difference between groups on the primary outcome measure. There was a statistically significant correlation between the primary outcome measure and the scores on the Family Impact Module of the Pediatric Quality of Life Inventory (ρ = 0.57; p < 0.0001). Children with better outcomes lived with families reporting better function at 6 months post injury. CONCLUSIONS: Although no significant effect of the intervention was demonstrated, this study represents the first conducted in Latin America that documents the complete course of treatment for pediatric patients with traumatic brain injury spanning hospital transport through hospital care and into the postdischarge setting.