Factors influencing antimicrobial resistance and outcome of Gram-negative bloodstream infections in children.

OBJECTIVE: The aim of this study was to collect data about pediatric Gram-negative bloodstream infections (BSI) to determine the factors that influence multidrug resistance (MDR), clinical course and outcome of children affected by Gram-negative sepsis. METHODS: In this observational, prospective, multicenter study we collected cases of pediatric Gram-negative BSI during a 2-year period. We analyzed epidemiological, microbiological and clinical factors that associated with acquisition of MDR infections and outcome. RESULTS: One-hundred and thirty-five BSI episodes were analyzed. Median age of children was 0.5 years (IQR 0.1-6.17, range 0-17 years). Predominant bacteria were Enterobacteriaceae (68.3 %), and Pseudomonas spp. (17.9 %). Multidrug resistance was detected in 45/134 cases (33.6 %), with the highest rates in Escherichia coli, Enterobacter and Pseudomonas spp. Acquisition of MDR pathogens was significantly associated with prior cephalosporin treatment, older age, admission to hemato-oncology unit, polymicrobial infections, higher rate of development of septic shock, and multiple organ failures. All-cause mortality was 17.9 %. Presence of septic shock at presentation and parenteral nutrition were associated with higher mortality. Pseudomonas spp., and Enterobacter spp. BSIs had the highest rate of mortality. Inappropriate empiric antibiotic therapy was more frequent in MDR patients, although not significantly associated with poor outcome. CONCLUSION: Rates of multidrug resistance and mortality in children with Gram-negative bloodstream infections remain high in our settings. Empiric broad-spectrum antibiotics and combination therapy could be recommended, especially in children with malignant diseases, patients admitted to the PICU, and for cases with septic shock, who have higher mortality risk.

Mild encephalitis/encephalopathy with a reversible splenial lesion in children.

Authors, most of them Japanese, have recently published an increasing number of articles on mild encephalitis/encephalopathy with a reversible splenial lesion. We report on two new white European patients and compare published data with our own observations. A 15-year-old girl developed headache, fever, dizziness, vomiting and nuchal rigidity over four days. CSF showed elevated protein and cell count, with the lowest serum Na being 131 mmol/L. MRI on day seven was normal, but she remained febrile, had cerebral edema and episodes of confusion. MRI on day 11 showed a small T2-hyperintense lesion with restricted diffusion in the callosal splenium. Adenoviral infection was proved, and the girl underwent a protracted course of recovery. MRI signal changes improved in six days and disappeared after four months. A 12.5-year-old girl developed headache, lethargy, drowsiness and vomiting. On day five she experienced right-sided numbness, weakness and inability to speak which lasted 12 hours. She was confused and disoriented. MRI disclosed a tiny area of increased T2-signal and restricted diffusion in the splenium. Serum Na was 133 mmol/L, CSF cell count and protein was markedly elevated, and enteroviral infection was detected. Echocardiography showed no changes predisposing to clot formation and no thrombophilia was found. Her symptoms resolved in a week and MRI was normal two months later. These two non-epileptic children increase the small number of white European patients with MERS reported so far. Both had hyponatremia and encephalitis and patient 2 had transient ischemic attack, possibly due to the cerebral edema also resulting in the splenial lesion.

[Serotype distribution and antimicrobial susceptibility of Streptococcus pneumoniae strains isolated from middle ear fluids of children aged 0-24 months with acute otitis media]. / Középfülváladékból izolált Streptococcus pneumoniae törzsek szerotípus-megoszlása és antibiotikum-érzékenysége kétéves kor alatti gyermekeknél.

UNLABELLED: Acute otitis media is one of the most common diseases in children aged 0-24 months and Streptococcus pneumoniae is the most frequently isolated bacterial pathogen of acute otitis media. It is well established and documented that the heptavalent pneumococcal conjugate vaccine reduces the frequency of otitis media, especially caused by vaccine-serotype pneumococcus (4, 6B, 9, 14, 18C, 19F, 23F). However, this effect depends on the serotype distribution of isolated otopathogenic pneumococcal strains. OBJECTIVE: Aim of this study was to determine the serotype distribution and antimicrobial resistance of pneumococcal strains causing acute otitis media in children aged 0-24 months. PATIENTS AND METHODS: Between year 2002 and 2005 we investigated 73 pneumoccocal strains isolated from middle ear fluids of children aged 0-24 months in 10 pediatric centers in Budapest, Hungary. After bacteriological identification, pneumococcal serotyping was performed through Quellung reaction in the Microbiological Laboratory of Szent Lászlo Hospital Budapest, Hungary. Antimicrobial resistance was determined according to the international standards accepted by the Hungarian Society for Microbiology. RESULTS: The 73 strains represented 14 different serotypes. The most common were serotypes 14 (13.7 %), 19F (13.7 %), 6B (13.7 %), 23A (11 %) and 3 (9.6 %). Coverage ratio of the heptavalent pneumococcal conjugated vaccine was 63 %. Intermediate penicillin susceptibility was 41 % among all serotypes and 90 % among vaccine-serotypes. No high level penicillin resistant strains were found. Among intermediate penicillin susceptible strains serotype 9V, 14 and 19F were the most frequent. CONCLUSION: Serotype distribution of otopathogenic pneumococcal strains and coverage ratio of heptavalent conjugated pneumococcal vaccine in Hungary are similar to the result found in other geographic regions. In conclusion, we suppose that use of the pneumococcal conjugated vaccines in Hungary would provide same effectiveness against acute otitis media showed in previous multinational efficacy trials.

[Pneumococcal meningitis in children--9 1/2-year-experience at Szent László Hospital, Budapest, Hungary]. / Pneumococcus-meningitis gyermekkorban--kilenc és fél év tapasztalata a Szent László kórházban.

BACKGROUND AND OBJECTIVE: No recent publications are available about pneumococcal meningitis in Hungarian children. The aim of this study was to collect data of epidemiological, clinical and prognostic features of pneumococcal meningitis in children treated at Szent László Hospital, Budapest, Hungary. METHODS: We conducted a retrospective review of medical charts and follow-up records of patients aged 1 to 18 years admitted to our Pediatric and Pediatric Intensive Care Units due to pneumococcal meningitis between 1st Jan 1998 and 30th Jun 2007. RESULTS: 31 children with 34 cases of pneumococcal meningitis were admitted to our hospital in the study period. Two children developed recurrent illness. The mean age was 6 years, 26% were under 1 year of age. The mean duration of hospital stay was 21 days, 97% required intensive care. Frequent clinical symptoms were fever (100%), nuchal rigidity and vomiting (78%), altered mental status (71%), Kernig's and Brudzinski's signs (58%) and seizures (41%). Otitis media, sinusitis, mastoiditis were present in 44%, 58%, 41%, respectively. Subdural effusion, parenchymal cerebral lesion and sinus thrombosis were documented in 5, 3 and 2 cases, respectively. One third of the patients received ceftriaxon, two thirds were administered ceftriaxon and vancomycin. Adjunctive therapy with dexamethasone was given to 91% of the children. 70% of patients required mechanical ventilation. 9 patients (25%) required endoscopic sinus surgery. In 13 cases (38%) mastoidectomy, in 5 children (15%) neurosurgery was performed. The case fatality rate was 23.5%. 8 (23.5%) patients had mild or moderate, 1 child (3%) developed severe neurological sequelae. CONCLUSION: Pneumococcal meningitis in children remains a source of substantial morbidity and mortality in childhood. The long hospital stay, the frequent need for intensive care and severe neurologic sequelae emphasize the importance of early diagnosis, early treatment and prevention with pneumococcal conjugate vaccines.