Infecciones osteoarticulares en pediatría : diagnóstico, tratamiento y evaluación del abordaje conservador

Tesis inédita de la Universidad Complutense de Madrid, Facultad de Medicina, leída el 03-06-2022Las infecciones osteoarticulares (IOA) son relativamente comunes. No obstante, pueden ser potencialmente severas. Tradicionalmente, el manejo de esta patología estaba basado en antibioterapia prolongada, inicialmente intravenosa, asociando cirugía en caso de afectación articular o mala evolución. Sin embargo, en los últimos años, se ha descrito como opción igual de segura y eficaz disminuir la duración de tratamiento intravenoso a 2-4 días, especialmente en pacientes menores de 3 años sin factores de riesgo y fuera del periodo neonatal. Además, de manera progresiva, se han ido publicando nuevas series de pacientes con compromiso articular que presentaban buena evolución clínica habiendo sido abordados mediante artroscopia, artrocentesis con lavado articular o incluso únicamente con actitud expectante, reservando la cirugía únicamente para aquellos casos con evolución tórpida días después de haber iniciado antibioterapia. Asimismo, la implementación progresiva de las técnicas de detección molecular ha permitido la detección de gérmenes de crecimiento difícil en métodos de cultivo convencionales, como Kingella kingae. De hecho, actualmente este germen se ha descrito como el principal agente etiológico en pacientes entre 6 meses y 4 años de edad. La poca repercusión clínica y analítica que suele acompañar a este microorganismo, cuestiona si los pacientes con sospecha de IOA por K. kingae, o con bajo riesgo de secuelas, deberían ser manejados siguiendo las recomendaciones clásicas o si un abordaje mínimamente invasivo podría ser suficiente...Osteoarticular infections (OAI) are relatively common. However, they can be potentially serious. Traditionally, the management of this pathology was based on prolonged antibiotic therapy, initially intravenous, followed by surgery in case of joint involvement or poor evolution. However, recently, reducing the duration of intravenous treatment to 2-4 days has been described as an equally safe and effective option, especially in patients younger than 3 years without risk factors and outside the neonatal period. In addition, progressively, new series of patients with joint involvement who presented good clinical evolution have been published. Those patients had been approached by arthroscopy, arthrocentesis with joint lavage or even only with an expectant attitude, reserving surgery only for those cases with torpid evolution days after having started antibiotic therapy.Likewise, the progressive implementation of molecular detection techniques has allowed the detection of difficult-to-grow germs in conventional culture methods, such as Kingella kingae. In fact, this germ has now been described as the main etiological agent in patients between 6 months and 4 years of age.The subtle clinical and analytical repercussion that usually accompanies this microorganism, questions whether patients with suspected OAI due to K. kingae or with low risk of sequelae should be managed following the classic recommendations or if a minimally invasive approach could be sufficient...Fac. de MedicinaTRUEunpu

Position statement on infection screening, prophylaxis, and vaccination in pediatric patients with rheumatic diseases and immunosuppressive therapies, part 2: infection prophylaxis

This study aims to provide practical recommendations on prophylaxis for infection in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify articles that analyzed data on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapy. The results were presented and discussed in a nominal group meeting comprising a committee of 12 pediatric rheumatologists from the Prevention and Treatment of Infections Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process that was extended to members of the Spanish Society of Pediatric Rheumatology and the Vaccine Advisory Committee of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (completely disagree) to 10 (completely agree). Agreement was considered to have been reached if at least 70% of participants voted ≥ 7. The literature review included more than 400 articles. Overall, 63 recommendations were generated (23 on infection prophylaxis) and voted by 59 pediatric rheumatologists and other pediatric specialists, all of whom achieved the pre-established level of agreement. The recommendations on prophylaxis of infection cover vaccination and prophylaxis against varicella zoster virus, tuberculosis, Pneumocystis jiroveccii, and invasive fungal infections in pediatric patients with immune-mediated rheumatic diseases receiving/scheduled to receive immunosuppressive therapy. Conclusion: Based on current evidence and a Delphi process, we provided consensus and updated recommendations on prophylaxis and treatment of infections to guide those caring for pediatric rheumatology patients.Funding for open access charge: Universidad de Málaga/CBU

Position statement on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies, part 3: precautions in situations of surgery, fever, and opportunistic infections

The objective of this study is to provide practical recommendations on the management of pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The recommendations specifically address the cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, invasive fungal disease). A qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using MeSH terms and free text to identify publications on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases receiving immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the Infection Prevention and Treatment Working Group of the Spanish Society of Pediatric Rheumatology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process; this was extended to members of the Spanish Society of Pediatric Rheumatology and Spanish Society of Pediatric Infectious Disease of the Spanish Association of Pediatrics. Participants produced a score ranging from 0 (totally disagree) to 10 (totally agree). Agreement was defined as a vote ≥ 7 by at least 70% of participants. The literature review included more than 400 articles. Overall, 63 recommendations (19 on surgery, fever, and opportunistic infections) were generated and voted by 59 pediatric rheumatologists and other pediatric specialists. Agreement was reached for all 63 recommendations. The recommendations on special situations cover management in cases of surgery, fever, and opportunistic infections (varicella, herpes-zoster, tuberculosis, and invasive fungal disease). Conclusions: Hereby, we provided consensus and updated of recommendations about the management of special situations such as surgery, fever, and opportunistic in children with immune-mediated rheumatic diseases receiving immunosuppressive therapies. Several of the recommendations depend largely on clinical judgement and specific balance between risk and benefit for each individual and situation. To assess this risk, the clinician should have knowledge of the drugs, the patient’s previous situation as well as the current infectious disease, in addition to experience. What is Known: • Infectious diseases and related complications are a major cause of morbidity and mortality in patients with immune-mediated rheumatic diseases. • Information on how to manage the treatment in situations of fever, opportunistic infections, and surgery in children is limited, and guidelines for action are often extrapolated from adults. What is New: • In the absence of strong evidence, a literature review and a Delphi survey were conducted to establish a series of expert recommendations that could support the clinical practice, providing a practical and simple day-to-day approach to be used by pediatric rheumatologists.Universidad Malaga/CBUASpringer NaturePfizerSERPE3.6 Q1 JCR 20221.036 Q1 SJR 2022No data IDR 2022UE

Correction to: Position statement of the Spanish society of pediatric rheumatology on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies: part 1 (screening)

CRUE-CSICSpringer NatureFunding agency CRUE-CSIC Springer Nature PfizerUniversidad de Malaga/CBUA3.860 JCR (2021) Q1, 28/130 Pediatrics0.806 SJR (2021) Q1, 65/319 Pediatrics, Perinatology and Child HealthNo data IDR 2021UE

Position statement of the Spanish Society of Pediatric Rheumatology on infection screening, prophylaxis, and vaccination of pediatric patients with rheumatic diseases and immunosuppressive therapies: Part 1 (screening)

Abstract This study provides practical recommendations on infection screening in pediatric patients with immune-mediated rheumatic diseases and immunosuppressive therapies. For this reason, a qualitative approach was applied. A narrative literature review was performed via Medline. Primary searches were conducted using Mesh and free texts to identify articles that analyzed data on infections and vaccinations in pediatric patients with immune-mediated rheumatic diseases and immunosuppressive therapies. The results were presented and discussed in a nominal group meeting, comprising a committee of 12 pediatric rheumatologists from the infections prevention and treatment working group of the Spanish Society of Pediatric Rheuma tology. Several recommendations were generated. A consensus procedure was implemented via a Delphi process that was extended to members of the Spanish Society of Pediatric Rheumatology and Vaccine Advisory Committee of the Spanish Association of Pediatrics. Participants to the process produced a score ranging from 0=totally disagree to 10=totally agree. Agreement was considered if at least 70% of participants voted≥7. The literature review included more than 400 articles. Overall, 63 recommendations were generated (21 on infection screening) voted by 59 pediatric rheumatologists and other pediatric specialists, all of them achieving the pre-established agreement level. The recommendations on screening cover all the procedures (serology, assessment of risk factors, and other clinical activities) connected with the screening for infections including tuberculosis; hepatitis A, B, and C viruses; measles; mumps; rubella; diphtheria; and other infections. Conclusion: Screening for infections is an essential part of risk management in pediatric patients with immune-mediated rheumatic diseases and immunosuppressive therapies.Open Access funding provided thanks to the CRUE-CSIC agreement with Springer Nature. This project was partially funded by an unrestricted grant of Pfzer. Pfzer did not take part in the design, development of the project, or in the manuscript. SERPE also provided funds to the project. Funding for open access charge: Universidad de Málaga / CBU