Etiología de la Neumonía Adquirida en la Comunidad en Niños Hospitalizados

INTRODUCCIÓN. La neumonía adquirida en la comunidad (NAC) es la primera causa de mortalidad en menores de 5 años a nivel global. En los países de nuestro entorno es causa de elevada morbilidad. Los estudios etiológicos son escasos y es frecuente la utilización innecesaria de antibióticos. OBJETIVOS PRINCIPALES. Describir la etiología de la NAC en la edad pediátrica en nuestro medio. Relacionar diversas variables epidemiológicas, clínicas, radiográficas, analíticas, de evolución y de gravedad con las diversas etiologías de este proceso. Establecer unos scores predictivos con los datos previos que ayuden al clínico a diferenciar la etiología del proceso en sus primeros momentos, antes del conocimiento de las pruebas microbiológicas. MÉTODOS. Estudio observacional, prospectivo, multicéntrico. Se incluían pacientes de 1 mes a 17 años, diagnosticados radiográficamente de NAC, ingresados en los Hospitales Universitarios Ramón y Cajal e Infanta Sofía de la Comunidad de Madrid (España), excluyendo los que presentaban comorbilidades, a excepción de asma. Se recogieron numerosas variables epidemiológicas, clínicas, analíticas, radiográficas, evolutivas y de gravedad. Se realizó un estudio microbiológico muy amplio, que incluía técnicas clásicas de cultivo, antigénicas, de serología y nuevas técnicas moleculares en sangre, orina, secreciones respiratorias y en el líquido pleural en el caso de realización de toracocentesis. Se correlacionaron todas las variables con la etiología de certeza o de alto grado de probabilidad y, con aquellas que presentaban los riesgos relativos más significativos, se buscó la obtención de dos scores que diferenciaran la etiología en los primeros momentos de la gestión del proceso. RESULTADOS PRINCIPALES. Se estudiaron 151 pacientes con una edad mediana de 41 meses (RIQ 19-70). Se documentó al menos un patógeno en 72 pacientes (48%). Fueron virus el 47%, bacterias atípicas (BAT) el 41% y bacterias típicas (BT) el 10%. El patógeno mayoritario fue Mycoplasma pneumoniae (37%), el virus más frecuente el VRS (18%) y la BT más frecuente Streptococcus pneumoniae (10%). La tasa de coinfección fue del 10%. El patrón radiográfico “infiltrado alveolar y/o derrame pleural” de la OMS se observó en todos los grupos etiológicos, pero el patrón “otros infiltrados” de la OMS, casi exclusivamente en las NAC virales. El 30% de los pacientes tuvo derrame pleural paraneumónico (DPP) (12% BT, 36% BAT y 9% virus). Con 4 datos clínicos, uno analítico y uno radiográfico se obtuvo un primer score que diferenciaba NAC bacteriana de vírica con una sensibilidad del 92%, una especificidad del 58% y elevados índices de probabilidad positiva y negativa pre-test. Si se hubiera aplicado, la tasa de reducción de antibioterapia hubiera sido del 55%. Una vez utilizado el primer score, se obtuvo un segundo con datos de biomarcadores sanguíneos que diferenciaba la etiología bacteriana típica de la atípica con una sensibilidad del 83%, una especificidad del 90% y elevados índices de probabilidad positiva y negativa pre-test. CONCLUSIONES PRINCIPALES. 1.- La etiología más frecuente de NAC en nuestro medio es la viral y el Mycoplasma pneumoniae el agente único más frecuente. 2.- El derrame pleural paraneumónico en NAC no es exclusivo de las bacterias típicas. 3.- La asociación de datos epidemiológicos, clínicos, radiográficos y analíticos puede diferenciar la etiología vírica de la bacteriana en NAC y, dentro de esta, la bacteriana típica de la bacteriana atípica

Expansion of serotype coverage in the universal pediatric vaccination calendar: Short-term effects on age- and serotype-dependent incidence of invasive pneumococcal clinical presentations in Madrid, Spain

In Madrid, Spain, the 13-valent pneumococcal conjugate vaccine (PCV13) replaced PCV7 in the pediatric universal vaccination calendar in June 2010. A prospective clinical surveillance that included all children hospitalized with culture- and/or PCR-confirmed invasive pneumococcal disease (IPD) was performed in all Madrid hospitals. The incidence rates (IRs) (defined as the number of cases/100,000 inhabitants aged<15 years) in the PCV7 (May 2007 to April 2010) versus PCV13 (May 2011 to April 2012) periods were compared. There were 499 cases in the PCV7 period and 79 cases in the PCV13 period. Globally, the IR significantly decreased from 17.09 (PCV7 period) to 7.70 (PCV13 period), with significant decreases (PCV7 versus PCV13 periods) in all age groups for bacteremic pneumonia (5.51 versus 1.56), parapneumonic pneumococcal empyema (PPE) (5.72 versus 3.12), and meningitis (2.16 versus 0.97). In the PCV13 period, significant reductions (the IR in the PCV7 period versus the IR in the PCV13 period) were found in IPDs caused by PCV13 serotypes (13.49 versus 4.38), and specifically by serotypes 1 (globally [4.79 versus 2.53], for bacteremic pneumonia [2.23 versus 0.97], and for PPE [2.26 versus 1.17]), serotype 5 (globally [1.88 versus 0.00], for bacteremic pneumonia [0.89 versus 0.00], and for PPE [0.55 versus 0.00]), and serotype 19A (globally [3.77 versus 0.49], for bacteremic pneumonia [0.72 versus 0.00], for PPE [0.89 versus 0.00], and for meningitis [0.62 versus 0.00]). IPDs caused by non- PCV13 serotypes did not increase (IR, 3.60 in the PCV7 period versus 3.31 in the PCV13 period), regardless of age or presentation. No IPDs caused by the PCV13 serotypes were found in children who received 3 doses of PCV13. The number of hospitalization days and sanitary costs were significantly lower in the PCV13 period. The switch from PCV7 to PCV13 in the universal pediatric vaccination calendar provided sanitary and economical benefits without a replacement by non-PCV13 serotypesThis work was supported in part by an unrestricted grant from Pfizer S.L.U., Madrid, Spain. J.P. and J.R.-C. have received travel fees from Pfizer for attending and/or speaking at symposiums and congresses. C.M. is an employee of Pfizer S.L.U., Madrid, Spain

Relationship between serotypes, age, and clinical presentation of invasive pneumococcal disease in Madrid, Spain, after introduction of the 7-valent pneumococcal conjugate vaccine into the vaccination calendar

To assess invasive pneumococcal disease (IPD) clinical presentations and relationships with age and serotype in hospitalized children (<15 years) after PCV7 implementation in Madrid, Spain, a prospective 2-year (May 2007 to April 2009) laboratory-confirmed (culture and/or PCR) IPD surveillance study was performed (22 hospitals). All isolates (for serotyping) and culture-negative pleural/cerebrospinal fluids were sent to the reference laboratory for pneumolysin (ply) and autolysin (lyt) gene PCR analysis. A total of 330 IPDs were identified: 263 (79.7%) confirmed by culture and 67 (20.3%) confirmed by PCR. IPD distribution by age (months) was as follows: 23.6% (<12), 15.8% (12 to 23), 15.5% (24 to 35), 22.4% (36 to 59), and 22.7% (>59). Distribution by clinical presentation was as follows: 34.5% bacteremic pneumonia, 30.3% pediatric parapneumonic empyema (PPE), 13.6% meningitis, 13.3% primary bacteremia, and 8.2% others. Meningitis and primary bacteremia were the most frequent IPDs in children <12 months old, and bacteremic pneumonia and PPE were most frequent in those >36 months old. Frequencies of IPD-associated serotypes were as follows: 1, 26.1%; 19A, 18.8%; 5, 15.5%; 7F, 8.5%; 3, 3.9%; nontypeable/ other 30 serotypes, 27.3%. Serotype 1 was linked to respiratory-associated IPD (38.6% in bacteremic pneumonia and 38.0% in PPE) and children of >36 months (51.4% for 36 to 59 months and 40.0% for >59 months), while serotype 19A was linked to nonrespiratory IPDs (31.1% in meningitis, 27.3% in primary bacteremia, and 51.9% in others) and children of <24 months (35.9% for children of <12 months and 36.5% for those 12 to 23 months old), with high nonsusceptibility rates for penicillin, cefotaxime, and erythromycin. After PCV7 implementation, non-PCV7 serotypes caused 95.5% of IPDs. The new 13-valent conjugate vaccine would provide 79.1% coverage of serotypes responsible for IPDs in this series

Viruses and Mycoplasma pneumoniae are the main etiological agents of community-acquired pneumonia in hospitalized pediatric patients in Spain

[Objectives]: To describe the etiology of community-acquired pneumonia (CAP) in hospitalized children in Spain and analyze the predictors of the etiology.[Hypothesis]: The different etiological groups of pediatric CAP are associated with different clinical, radiographic, and analytical data.[Design]: Observational, multicenter, and prospective study.[Patient selection]: This study included children aged 1 month to 17 years with CAP, who were hospitalized between April 2012 and May 2019.[Methods]: An extensive microbiological workup was performed. The clinical, radiographic, and analytical parameters were analyzed for three etiological groups.[Results]: Among the 495 children included, at least one causative pathogen was identified in 262 (52.9%): pathogenic viruses in 155/262 (59.2%); atypical bacteria (AB), mainly Mycoplasma pneumonia, in 84/262 (32.1%); and typical bacteria (TyB) in 40/262 (15.3%). Consolidation was observed in 89/138 (64.5%) patients with viral CAP, 74/84 (88.1%) with CAP caused by AB, and 40/40 (100%) with CAP caused by TyB. Para-pneumonic pleural effusion (PPE) was observed in 112/495 (22.6%) patients, of which 61/112 (54.5%) presented a likely causative pathogen: viruses in 12/61 (19.7%); AB in 23/61 (37.7%); and TyB in 26/61 (42.6%). Viral etiology was significantly frequent in young patients and in those with low oxygen saturation, wheezing, no consolidation, and high lymphocyte counts. CAP patients with AB as the etiological agent had a significantly longer and less serious course as compared to those with other causative pathogens.[Conclusions]: Viruses and M. pneumoniae are the main causes of pediatric CAP in Spain. Wheezing, young age, and no consolidation on radiographs are indicative of viral etiology. Viruses and AB can also cause PPE. Since only a few cases can be directly attributed to TyB, the indications for antibiotics must be carefully considered in each patient.Instituto de Investigación Hospital 12 de Octubre (i+12), Grant/Award Number: AY191212‐1; Instituto de Salud Carlos III (Ministry of Economy, Industry and Competitiveness) and co‐funded by the European Regional Development Funds, Grant/Award Number: Project PI17/01458; Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Grant/Award Number: PCAPE 2011_0025 Register 320/11; Research Project of Universidad Europea de Madrid, Grant/Award Number: 2017/UEM03Peer reviewe

Bacteremic pneumonia before and after withdrawal of 13-valent pneumococcal conjugate vaccine from a public vaccination program in Spain: a case-control study

The objective of this study is to compare the incidence and epidemiology of bacteremic community-acquired pneumonia (CAP) in the setting of changes in 13-valent pneumococcal conjugate vaccine (PCV13) coverage. In the region of Madrid, universal immunization with the PCV13 started in May 2010. In July 2012, public funding ceased. Vaccination coverage decreased from >95% to 82% in 2013 and to 67% in 2014. We performed a multicenter surveillance and case-control study from 2009-2014. Cases were hospitalized children with bacteremic CAP. Controls were children selected 1:1 from next-admitted with negative blood cultures and typical, presumed bacterial CAP. Annual incidence of bacteremic CAP declined from 7.9/100 000 children (95% CI 5.1-11.1) in 2009 to 2.1/100 000 children (95% CI 1.1-4.1) in 2012. In 2014, 2 years after PCV13 was withdrawn from the universal vaccination program, the incidence of bacteremic CAP increased to 5.4/100 000 children (95% CI 3.5-8.4). We enrolled 113 cases and 113 controls. Streptococcus pneumoniae caused most of bloodstream infections (78%). Empyema was associated with bacteremia (P = .003, OR 3.6; 95% CI 1.4-8.9). Simple parapneumonic effusion was not associated with bacteremia. Incomplete PCV immunization was not a risk factor for bacteremic pneumonia.Sin financiación3.874 JCR (2016) Q1, 7/121 PediatricsUE

Complications of pneumococcal bacteremia after 13-valent conjugate vaccine withdrawal

In the Region of Madrid, universal immunization with the 13-serotypes pneumococcal conjugate vaccine (PCV13) started in May 2010. In July 2012, public funding ceased. Vaccination coverage decreased from >95% to 82% in 2013 and to 67% in 2014. Our aim was to investigate the impact of PCV13 withdrawal from Madrid Region's universal immunization program on the incidence of complicated pneumococcal bacteremia. We performed a multi-center retrospective cohort study, from 2009 to 2014. Participants were children aged 100 mg/L, and serotype 1. A multivariate analysis indicated that complications were associated with meningitis and hospital admission after July 2012. Sequelae were significantly associated with children <2 years of age, meningitis and no-PCV13 serotypes. The incidence of complications due to PCV13 serotypes did not increase two years after PCV13 withdrawal. Nevertheless, all-serotypes complications increased. The likely cause was that no-PCV13 serotypes (associated with meningitis) are on the rise.Sin financiación2.486 JCR (2016) Q1, 27/121 Pediatrics; Q3, 43/84 Infectious Diseases; Q3, 99/151 ImmunologyUE

Screening and Severity of Coronavirus Disease 2019 (COVID-19) in Children in Madrid, Spain

This case series describes the testing for and treatment of children with coronavirus disease 2019 (COVID-19) in Madrid, Spain.Sin financiación16.193 JCR (2020) Q1, 1/129 Pediatrics4.004 SJR (2020) Q1, 1/301 Pediatrics, Perinatology and Child HealthNo data IDR 2019UE

Hyponatremia in children with pneumonia rarely means SIADH

BACKGROUND: Hyponatremia (HN) < 135 mmol/L is a frequent finding in children with community-acquired pneumonia (CAP). We aimed to determine the proportion of syndrome of inappropriate antidiuretic hormone secretion (SIADH) among patients with CAP and HN. Moreover, we wished to investigate the relationship between HN and inflammatory markers, bacterial etiology and prognosis in hospitalized children with CAP. METHODS: We carried out a prospective, observational, multicentre, prospective cohort study. Eligible participants were children from 1 month to 17 years old hospitalized due to CAP from 2012 to 2015. RESULTS: A total of 150 children were analyzed. Forty-five (30%) patients had serum sodium levels of less than 135 mmol/L. Patients with HN had significantly higher concentrations of inflammatory biomarkers. They also had significantly lower osmolality and urine sodium. They also had longer hospitalizations and more days of fever. Only 16 out of the 45 (35%) patients with HN had confirmed calculated plasma osmolality (<275 mOsm/kg). Only 5 out of 37 (13%) patients with available measurements of plasma osmolality and urine sodium fulfilled the criteria for SIADH. Among the 16 patients with HN and hypo-osmolality, 15 had a fractional sodium excretion (EFNa) levels of less than 1%. We found a significant inverse linear correlation between serum sodium and C-reactive protein, as well as serum sodium and procalcitonin. We found a significant direct correlation between serum sodium and urine sodium. CONCLUSION: HN is a common finding in hospitalized children with CAP. True SIADH is a rare event. HN has a good correlation with inflammatory biomarkers.Sin financiación1.059 JCR (2018) Q4, 100/125 Pediatrics0.398 SJR (2018) Q3, 154/318 Pediatrics, Perinatology and Child HealthNo data IDR 2018UE