Cribado de la infección congénita por citomegalovirus en prematuros de peso adecuado y neonatos de bajo peso para la edad gestacional

Tesis doctoral inédita leída en la Universidad Autónoma de Madrid, Facultad de Medicina, Departamento de Pediatría. Fecha de lectura: 06-07-2017Esta tesis tiene embargado el acceso al texto completo hasta el 06-01-201

Estudio descriptivo de la endocarditis infecciosa quirúrgica

Introducción: la endocarditis infecciosa es una enfermedad grave cuya incidencia y mortalidad no se han modificado a pesar de los nuevos avances. Métodos: con un diseño retrospectivo descriptivo se incluyeron todos los pacientes intervenidos quirúrgicamente durante 6 años. Obtuvimos la información a partir de las historias clínicas. Resultados: los pacientes analizados(n=55) fueron 72,2% varones y presentaron una edad media de 64,1±12,8 años. Como factores predisponentes encontramos EI previa 9,1%, válvula aórtica bicúspide 9,1%, prótesis valvulares 34,1%, marcapasos 15,9%, y valvulopatía 20,5%. Las presentaciones más habituales fueron FOD 51,9% y IC 32,7%. Los gérmenes más frecuentes fueron S. aureus 22,2%, S. epidermidis 20,4%, y E. faecalis 14,8%. De las vegetaciones objetivadas en la cirugía se visualizaron un 70,8% mediante ETT y un 85,4% mediante ETE, los abscesos 55% mediante ETT y 81% mediante ETE y los pseudoaneurismas 20% mediante ETT y 80% mediante ETE. Conclusiones: la mayoría de los pacientes eran varones de edad avanzada. La FOD fue la forma de presentación en más de la mitad de los casos. Los factores predisponentes más importantes fueron el material protésico, tanto prótesis valvulares como dispositivos intracardiacos, y las valvulopatía orgánica. El microorganismo más frecuente fue el estafilococo. La ecocardiografia fue esencial en el diagnóstico de la enfermedad, objetivando la gran mayoría de las vegetaciones. La ETE fue marcadamente más sensible que la ETT a la hora de diagnosticar abscesos y pseudoaneurismas

Validación de la escala de riesgo de sangrado crusade en los pacientes con scacest sometidos a cateterismo urgente por fibrinolisis fallida

Introducción y objetivos: Es por todos conocidos la utilidad de la escala de riesgo CRUSADE en cuanto a predicción de sangrados mayores en el síndrome coronario sin elevación del segmento ST (SCASEST). En trabajos recientes se ha estudiado su capacidad predictora de eventos hemorrágicos en los pacientes con síndrome coronario agudo con elevación del ST (SCACEST) con buenos resultados incluso con mayor precisión que la reportada en los pacientes con SCASEST. Dentro del grupo del SCACEST se encuentra un grupo que requiere consideraciones especiales que son los pacientes a los que se les ha realizado fibrinolisis resultando ésta fallida y posteriormente son sometidos a cateterismo urgente de rescate. Estos pacientes van recibir en un corto periodo de tiempo el fármaco fibrinolítico así como los antiagregantes y anticoagulantes utilizados durante el intervencionismo coronario lo cual va a aumentar en gran medida el riesgo de complicaciones hemorragicas. Nuestro objetivo es valorar la capacidad predictora de sangrados de la escala CRUSADE en estos pacientes. Material y métodos: Estudiamos retrospectivamente a los pacientes sometidos a ICP de rescate entre enero de 2006 y octubre de 2012 en nuestro centro . Calculamos los valores del CRUSADE al ingreso. Registramos el numero de hemorragias mayores (definida según la clasificación CRUSADE). Posteriormente analizamos la capacidad predictora de sangrados mayores y la precisión del score. Resultados: 480 pacientes con SCACEST fueron tratados con ICP de rescate en nuestro centro desde enero de 2006 a octubre de 2012. Calculamos el CRUSADE en 426 pacientes. El número registrado de hemorragias mayores durante el ingreso fue de 48 (11%). La incidencia de hemorragia mayor atendiendo a cada quintil que propone la escala fue: 2,5% en los pacientes con muy bajo riesgo; 11,3% en aquellos con bajo riesgo; 15% en aquellos con riesgo moderado; 26,3% en aquellos con alto riesgo y 22,2% en aquellos con muy alto riesgo (p < 0,001). El área bajo la curva ROC fué de 0,74. Conclusión: la escala de riesgo de sangrado CRUSADE predice adecuadamente el riesgo de sangrado en los pacientes con SCACEST sometidos a ICP de rescate aunque sería necesario ampliar el estudio en los grupos de muy bajo y muy alto riesgo

Prognostic factors of a lower CD4/CD8 ratio in long term viral suppression HIV infected children

CoRISpe (Cohorte Nacional de VIH pediátrica de la RED RIS).[Background] Combination antiretroviral therapy (cART) is associated with marked immune reconstitution. Although a long term viral suppression is achievable, not all children however, attain complete immunological recovery due to persistent immune activation. We use CD4/CD8 ratio like a marker of immune reconstitution.[Methods] Perinatal HIV-infected children who underwent a first-line cART, achieved viral suppression in the first year and maintained it for more than 5 years, with no viral rebound were included. Logistic models were applied to estimate the prognostic factors, clinical characteristics at cART start, of a lower CD4/CD8 ratio at the last visit.[Results] 146 HIV-infected children were included: 77% Caucasian, 45% male and 28% CDC C. Median age at cART initiation was 2.3 years (IQR: 0.5–6.2). 42 (30%) children received mono-dual therapy previously to cART. Time of undetectable viral load was 9.5 years (IQR: 7.8, 12.5). 33% of the children not achieved CD4/CD8 ratio >1. Univariate analysis showed an association between CD4/CD8 1 was not achieved in 33% of the children. Lower CD4 nadir and previous exposure to suboptimal therapy, before initiating cART, are factors showing independently association with a worse immune recovery (CD4/CD8 < 1).Peer reviewe

Posicionamiento de la sociedad Española de infectología pediátrica sobre la implementación, ejecución y monitorización de los programas de optimización de uso de antimicrobianos (PROA) en pediatría hospitalaria

Pediatría; Resistencia antibióticaPaediatrics; Antimicrobial resistancePediatria; Resistència antibiòticaIn the past few years, antimicrobial resistance has increased, becoming a serious public health problem. The irrational use of antimicrobials is one of the main contributors to antimicrobial resistance. The paediatric population is not free from this problem, as antimicrobials are widely prescribed in this age group, often inappropriately. The introduction of antimicrobial stewardship programmes (ASPs) has proven crucial in curbing the emergence of antimicrobial resistance. At the international level, the need to develop specific paediatric ASPs has been recognised on account of the differences between adult and paediatric patients as concerns infection and approaches to diagnosis and treatment. For this reason, paediatric ASPs should be multidisciplinary programmes led by paediatric infectious disease specialists and use specific paediatric indicators (such as days of treatment, antimicrobial susceptibility patterns in the paediatric population, or clinical indicators) to help identify areas of improvement and develop effective targeted interventions. On the other hand, the support and leadership of the pertinent scientific societies are also essential. The purpose of this document is to present the position of the Sociedad Española de Infectología Pediátrica (SEIP, Spanish Society of Paediatric Infectious Diseases) concerning the implementation of paediatric ASPs in hospitals in Spain and to provide tools to facilitate their application in hospitals throughout the regional health care systems in the country.Durante los últimos años ha habido un aumento en la aparición de resistencias antimicrobianas, lo cual supone un grave problema de salud pública. El mal uso de antimicrobianos es un factor determinante en su desarrollo. La población pediátrica no queda exenta de dicha problemática ya que la prescripción de antibióticos en pediatría es elevada y en muchas ocasiones inadecuada. La incorporación de los programas de optimización de uso de antimicrobianos (PROA) ha resultado ser una medida crucial para disminuir el riesgo en la aparición de resistencias antibióticas. A nivel internacional se reconoce la necesidad de crear PROAs específicos en pediatría (PROA-P) debido a las diferencias existentes entre pacientes adultos y pediátricos en referencia a las infecciones, así como al abordaje tanto diagnóstico como terapéutico de las mismas. Por esta misma razón, los PROA-P deben ser programas multidisciplinares liderados por especialistas en infecciones pediátricas y trabajar con indicadores específicos pediátricos (DOT, patrones de sensibilidad antibiótica de población pediátrica, indicadores clínicos…) que permitan detectar puntos de mejora y establecer estrategias dirigidas eficaces. Por otro lado, es imprescindible el apoyo y liderazgo por parte de las distintas sociedades científicas implicadas. El objetivo de este documento es dar a conocer el posicionamiento de la Sociedad Española de Infectología Pediátrica (SEIP) sobre la implementación de los PROA pediátricos hospitalarios en nuestro territorio así como aportar herramientas que ayuden en la aplicación de dichos programas en los diferentes hospitales de las distintas regiones sanitarias del país

Nutritional Supplementation to Increase Influenza Vaccine Response in Children Living With HIV: A Pilot Clinical Trial

Final results of this work have been presented at the following meetings: 36rd Annual Meeting of the European Society for Pediatric Infectious Diseases (ESPID 2018), Malmö, Sweden, 28th May-June 2nd, 2018. (Ref. ESP18-0517).Aims: Vaccine response is poor among children living with HIV. The gut microbiota has been identified as a potential target to improve vaccine immunogenicity, but data are scarce in the context of HIV infection. Methods: Pilot, double-blind, randomized placebo-controlled trial in which 24 HIV-infected children were randomized to receive a mixture of symbiotics, omega-3/6 fatty acids, and amino acids or placebo for 4 weeks, each in combination with ART, and were then immunized against influenza. Vaccine response and safety of the nutritional supplementation were the primary outcomes. Results: Eighteen HIV-infected children completed the follow-up period (mean age 11.5 ± 4.14 years, 61% female). The nutritional supplement was safe but did not enhance the response to the influenza vaccine. A 4-fold rise in antibody titers was obtained in only 37.5% of participants in the intervention arm vs. 40% in the placebo. No immunological or inflammatory predictors of vaccine response were identified. Conclusions: In this exploratory study, a 4-week course of symbiotics did not increase influenza vaccine immunogenicity in HIV-infected children. Larger studies are warranted to address the potential of modulating the microbiome in children living with HIV.This work was funded by the Instituto de Salud Carlos III-Fondos FEDER (grant number CB21/17/00025), Acción Estratégica en Salud (PI13/0422, PI17/01283, PI18/00154, and PI18CIII/00009). TS and SS-V have been funded by the Instituto de Salud Carlos III-Fondos FEDER (BA21/00022 and BA21/00017). The funding bodies did not have a role in the design or conduct of the study, the analysis and interpretation of the results, and the writing of the report or the decision to publish. The authors would like to particularly acknowledge all the children and adolescents as well as their families for their participation in this study. They acknowledge the Spanish Pediatric HIV infection Group CORISPE and the Pediatric HIV BioBank integrated in the Spanish AIDS Research Network and collaborating Centers [supported by the Instituto de Salud Carlos III, Spanish Health Ministry (Grant n◦ RD06/0006/0035)] for its collaboration and cession of clinical information and samples used in this work. Nutricion Médica S.L., manufactured and packaged the nutritional product under investigation. Final results of this work have been presented at the following meetings: 36rd Annual Meeting of the European Society for Pediatric Infectious Diseases (ESPID 2018), Malmö, Sweden, 28th May-June 2nd, 2018. (Ref. ESP18-0517).S

Risk factors for antibiotic-resistant bacteria colonisation in children with chronic complex conditions

To assess drug-resistant bacterial colonisation rates and associated risk factors in children with complex chronic conditions admitted to a national reference unit in Spain. Cross-sectional study that included all children admitted to our unit from September 2018 to July 2019. Rectal swabs were obtained to determine multidrug-resistant Gram-negative bacilli (MR-GNB) colonisation, and nasal swab to determine S. aureus and methicillin-resistant S. aureus (MRSA) colonisation. Medical records were reviewed. 100 children were included, with a median of four complex chronic conditions. Sixteen percent had S. aureus colonisation, including two MRSA. S. aureus colonisation was associated with technology-dependent children, while being on antibiotic prophylaxis or having undergone antibiotic therapy in the previous month were protective factors. The prevalence of MR-GNB colonisation was 27%, which was associated with immunosuppressive therapy (aOR 31; 2.02-47]; p = 0.01), antibiotic prophylaxis (aOR 4.56; 1.4-14.86; p = 0.012), previously treated skin-infections (aOR 2.9; 1.07-8.14; p = 0.03), surgery in the previous year (aOR 1.4; 1.06-1.8; p = 0.014), and hospital admission in the previous year (aOR 1.79; [1.26-2.56]; p = 0.001). The rate of S. aureus nasal colonisation in this series was not high despite the presence of chronic conditions, and few cases corresponded to MRSA. Antibiotic prophylaxis, immunosuppressive therapies, history of infections, previous surgeries, and length of admission in the previous year were risk factors for MR-GNB colonisation.This study was supported by Te Spanish Ministry of Science and Innovation-Carlos III Health Institute, and European Regional Development Funds; Grant No. PI18CIII/00372 [Fondo de Investigaciones Sanitarias-Spanish Health Research Fund (ISCIII)]; Grant Award “Jose María Corretger” from the Spanish Society for Paediatric Infectious Diseases; Grant Research Award from the Spanish Association of Paediatric Primary Care; and a small grant award from the European Society for Paediatric Infectious Diseases.S

Nutritional Supplementation to Increase Influenza Vaccine Response in Children Living With HIV: A Pilot Clinical Trial

AimsVaccine response is poor among children living with HIV. The gut microbiota has been identified as a potential target to improve vaccine immunogenicity, but data are scarce in the context of HIV infection.MethodsPilot, double-blind, randomized placebo-controlled trial in which 24 HIV-infected children were randomized to receive a mixture of symbiotics, omega-3/6 fatty acids, and amino acids or placebo for 4 weeks, each in combination with ART, and were then immunized against influenza. Vaccine response and safety of the nutritional supplementation were the primary outcomes.ResultsEighteen HIV-infected children completed the follow-up period (mean age 11.5 ± 4.14 years, 61% female). The nutritional supplement was safe but did not enhance the response to the influenza vaccine. A 4-fold rise in antibody titers was obtained in only 37.5% of participants in the intervention arm vs. 40% in the placebo. No immunological or inflammatory predictors of vaccine response were identified.ConclusionsIn this exploratory study, a 4-week course of symbiotics did not increase influenza vaccine immunogenicity in HIV-infected children. Larger studies are warranted to address the potential of modulating the microbiome in children living with HIV

Characterization of methicillin-resistant Staphylococcus aureus strains colonizing the nostrils of Spanish children

Objective: To characterize the Staphylococcus aureus strains colonizing healthy Spanish children. Methods: Between March and July 2018, 1876 Spanish children younger than 14 years attending primary healthcare centers were recruited from rural and urban areas. Staphylococcus aureus colonization of the anterior nostrils was analyzed. MecA and mecC genes, antibiotic susceptibility, and genotyping according to the spa were determined in all strains, and the following toxins were examined: Panton-Valentine leucocidin (pvl), toxic shock syndrome toxin (tst), and exfoliative toxins (eta, etb, etd). Multilocus sequence typing (MLST) and staphylococcal cassette chromosome (SCCmec) typing were performed on methicillin-resistant Staphylococcus aureus (MRSA) strains, as well as pulsed-field gel electrophoresis (PFGE). Results: 619 strains were isolated in 1876 children (33%), and 92% of them were sent for characterization to the Spanish National Centre of Microbiology (n = 572). Twenty (3.5%) of these strains were mecA-positive. Several spa types were detected among MRSA, being t002 the most frequently observed (30%), associating with SCCmec IVc. Among MSSA, 33% were positive for tst, while only 0.73% were positive for pvl. The 20 MRSA strains were negative for pvl, and 6 (30%) harbored the tst gene. Conclusions: methicillin-resistant Staphylococcus aureus nasal colonization in Spanish children is rare, with t002 being the most observed spa type, associated with SCCmec IVc. None of the MRSA strains produced pvl, but up to 30% of S. aureus strains were positive for tst.Sociedad Española Infectologia Pediatrica, Grant/Award Number: José María Corretger. Grant 2018; Spanish Association of Paediatric Primary Care, Grant/Award Number: Grant 2018; European Society for Paediatric Infectious Diseases, Grant/Award Number: Small Grant Award 2018; Instituto de Salud Carlos III, Grant/Award Number: PI18CIII/00372S

Characterization of methicillin-resistant Staphylococcus aureus strains colonizing the nostrils of Spanish children

Objective: To characterize the Staphylococcus aureus strains colonizing healthy Spanish children. Methods: Between March and July 2018, 1876 Spanish children younger than 14 years attending primary healthcare centers were recruited from rural and urban areas. Staphylococcus aureus colonization of the anterior nostrils was analyzed. MecA and mecC genes, antibiotic susceptibility, and genotyping according to the spa were determined in all strains, and the following toxins were examined: Panton-Valentine leucocidin (pvl), toxic shock syndrome toxin (tst), and exfoliative toxins (eta, etb, etd). Multilocus sequence typing (MLST) and staphylococcal cassette chromosome (SCCmec) typing were performed on methicillin-resistant Staphylococcus aureus (MRSA) strains, as well as pulsed-field gel electrophoresis (PFGE). Results: 619 strains were isolated in 1876 children (33%), and 92% of them were sent for characterization to the Spanish National Centre of Microbiology (n = 572). Twenty (3.5%) of these strains were mecA-positive. Several spa types were detected among MRSA, being t002 the most frequently observed (30%), associating with SCCmec IVc. Among MSSA, 33% were positive for tst, while only 0.73% were positive for pvl. The 20 MRSA strains were negative for pvl, and 6 (30%) harbored the tst gene. Conclusions: methicillin-resistant Staphylococcus aureus nasal colonization in Spanish children is rare, with t002 being the most observed spa type, associated with SCCmec IVc. None of the MRSA strains produced pvl, but up to 30% of S. aureus strains were positive for tst