Recent Chemotherapy for Child Pneunomia and Empyema

Recent progress in chemotherapy has contributed to the remarkable decrease in mortality from pneumonia in infancy and childhood; however, wide use of antimicrobials has resulted in incapability of etiologic diagnosis. Appropriate chemotherapy for pneumonia should be initiated based on the relative frequency of causative organisms related to age groups, and their antimicrobial susceptibility. Therapeutic development should be reevaluated by the pathogens isolated prior to antimicrobial administration. S. aureus is the most important causative agent in fatal cases of pneumonia. Judging from our studies on offending bacteria in bronchopulmonary infections, H. influenzae, S. pneumoniae and S. aureus are the major pathogens in pneumonia. Therefore, the main initial antimicrobials in uncompromised infants and children should be ampicillin (plus penicillinase-resistant penicillin) covering these organisms. Methicillin-resistant S. aureus, ampicillin-resistant H influenzae and penicillin-resistant S. penumoniae are of great concern. Chemotherapy for these strains is discussed. Treatment with macrolides is mainly recommended for M. pneumoniae. Chemotherapeutic results of treatment of C. trachomatis will be elucidated in a few years.     

Antibiothérapie des infections ostéo-articulaires de l’enfant : ce qui a changé

Management of bone and joint infections in children associates early appropriate antibiotic therapy against Staphylococcus aureus and Kingella kingae and, if necessary, surgical drainage of abscess or septic arthritis. In 2007, the Paediatric Infectious Diseases Group of the French Society of Paediatrics (GPIP) proposed guidelines for antibiotherapy in acute and non-complicated cases, with an intravenous therapy during 4 to 7 days followed by oral therapy during 3 weeks.     

Parasitic diseases in pediatric cancer patients

Parasitic infections are rare events in pediatric oncology. Transmission routes and diseases of most parasites do not differ significantly from those seen in otherwise healthy children. However, latent asymptomatic infections with Cryptosporidium spp., Leishmania spp., Strongyloides stercoralis and Toxoplasma gondii might exacerbate during immunosuppression. Screening in asymptomatic patients is often unsuccessful due to the low sensitivity of available assays except in toxoplasmosis. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for the appropriate diagnostic procedures and antiparasitic treatment immunocompromised patients.     

Nosocomial Infections and Multidrug-Resistant Bacterial Organisms in the Pediatric Intensive Care Unit

Nosocomial infections in Pediatric Intensive Care Units (PICUs) caused by multidrug-resistant bacterial organisms are increasing. This review attempts to report on significant findings in the current literature related to nosocomial infections in PICU settings with an international perspective. The types of nosocomial infections are addressed, including catheter-related bloodstream infections, ventilator-associated pneumonia, urinary tract infections, gastrointestinal infections and post-surgical wound infections. A review of emerging resistant bacterial pathogens includes methicillin-resistant Staphylococcus aureus, vancomycin-resistant Enterococcus sp., Clostridium difficile, extended-spectrum β-lactamase producing Gram-negative organisms, Klebsiella pneumoniae carbapenemase-producing strains and multi-drug resistant Acinetobacter baumannii. Basic and enhanced infection control methods for the management and control of multidrug-resistant organisms are also summarized with an emphasis on prevention.     

Intraabdominal and hepatic infections in pediatric cancer patients

Common complications involved in treating pediatric patients with cancer are bacterial, viral and fungal infections of the gastrointestinal tract including esophagitis, gastritis, duodenitis, colitis and hepatobiliar infections. In many cases there are multiple factors that predispose these patients to gastrointestinal infections, such as granulocytopenia, T-cell dysfunction, and mucosal damage. In addition, newer therapies have changed the spectrum of infection that is seen in these patients. The profound T-cell suppression associated with therapies such as stem cell transplantation has led to the emergence of previously rare infections including cytomegalovirus and adenovirus. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for diagnosis, prevention, and management of local as well as invasive infections of the gastrointestinal tract.     

Diagnosis and management of fungal infections and pneumocystis pneumonitis in pediatric cancer patients

Invasive fungal infections are important causes of morbidity and mortality in pediatric cancer patients with hematological malignancies and following allogeneic hematopoietic stem cell transplantation. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for diagnosis and treatment of fungal infections including Pneumocystis jiroveci. They are based on specific pediatric pharmacological and regulatory considerations and on the results of clinical trials, case series and expert opinions using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA). Recommendations for the most frequent clinical entities are summarized here. Options for initial therapy of uncomplicated candidemia include deoxycholate amphotericin B (DAMB), fluconazole (FLC), liposomal amphotericin B (LAMB), the combination of DAMB plus FLC as well as voriconazole (VCZ) for patients > 11 years. For acute disseminated candidiasis, the combination of DAMB plus flucytosine is recommended. Indwelling central venous catheters serve as infectious nidus and should be removed whenever feasible. First-line therapy for presumed or proven invasive Aspergillus infections in patients 12 years and older is VCZ with DAMB and LAMB serving as alternatives. Choices for patients < 12 years of age are essentially limited to DAMB and LAMB. Due to the yet lacking evidence for enhanced antifungal efficacy and the ongoing dosage finding of caspofungin (CAS) in pediatric patients, combination therapies (LAMB plus CAS or VCZ plus CAS) should only be considered for fulminant or massive, life threatening infections. In granulocytopenic patients, adjunctive therapy with colony-stimulating factors (G-CSF) is recommended. In patients under immunosuppressive therapy, glucocorticosteroids ought to be reduced or discontinued, if feasible. Surgical interventions are restricted to specific indications. Zygomyces infections are an indication for high-dose LAMB. The combination of DAMB plus flucytosine is the initial treatment of choice of cryptococcal mengoencephalitis, and for treatment of Pneumocystis jiroveci pneumonitis, trimethoprim/sulfamethoxazol or intravenous pentamidine is recommended. Beyond the listed entities, the article provides a brief review on the pharmacokinetics and dosing of antifungal agents in children and adolescents as well as detailed discussions and evidence-based recommendations for empirical antifungal therapy, diagnosis and treatment of superficial fungal infections, of invasive infections by previously rare fungal pathogens and endemic moulds and for adjunctive immunomodulatory and surgical interventions.     

Bacterial infections in pediatric cancer patients

Increased dose intensity and a better long term survival can not be reached in pediatric oncology without the judicious use of antibiotics. During periods with profound neutropenia and between intensive chemotherapy cycles are bacterial infections capable of disturbing the patients' quality of life; they may cause an acute life threatening situation and lead to a substantial increase in expenditures and consumption of ressources in supportive care. The non-judicious use of antibacterials may face the patient to an increased risk of adverse events and fosters the selection of resistant bacteria. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for antibacterial therapy in pediatric oncology patients based upon the available literature and the clinical experience of the authors.     

Viral infections in pediatric cancer patients

Children with cancer or stem cell transplantation (SCT) are at considerable risk to develop life threatening viral infections. Due to both underlying disease and immunosuppressive therapy lymphocyte number and function are low and the cellular immunity against viral infections is restricted or missing. As immunosuppressive treatment regimens and mismatched or T-cell-depleted stem cell products are being used increasingly, viral infections will become an even greater problem in the future. PCR-based methods have become an indispensable tool for early recognition, preemptive therapy, and monitoring therapeutic responses by qualitative and quantitative approaches. Assays are now available that allow for parallel screening of the 16 most common viral agents. Responses to antiviral therapy are often limited in immunocompromised patients and mainly depend on the time of their initiation. Most antiviral agents have a toxicity profile that may become clinically relevant and curtail antiviral therapy. New options for treatment are therefore warranted. For the next future, these may include the transfer of specific T-cells and other immunotherapeutic approaches. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Hematology/Oncology (GPOH) and the German Society for Pediatric Infectious Diseases (DGPI) for diagnosis and treatment of viral infections in children with cancer or post HSCT. They are based on the results of clinical trials, case series and expert opinions using the evidence criteria set forth by the Infectious Diseases Society of America (IDSA).     

Diagnosis and management of central nervous system infections in pediatric cancer patients

Infections of the central nervous system (CNS) are a common cause of neurological abnormalities in pediatric oncology patients apart from cancer disease of the CNS. Often symptoms do not present unequivocally, impeding a clear distinction from other differential diagnosis. Repeated neurological examinations of the patient allow selecting the necessary laboratory tests and imaging techniques. As delayed antiinfectious treatment is associated with high mortality and severe sequelae of survivors, patients do need empirical therapy using adequate doses until diagnostic results allow a more specific treatment. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for diagnosis and treatment of infections of the CNS in immunocompromised patients.     

Management of septic shock and acquired respiratory distress syndrome in pediatric cancer patients

Septic shock occurs in 6 % of paediatric cancer patients with neutropenia and fever. The mortality of the septic shock is 40 % in BMT patients and 5 % in others. One third of paediatric ARDS cases affect immunocompromised individuals with a total mortality of 45 % and 80 % after BMT. Septic shock is caused by gram-negative bacteria in more than 75 %. ARDS is due to pneumonia in more than 50 %, sepsis in about 25 %. This article provides the recommendations of the Infectious Diseases Working Party of the German Society for Pediatric Infectious Diseases (DGPI) and the German Society for Pediatric Hematology/Oncology (GPOH) for treatment of septic shock and ARDS. Therapy of septic shock includes early antibiotic therapy and volume expansion (> or = 40 ml/kg initially). Refractory shock requires vasopressors (noradrenaline), followed by a judicious circulatory management. Hydrocortisone is indicated in patients with high probability of adrenal insufficiency. Mainstay of ARDS therapy is ventilation with sufficient end-expiratory pressure (PEEP) to prevent loss of functional residual capacity and with limited tidal volumes (< or = 6 ml/kg) and limited inspiratory pressure (< 35 cm H(2)O) respectively, to minimize ventilator induced lung injury. Volume therapy consists of maintenance of sufficient preload to counteract the impaired venous return, induced by positive pressure ventilation. Diuretics and eventually veno-venous haemofiltration are used to reduce free lung water. Surfactant application may be considered in severe cases. Steroids are indicated in pneumocystis carinii pneumonia and in engraftment pneumonitis.     

Japanese pediatric guidelines for the treatment and management of bronchial asthma 2008

The fourth version of the Japanese Pediatric Guidelines for the Treatment and Management of Bronchial Asthma 2008 (JPGL 2008) was published by the Japanese Society of Pediatric Allergy and Clinical Immunology in December 2008. In JPGL 2008, the recommendations were revised on the basis of the JPGL 2005. The JPGL 2008 is different to the Global Initiative for Asthma guideline in that it contains the following items: a classification system of asthma severity; recommendations for long‐term management organized by age; a special mention of infantile asthma; and an emphasis on prevention and early intervention. Here we show a summary of the JPGL 2008 revising our previous report concerning JPGL 2005.     

Magnetic resonance imaging of lung infections in children

The advantages and limitations of MRI in lung infections in children have not been well established. This article illustrates the MRI findings in children with pneumonia caused by Mycoplasma pneumoniae, Streptococcus pneumoniae, and other pathogens. Lung parenchymal, pleural, and lymph node abnormalities are well characterized by MRI. Loculation of pleural fluid is detected in children with empyema. Contrast enhancement may be useful in the differentiation of active inflammation from noninflammatory changes. MRI can be particularly useful in the follow-up of children with chronic pulmonary diseases.     

Etiology of community-acquired pneumonia in hospitalized children based on WHO clinical guidelines

Community-acquired pneumonia (CAP) is a major cause of death in developing countries and of morbidity in developed countries. The objective of the study was to define the causative agents among children hospitalized for CAP defined by WHO guidelines and to correlate etiology with clinical severity and surrogate markers. Investigations included an extensive etiological workup. A potential causative agent was detected in 86% of the 99 enrolled patients, with evidence of bacterial (53%), viral (67%), and mixed (33%) infections. Streptococcus pneumoniae was accounted for in 46% of CAP. Dehydration was the only clinical sign associated with bacterial pneumonia. CRP and PCT were significantly higher in bacterial infections. Increasing the number of diagnostic tests identifies potential causes of CAP in up to 86% of children, indicating a high prevalence of viruses and frequent co-infections. The high proportion of pneumococcal infections re-emphasizes the importance of pneumococcal immunization.     

The cephalosporin compounds in severe neonatal infection

The new cephalosporin compounds have increased in vitro activity against gram-negative enteric bacilli and penetrate well into cerobrospinal fluid. Moreover, their pharmacokinetic properties are favorable and their safety seems adequate, although insufficiently evaluated to date. Interest has been focused on them as therapeutic agents for neonatal sepsis and meningitis caused by Enterobacteriaceae. In this review the third generation cephalosporins are evaluated for their possible use in the neonates; opinions are based on currently available data. It is concluded that moxalactam and cefotaxime and probably also ceftriaxone and ceftazidime represent valuable alternatives to aminoglycosides for therapy of severe neonatal infection. Curriculum vitae. Urs B. Schaad was born 1945 in Switzerland. He graduated 1971 from the Medical Faculty of the Bernese University and his postgraduate training included 1 year General Surgery (Lugano), 11/2 years Internal Medicine (Langenthal) and 41/2 years Pediatrics (Berne). From 1978 to 1980 he completed a Research Fellowship in Pediatric Infectious Diseases at the University of Texas at Dallas, USA (Directors of Program: Prof. George H. McCracken, Jr., and Prof. John D. Nelson). Since 1981 he is back at the Department of Pediatrics, University of Berne (Head: Prof. E. Rossi), conducting clinical, research and teaching activities in Pediatric Infectious Diseases. In June 1983 he was promoted to Privatdozent and received the Venia Docendi in Pediatrics with special regard to Infectious Diseases. Main topics of research have been experimental meningitis and studies on pharmacokinetics and efficacy of different antimicrobial agents in pediatric patients. Previous reviews included recrudescence and relapse in bacterial meningitis, atypical myobacterial lymphadenitis, melioidosis, pyogenic sacroiliitis, arthritis in meningococcal disease, infantile chlamydial pneumonia, Campylobacter-reactive arthritis, prophylaxis against pneumococcal, meningococcal and H. influenzae type b infections in childhood, neonatal sepsis and meningitis, and infectious diarrhea in the pediatric age group.     

A Single Center's Experience with Candida parapsilosis Related Long-Term Central Venous Access Device Infections: The Port Removal Decision and Its Outcomes

Pediatric cancer patients have an increased risk of potentially life-threatening fungal infections such as Candida parapsilosis, associated with long-term CVADs. The Infectious Diseases Society of America (IDSA) guidelines on Candida catheter-related bloodstream infections recommend systemic antifungal therapy and catheter removal. In this study, we focused on our experience with antifungal failure due to totally implanted catheter-associated C. parapsilosis bloodstream infections. We investigated cases leading to port removal in pediatric malignancy patients and the associated patient outcomes. In the first phase of the study, a retrospective chart review was performed to collect patient information, including primary disease; time from hospitalization to port-related candidemia; antifungal drug choice; and the time at which port removal occurred. During the second phase, antifungal susceptibility tests for C. parapsilosis were performed in our microbiology laboratory. All patients had fevers and were neutropenic at the time of candidemia diagnosis. The mean duration between the first isolation of Candida parapsilosis from the port samples to the port removal was 9.75 ± 5.29 days for 11 patients. Patient fevers lasted for a mean time of 16.22 ± 6.51 days. The median recovery duration from fever after CVC removal was four days (range 2–12 days). The median duration for achieving negative blood cultures, following antifungal treatment was 18 days (range 10–27 days). Our data favored the removal of catheters in the presence of ongoing fever, as suggested by the guidelines, independent of the chosen antifungal treatment. Future studies with large samples are needed to evaluate the effects of catheter removal on mortality rates and patient outcomes.     

Prevalence of Chlamydia pneumoniae in acute lower respiratory infection in the pediatric population in Japan

Chlamydia pneumoniae has been established as an important etiologic agent of acute respiratory tract infection in humans, especially in adults. However, there is little information available on C. pneumoniae infection in the pediatric age group. The microimmunofluorescence test and Chlamydia pneumoniae-specific polymerase chain reaction (PCR) method were applied to reveal the role of C. pneumoniae as an etiologic agent of acute lower respiratory tract infection in children in Japan. Among 136 patients aged between 2 months and 15 years with acute lower respiratory tract infection, five patients with pneumonia were found to have recent C. pneumoniae infection by the microimmunofluorescence test. C. pneumoniae-specific PCR products were detected from specimens of four patients among these five. Neither C. trachomatis nor C. psittaci infection was found in this population. These results suggest that C. pneumoniae is an important causative agent of acute childhood pneumonia and may be the most prevalent pathogen among the genus Chlamydia that causes acute lower respiratory disease in this age group in Japan.     

Streptococcus pneumoniae-associated haemolytic uremic syndrome following influenza A virus infection

Influenza virus is a seasonal cause of community-acquired pneumonia, and Streptococcus pneumoniae is one of the most common pathogens causing secondary bacterial pneumonia. S. pneumoniae-induced haemolytic uremic syndrome is an uncommon condition mainly observed in young children. We present a patient who had invasive pneumococcal disease and haemolytic uremic syndrome. Simultaneous viral cultures grew influenza A. To the best of our knowledge, this is the first such reported case.     

Neonatal community‐acquired pneumonia: Pathogens and treatment

Aim: To analyse the bacterial pathogens and drug sensitivities for neonatal community‐acquired pneumonia. Methods: Seven hundred sixty sputum samples from newborns with community‐acquired pneumonia were cultured to determine microbial organisms present and their drug sensitivities. Results: Of the 760 specimens, 425 grew pathogens for a 55.9% positive rate. Among the 425 positive cultures, 278 grew gram‐negative organisms (65.4%), 142 grew gram‐positive organisms (33.3%), while 5 grew fungus (1.3%). The most common gram‐negative organisms were Escherichia coli, Klebsiella pneumoniae and Hemophilus influenzae, while the most common gram‐positive organisms were Staphylococcus aureus, Staphylococcus epidermidis and Staphylococcus haemolyticus. To the gram‐negative organisms, the most sensitive drugs were meropenem, imipenem and amikacin, while to the gram‐positive ones were vancomycin, teicoplanin and quinupristin/dalfopristin. Conclusions: The most common causative bacteria were gram‐negative organisms, which were highly sensitive to Meropenem, Imipenem and Amikacin, yet often treatable with more focused antibiotic coverage, which depended on the bacterium identified.